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Introduction: In honouring the legacy of Jude Byrne's life‐long advocacy for women and mothers who use drugs, this paper presents a case study of a group of women about whom we know little about and hear even less from: women who inject drugs in relatively affluent suburbs. Methods: Based on a 2020 qualitative study of people who inject drugs in an affluent area of Sydney known as 'The Beaches', we use in‐depth interview data to thematically explore the lived experiences of gendered stigma among women who inject drugs. Results: Even when women occupy the 'ideal' social position in terms of class (middle‐class) and race (White) they remain subject to harmful forms of gendered stigma related to injecting drug use. Participants had internalised negative attitudes around injection drug use as a form of failed femininity and, despite being part of 'good' families and neighbourhoods, participants experienced forced child removal. Discussion and Conclusions: Taking the lead from feminist intersectionality scholarship, our data illustrate how stigma and discrimination act as a form of structural violence against women who inject drugs in affluent communities. While the social relations of gender provide some degree of protection by 'performing proximity to Whiteness', gendered stigma and violence persist. [ABSTRACT FROM AUTHOR]

Introduction: Children in families affected by substance use disorders are at high risk of being placed in out‐of‐home care (OOHC). We aimed to describe the characteristics of parents who inject drugs and identify correlates associated with child placement in OOHC. Method s : We used baseline data from a community‐based cohort of parents who inject drugs (SuperMIX) from Melbourne, Australia. Participants were recruited via convenience, respondent‐driven and snowball sampling from April 2008 to November 2020, with follow‐up until March 2021. To explore correlates associated with child placement to OOHC, we used multivariable logistic regression and assessed for potential interactions between gender and a range of relevant covariates. Results: Of the 1067 participants, 611 (57%) reported being parents. Fifty‐six percent of parents reported child protection involvement. Almost half (49%) had children in OOHC. Nearly half of the parents lived in unstable accommodation (44%) and many of them experienced moderate–severe levels of anxiety (48%) and depression (53%). Female or non‐binary gender, identifying as Aboriginal or Torres Strait Islander, experiencing assault and having more children were associated with child removal to OOHC. Of the 563 participants who reported their own childhood care status, 135 (24%) reported they had been removed to OOHC. Discussion and Conclusions: We identified high rates of child placement in OOHC among parents who inject drugs. There is a need for targeted health and social services, that are gender and culturally responsive, in addition to systems‐level interventions addressing social inequities, such as housing, to support parents to care for their children. [ABSTRACT FROM AUTHOR]

This article is a special section in the Drug & Alcohol Review journal dedicated to honoring the life and work of Jude Byrne, a prominent advocate, policy influencer, and researcher in the alcohol and drug field. Jude's impact was significant and wide-reaching, both locally and globally. The collection of papers in this special section covers various topics, including community-researcher partnerships, parent and family advocacy, equitable and ethical research, gendered stigma, healthcare access for women who use drugs, and the importance of peer knowledge and expertise in research and policy. Jude's legacy is one of challenging inequalities, centering the experiences of people who use drugs, and advocating for human rights. [Extracted from the article]

Early neutralizing antibodies against hepatitis C virus (HCV) and CD8 + T cell effector responses can lead to viral clearance. However, these functions alone are not sufficient to protect patients against HCV infection, thus undefined additional antiviral immune mechanisms are required. In recent years, Fc‐receptor‐dependent antibody effector functions, particularly, antibody‐dependent cellular phagocytosis (ADCP) were shown to offer immune protection against several RNA viruses. However, its development and clinical role in patients with HCV infection remain unknown. In this study, we found that patients with chronic GT1a or GT3a HCV infection had significantly higher concentrations of anti‐envelope 2 (E2) antibodies, predominantly IgG1 subclass, than patients that cleared the viruses while the latter had antibodies with higher affinities. 97% of the patients with HCV had measurable ADCP of whom patients with chronic disease showed significantly higher ADCP than those who naturally cleared the virus. Epitope mapping studies showed that patients with antibodies that target antigenic domains on the HCV E2 protein that are known to associate with neutralization function are also strongly associated with ADCP, suggesting antibodies with overlapping/dual functions. Correlation studies showed that ADCP significantly correlated with plasma anti‐E2 antibody levels and neutralization function regardless of clinical outcome and genotype of infecting virus, while a significant correlation between ADCP and affinity was only evident in patients that cleared the virus. These results suggest ADCP was mostly driven by antibody titer in patients with chronic disease while maintained in clearers due to the quality (affinity) of their anti‐E2 antibodies despite having lower antibody titers. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic triggered widespread socioeconomic hardship, disproportionately impacting disadvantaged populations. People who use illicit drugs are more likely to experience unemployment, homelessness, criminal justice involvement and poorer health outcomes than the general community, yet little is known about the socioeconomic impacts of the pandemic on their lives. To address this gap in the literature, we conducted in‐depth interviews with 76 participants from two cohort studies of people who use illicit drugs (people who inject drugs and/or use methamphetamine) in Victoria, Australia. Findings support claims that pandemic‐related Social Security supplementary payments and initiatives to reduce homelessness, although not systemically transforming people's lives, produced temporary relief from chronic socioeconomic hardship. Results also indicate how temporary interruptions to drug supply chains inflated illicit drug prices and produced adverse consequences such as financial and emotional stress, which was exacerbated by drug withdrawal symptoms for many participants. Furthermore, increased community demand for emergency food and housing support during the pandemic appeared to reduce participants' access to these services. Our findings about the unintended consequences of pandemic responses on the socioeconomic lives of a group of people who use illicit drugs provide insights into and opportunities for policy reform to redress their entrenched disadvantage. [ABSTRACT FROM AUTHOR]

Background and Aims: Few studies of the impacts of the coronavirus disease 2019 (COVID‐19) public health measures on drug markets and drug use patterns have used longitudinal data. We aimed to examine whether COVID‐19 measures were associated with increases in methamphetamine price, decreases in methamphetamine use frequency and subsequent changes in secondary outcomes of other drug use frequency in metropolitan Melbourne and regional Victoria. Design: Longitudinal analysis framework was used from a longitudinal cohort of people who use methamphetamine. Setting: Victoria state, Australia. Participants: One hundred eighty‐five VMAX study participants who reported a methamphetamine purchase after the onset of the pandemic were used for the price paid analysis. Methamphetamine or other drug use frequency analysis was performed using 277 participants who used methamphetamine during the pandemic or in the year before the pandemic. Measurements Price paid per gram of methamphetamine derived from the most recent purchase price and most recent purchase quantity. Frequency of methamphetamine and other drug use measured as the average number of days per week used in the last month. Findings Compared with pre‐COVID‐19 period, methamphetamine prices increased by AUD351.63 (P value <0.001) and by AUD456.51 (P value <0.001) in Melbourne and regional Victoria, respectively, during the period in which the most intense public health measures were implemented in Victoria. Although prices decreased after harder restrictions were lifted (by AUD232.84, P value <0.001 and AUD263.68, P value <0.001, in Melbourne and regional Victoria, respectively), they remained higher than pre‐COVID‐19 levels. A complementary 76% decrease was observed in relation to methamphetamine use frequency in regional Victoria (P value = 0.006) that was not offset by any changes in the frequency of use of other drugs such as alcohol, tobacco or other illicit drugs. Conclusion: COVID‐19 public health measures in Victoria state, Australia, appear to have been associated with major price changes in the methamphetamine market and decreased frequency of use of the drug. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to describe COVID‐19 vaccination attitudes and identify potential facilitators for vaccine uptake among people who inject drugs. Methods: People who inject drugs were recruited from all eight Australian capital cities (N = 884; 65% male, mean age 44 years) and interviewed face‐to‐face or via telephone in June–July 2021. COVID‐19 and broader vaccination attitudes were used to model latent classes. Correlates of class membership were assessed through multinomial logistic regression. Probability of endorsing potential vaccination facilitators were reported by class. Results: Three classes of participants were identified: 'vaccine acceptant' (39%), 'vaccine hesitant' (34%) and 'vaccine resistant' (27%). Those in the hesitant and resistant groups were younger, more likely to be unstably housed and less likely to have received the current season influenza vaccine than the acceptant group. In addition, hesitant participants were less likely to report a chronic medical condition than acceptant participants. Compared to vaccine acceptant and hesitant participants, vaccine‐resistant participants were more likely to predominantly inject methamphetamine and to inject drugs more frequently in the past month. Both vaccine‐hesitant and resistant participants endorsed financial incentives for vaccination and hesitant participants also endorsed facilitators related to vaccine trust. Discussion and Conclusion: People who inject drugs who are unstably housed or predominantly inject methamphetamine are subgroups that require targeted interventions to increase COVID‐19 vaccination uptake. Vaccine‐hesitant people may benefit from interventions that build trust in vaccine safety and utility. Financial incentives may improve vaccine uptake among both hesitant and resistant people. [ABSTRACT FROM AUTHOR]

Background and Aims: Although the Netherlands, Canada and Australia were early adopters of harm reduction for people who inject drugs (PWID), their respective HIV and hepatitis C (HCV) epidemics differ. We measured the pooled effect of needle and syringe program (NSP) and opioid agonist therapy (OAT) participation on HIV and HCV incidence in these settings. Design: For each cohort, we emulated the design and statistical analysis of a target trial using observational data. Setting and Participants: We included PWID at risk of HIV or HCV infection from the Amsterdam Cohort Studies (1985–2013), Vancouver Injection Drug Users Study (1997–2009) and Melbourne Injecting Drug User Cohort Study (SuperMIX) (2010–2021). Measurements Separately for each infection and cohort (only HCV in SuperMIX), marginal structural models were used to compare the effect of comprehensive (on OAT and 100% NSP coverage or on OAT only if no recent injection drug use) versus no/partial NSP/OAT (no OAT and/or <100% NSP coverage) participation. Pooled hazard ratios (HR) and 95% CI were calculated using random‐effects meta‐analysis. Findings We observed 94 HIV seroconversions and 81 HCV seroconversions among 2023 and 430 participants, respectively. Comprehensive NSP/OAT led to a 41% lower risk of HIV acquisition (pooled HR = 0.59, 95% CI = 0.36–0.96) and a 76% lower risk of HCV acquisition (pooled HR = 0.24, 95% CI = 0.11–0.51), compared with no/partial NSP/OAT, with little heterogeneity between studies for both infections (I2 = 0%). Conclusions: In the Netherlands, Canada and Australia, comprehensive needle and syringe program and opioid agonist therapy participation appears to substantially reduce HIV and hepatitis C acquisition compared with no or partial needle and syringe program/opioid agonist therapy participation. These findings from an emulated trial design reinforce the critical role of comprehensive access to harm reduction in optimizing infection prevention for people who inject drugs. [ABSTRACT FROM AUTHOR]

Aims: The 2016 Global Health Sector Strategy (GHSS) on viral hepatitis aims to reduce new hepatitis C virus (HCV) infections by 80% by 2030, including a 30% reduction by 2020. This study aimed to estimate primary HCV incident infection among a national sample of people who inject drugs (PWID) before and after the introduction of unrestricted access to HCV direct‐acting antiviral (DAA) therapy via Australia's Pharmaceutical Benefits Scheme in 2016. Design: A simple deterministic linkage method identified repeat respondents in serial cross‐sectional surveys conducted among PWID. Two separate retrospective cohorts of HCV antibody‐negative respondents were created, corresponding to the pre‐ (2010–15) and post‐ (2016–21) DAA time‐periods. Setting and Participants: This study took place in Australia. Among 757 PWID retained (376 pre‐DAA, 381 post‐DAA), more than half were male (60%), the majority were heterosexual (80%), the median age was 40 years (interquartile range = 33–46 years) and the predominant drugs last injected were heroin (24%), pharmaceutical opioids (27%) and methamphetamine (41%). Measurements The primary outcome was HCV seroconversion, defined as a negative HCV antibody test result followed by a positive HCV antibody result. Time to primary incident HCV infection was estimated using the person‐years (PY) method. Findings A total 97 of 376 (2010–15) and 41 of 381 (2016–21) HCV seroconversions were identified. Primary HCV incidence more than halved, from 13.6 per 100 PY [95% confidence intervals (CI) = 11.2, 16.6] in 2010–15 to 5.4 per 100 PY (95% CI = 3.9, 7.3) in 2016–21. The decline was independent of observed differences in demographic and drug use characteristics over the two time‐periods (adjusted hazard ratio = 0.47, 95% CI = 0.31–0.69, P < 0.001). Conclusions: Australia has had a 53% reduction in primary hepatitis C virus (HCV) incidence among people who inject drugs following unrestricted availability of HCV direct acting antiviral therapy in March 2016. Given that PWID are the predominant population at risk of HCV infection in Australia, findings add to the evidence that Australia has probably met its 2020 Global Health Sector Strategy subtarget of a 30% decline in new infections. [ABSTRACT FROM AUTHOR]

Introduction: Social research on injection drug use has focussed on marginalised groups and communities, leaving a large gap in the field's understanding of how it is experienced in other settings, including in relatively affluent communities. Methods: This research is based on fieldwork and 18 in‐depth qualitative interviews conducted in suburban beach‐side communities in Sydney collectively known as the Northern Beaches. Results: Participants did not experience stigmatisation by local health services as the norm or as a deterrent to access. Drug acquisition on the Northern Beaches occurred among closed networks of friends and acquaintances, and injecting use rarely occurred in public settings. Police contact was minimal, resulting in lower levels of criminalisation. Discussion and Conclusions: Unlike many of the participants featured in the literature, our study participants grew up in middle and upper middle‐class households, typically experiencing comfortable childhoods with little to no exposure to injection drug use. In this setting injection drug use operates covertly within the normal rhythms of middle‐class life, hidden in amongst the bustle of cafés and shopping centres, and through the friendliness of neighbourhood driveway and doorstep interactions. Drug use is described as common in the area, with injecting behaviours stigmatised in ways that set it against the 'good' families and neighbourhoods of this beach‐side enclave. In contrast to much of the Australian qualitative literature which frames injection drug use as a means of psychological relief or a subcultural norm, our participants described injecting as motivated by the desire to enhance pleasure and social connection. [ABSTRACT FROM AUTHOR]

Background & Aims: People who inject drugs (PWID) experience high incarceration rates which are associated with increased hepatitis C virus (HCV) transmission risk. We assess the importance of prison‐based interventions for achieving HCV elimination among PWID in New South Wales (NSW), Australia. Methods: A model of incarceration and HCV transmission among PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from NSW, incorporating elevated HCV acquisition risk among recently released PWID. We projected the contribution of differences in transmission risk during/following incarceration to HCV transmission over 2020–2029. We estimated the past and potential future impact of prison‐based opioid agonist therapy (OAT; ~33% coverage) and HCV treatment (1500 treatments in 2019 with 32.9%–83.3% among PWID) on HCV transmission. We estimated the time until HCV incidence reduces by 80% (WHO elimination target) compared to 2016 levels with or without prison‐based interventions. Results: Over 2020–2029, incarceration will contribute 23.0% (17.9–30.5) of new HCV infections. If prison‐based interventions had not been implemented since 2010, HCV incidence in 2020 would have been 29.7% (95% credibility interval: 22.4–36.1) higher. If current prison and community HCV treatment rates continue, there is an 98.8% probability that elimination targets will be achieved by 2030, with this decreasing to 10.1% without current prison‐based interventions. Conclusions: Existing prison‐based interventions in NSW are critical components of strategies to reduce HCV incidence among PWID. Prison‐based interventions are likely to be pivotal for achieving HCV elimination targets among PWID by 2030. [ABSTRACT FROM AUTHOR]

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]

People who inject drugs may be at higher risk of COVID‐19 transmission and more severe negative health outcomes following COVID‐19 infection. Early research on hypothetical COVID‐19 vaccines suggests this population may be less likely to accept vaccination. This commentary extends this research by presenting vaccine intention data from Illicit Drug Reporting System interviews conducted in June–July 2021, in the early stages of vaccine rollout, with people in Australia who inject drugs (N = 888). Half the sample (48%, n = 419) reported that they were hesitant to receive the COVID‐19 vaccine, with key barriers relating to vaccine safety and side effect concerns. This level of hesitancy is substantially higher than that of the general population at a similar time. While we note that the subsequent Delta variant‐driven third wave of cases in Australia and efforts to increase population vaccination coverage may have altered intent in this group, this level of hesitancy warrants a targeted strategy to mitigate vaccine‐related concerns and maximise uptake. Ideally, this should comprise an inclusive health response that is peer‐led, with peer‐based organisations ideally positioned to direct immunisation service delivery and provide vaccine‐related messaging. [ABSTRACT FROM AUTHOR]

Introduction: Vaccine acceptability is a key determinant of vaccination uptake. Despite being at risk of adverse outcomes from coronavirus‐19 disease (COVID‐19), COVID‐19 vaccine acceptability among people who inject drugs is unknown. We surveyed people who inject drugs in Melbourne, Australia to assess potential uptake of COVID‐19 vaccines prior to distribution. Methods: Cross‐sectional study, comprising interviewer‐administered structured telephone interviews completed from 30 November to 22 December 2020 in Melbourne, Australia. Participants were people aged 18 years or older who injected drugs at least monthly in the past 6 months and had resided in Melbourne in the past 12 months recruited via needle‐syringe programs and word‐of‐mouth. Measurements: COVID‐19 hypothetical vaccine acceptability, participants' demographic, drug use and drug treatment characteristics. Results: Fifty‐eight percent (57/99) of the sample reported that they would definitely or probably be vaccinated for COVID‐19, with the remainder indicating that they would not (22%) or were undecided (20%). Among those who indicated that they would definitely or probably not be vaccinated or were undecided (n = 42), safety concerns were most often cited as a reason for not wanting to be vaccinated. Discussion and Conclusions: Although a majority of sampled people who inject drugs indicated that they would definitely or probably be vaccinated, efforts to reduce hesitancy and allay COVID‐19 vaccine safety concerns will be necessary to optimise vaccine uptake among this population. [ABSTRACT FROM AUTHOR]

Background and aims: Major declines in HIV and hepatitis C and B virus (HCV/HBV) incidence among people who inject drugs (PWID) have been attributed to early implementation of harm‐reduction programs (HRP) in the Netherlands, but alternative factors such as selective mortality and demographic and drug market shifts over time probably contributed to observed incidence declines. We quantified and tested the effect of HRP participation on risk of these infections among PWID in Amsterdam, the Netherlands. Design We emulated the design of a hypothetical, ideal randomized trial using observational data from the Amsterdam Cohort Studies (1985–2014). Setting: Amsterdam, the Netherlands. Participants: We included PWID who ever used opioids, had a recent history of injecting drug use (IDU) and tested negative for HIV, HCV or HBV. Of 983 participants, 640, 137 and 308 were included for the HIV, HCV and HBV analyses and 59, 45 and 49 seroconversions were observed, respectively. Interventions: Intervention arms were: complete HRP participation [≥ 60 mg/day methadone and 100% needle and syringe program (NSP) coverage, or any methadone dose if no recent injection drug use] versus no HRP and partial HRP participation combined (< 60 methadone mg/day and/or < 100% NSP coverage). Conclusions: Complete participation in harm reduction programs appears to have led to substantial decreases in HIV and hepatitis C and B virus acquisition risk among people who inject drugs in the Netherlands. Measurements Separately for each infection, we estimated the hazard ratios (HR) comparing HRP arms using marginal structural models. Findings Compared with no/partial HRP participation, complete HRP participation led to lower risk of HIV [HR = 0.54, 95% confidence interval (CI) = 0.27–1.08], HCV (HR = 0.16, 95% CI = 0.06–0.40) and HBV (HR = 0.28, 95% CI = 0.13–0.61) acquisition. [ABSTRACT FROM AUTHOR]

Background and Aim: The recent downward revision of the estimated number of people living with chronic hepatitis C in Australia means that the annual number of new hepatitis C infections should also be revised. We aimed to estimate the annual number of new hepatitis C infections among people who inject drugs (PWID) in Australia in 2015, prior to the introduction of direct‐acting antiviral (DAA) treatment for hepatitis C, as an updated baseline measure for assessing the impact of DAAs on hepatitis C incidence over the next 10 years. Methods: A systematic review identified articles estimating hepatitis C incidence rates among PWID between 2002 and 2015. Reported incidence rates were adjusted to account for unrepresentative needle and syringe program (NSP) coverage among study participants compared with PWID overall. The total number of PWID in Australia and the hepatitis C RNA prevalence among PWID were taken from published estimates. The annual number of new infections was estimated by multiplying the pooled NSP coverage‐adjusted incidence rate by the number of susceptible PWID in 2015. Results: Five studies were included, with unadjusted incidence rates ranging from 7.6 to 12.8 per 100 person‐years. The overall pooled incidence rate (after adjusting for NSP coverage) was 9.9 per 100 person‐years (95% confidence interval: 8.3–11.8). This led to an estimate of 4126 (range 2499–6405) new hepatitis C infections in 2015. Conclusions: Our updated estimate provides an important baseline for evaluating the impact of hepatitis C elimination efforts and can be used to validate outcomes of future modeling studies. [ABSTRACT FROM AUTHOR]

While the Australian government is responsible for selecting, purchasing and transporting vaccines and specifying priority populations, state and territory governments are responsible for providing the vaccine delivery workforce and identifying specific vaccination sites. COVID-19 vaccination among people who inject drugs: Leaving no one behind Timely rollout and widespread uptake of safe and effective vaccines will be necessary to reduce mortality, improve health outcomes, restore societal well-being and inspire economic recovery from the coronavirus disease (COVID-19) pandemic. The Australian Government has secured access to both the Pfizer and the University of Oxford/AstraZeneca vaccines and plans to commence a national COVID-19 vaccine rollout in early 2021. [Extracted from the article]

Aims: To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co‐injection) among a community‐recruited cohort of people who inject drugs. Design Cross‐sectional study. Setting: Melbourne, Australia. Participants: A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted. Measurements We constructed two statistical models: a logistic regression model analysing correlates of co‐injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin–diphenhydramine co‐injection only, co‐injection of other substances and no co‐injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non‐fatal overdose. Findings One‐third [n = 226, 31%; 95% confidence interval (CI): 28–34%] of participants reported co‐injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin–diphenhydramine (n = 121, 54%; 95% CI = 48–60%) and heroin–methamphetamine (n = 121, 54%; 95% CI = 48–60%). In logistic regression analyses, reporting co‐injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18–2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31–3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin–diphenhydramine co‐injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80–13.56, P < 0.001] and overdose (requiring an ambulance) in the past 12 months (aRRR = 2.81, 95% CI = 1.17–6.72, P = 0.021) compared with participants reporting no co‐injection or co‐injection of other substances. Conclusions: A substantial proportion of people who inject drugs report co‐injection of multiple substances, which is associated with a range of socio‐demographic, drug use and health service use risk factors. [ABSTRACT FROM AUTHOR]

Aims: To estimate incidence and predictors of opioid agonist therapy (OAT) discontinuation in a national cohort of people who inject drugs (PWID). Design and Setting: Annually repeated cross‐sectional serosurveillance among PWID attending ~50 needle–syringe programmes across Australia. Participants: Between 1995 and 2018, 2651 PWID who reported current OAT and had subsequent survey participation completed 6739 surveys. Respondents were followed over 11 984 person‐years of observation (PYO). Respondents were predominantly male (60%), and the median age was 34 years. Heroin was the most commonly reported drug last injected (46%), and methadone was the most commonly prescribed OAT (77%). Measurements The primary outcome was discontinuation of OAT (methadone, buprenorphine or buprenorphine–naloxone). Among respondents who reported current OAT, those who did not report current OAT in all subsequent records were defined as discontinued, and those with current OAT at all subsequent records were defined as retained. Predictors of discontinuation included self‐reported demographic (sex, location, Indigenous status) and drug use characteristics (drug last injected, frequency of injection). Findings Just fewer than one‐third of respondents (29%) reported an OAT discontinuation event. The crude discontinuation rate was 6.3 [95% confidence intervals (CI) = 5.9–6.8] per 100 PYO. Discontinuation was significantly higher among respondents who reported last injecting pharmaceutical opioids [adjusted hazard ratio (aHR) = 1.75, 95% CI = 1.41–2.17, P < 0.001], being prescribed buprenorphine (aHR = 1.44, 95% CI = 1.18–1.76, P = 0.001) or buprenorphine–naloxone (aHR = 1.68, 95% CI = 1.20–2.34, P = 0.002), daily or more frequent injection (aHR = 1.51, 95% CI = 1.23–1.85, P < 0.001), recent public injecting (aHR = 1.37, 95% CI = 1.17–1.60, P < 0.001), incarceration in the previous 12 months (aHR = 1.31, 95% CI = 1.05–1.64, P = 0.017), recent receptive syringe or injection equipment sharing (aHR = 1.28, 95% CI = 1.10–1.48, P = 0.001) and male sex (aHR = 1.27, 95% CI = 1.09–1.47, P = 0.002). Conclusion: People who inject drugs attending needle–syringe programmes in Australia appear to be significantly more likely to discontinue opioid agonist treatment if they were prescribed buprenorphine or buprenorphine–naloxone compared with methadone, are male or report injection risk behaviours and recent incarceration. [ABSTRACT FROM AUTHOR]

Summary: Communal buildings have been reported from a number of early Neolithic sites from the Levant and Anatolia, but none were known from the central Zagros. Here we report on the recent excavations at Asiab, Kermanshah province, Iran, and argue that the principal feature found during Robert Braidwood's excavation at the site in 1960 should be interpreted as an example of a communal building. We discuss the results of the previous and recent excavations, highlight the key features of this building, and the implications for our understanding of the early Neolithic in the 'eastern wing' of the Fertile Crescent. [ABSTRACT FROM AUTHOR]

Introduction: Key populations at elevated risk to contract or transmit HIV may also be at higher risk of COVID‐19 complications and adverse outcomes associated with public health prevention measures. However, the conditions faced by specific populations vary according to social, structural and environmental factors, including stigma and discrimination, criminalization, social and economic safety nets and the local epidemiology of HIV and COVID‐19, which determine risk of exposure and vulnerability to adverse health outcomes, as well as the ability to comply with measures such as physical distancing. This commentary identifies common vulnerabilities and cross‐cutting themes in terms of the impacts of COVID‐19 on key populations before addressing issues and concerns specific to particular populations. Discussion: Cross‐cutting themes include direct impacts such as disrupted access to essential medicines, commodities and services such as anti‐retroviral treatment, HIV pre‐exposure prophylaxis, opioid agonist treatment, viral load monitoring, HIV and sexually transmitted infections testing, condoms and syringes. Indirect impacts include significant collateral damage arising from prevention measures which restrict human rights, increase or impose criminal penalties, and expand police powers to target vulnerable and criminalized populations. Significant heterogeneity in the COVID‐19 pandemic, the underlying HIV epidemic and the ability of key populations to protect themselves means that people who inject drugs and sex workers face particular challenges, including indirect impacts as a result of police targeting, loss of income and sometimes both. Geographical variations mean that transgender people and men who have sex with men in regions like Africa and the middle east remain criminalized, as well as stigmatized and discriminated against, increasing their vulnerability to adverse outcomes in relation to COVID‐19. Conclusions: Disruptions to both licit and illicit supply chains, loss of income and livelihoods and changes in behaviour as a result of lockdowns and physical distancing have the potential to exacerbate the impacts of the COVID‐19 pandemic on key populations. While these impacts will vary significantly, human‐rights approaches to COVID‐19 emergency laws and public health prevention measures that are population‐specific and sensitive, will be key to reducing adverse health outcomes and ensuring that no one is left behind. [ABSTRACT FROM AUTHOR]

Background: Men who have sex with men in Australia are currently ineligible to donate blood (are "deferred") for 12 months since last oral or anal sexual contact with another man. In Australia and overseas, there has been limited research on attitudes and perceptions related to blood donation in this population.Study Design and Methods: Questions on blood donation histories and attitudes toward the deferral policy were included in the questionnaire of an online prospective cohort of gay and bisexual men (GBM) living in Australia.Results: In 2018, 1595 GBM responded to the survey. In this sample, 28.7% reported previously donating blood. Among the remaining men who had never donated blood, 64.5% expressed an interest in doing so. Nearly all men indicated they were not willing to abstain from sex with another man for 12 months in order to donate, and the vast majority believed the rule was unfair, too strict, and homophobic. Three-quarters (77.7%) said that if the policy changed, they would likely donate blood. Age and openness about one's sexuality were independently associated with one's willingness to donate blood in the absence of the deferral.Conclusion: There was a high level of willingness and desire to donate blood among GBM. However, rather than abstaining from sex in order to donate, many men comply with the deferral policy and do not donate. A less conservative deferral policy may increase donations from GBM. [ABSTRACT FROM AUTHOR]

Background and objectives: Until recently, people in Australia with a history of injection drug use (IDU) were deferred indefinitely from donating blood. Knowledge gaps regarding policy non‐compliance and the prevalence of blood donation practices amongst people who inject drugs (PWID) precluded changes to this policy. We sought to address these gaps and to estimate the additional risk to Australia's blood supply associated with changing the indefinite deferral policy to 1 or 5 years since last injecting episode. Materials and methods: Data on blood donation amongst PWID were collected from 1853 interviews across two Australian studies of PWID conducted during 2015/16. Mathematical modelling was used to estimate the additional risk of hepatitis C (HCV)‐infected window period collections as a result of changing the deferral policy. Results: A very few (2–4%) study participants reported ever donating blood after ≥1 IDU episode. Changing the deferral policy from indefinite to 1 or 5 years was estimated to result in an additional 0·00000070 (95%CI: 0·00000033–0·00000165) or 0·00000020 (95%CI: 0·00000008–0·00000041) HCV‐positive window period collections per year, respectively. Conclusion: Changing Australia's indefinite deferral period to 1 or 5 years since last injecting episode poses a negligible increase in the risk of HCV‐infected window period collections from blood donors with a history of IDU. Our results informed a successful submission to the Australian regulator to change the deferral period from indefinite to 5 years since last injecting episode, a policy which came into effect in September 2018. [ABSTRACT FROM AUTHOR]

Background and aims: Randomized controlled trials (RCTs) are important for evaluating interventions, and qualitative research is increasingly recognized as being crucial to the success of this enterprise. We aimed to describe and demonstrate a temporal parallel purpose framework to help researchers understand how to make optimum use of qualitative research before, during and after RCTs. This framework sets out specific rationales for conducting qualitative research at each stage of a trial, where the rationales presented relate to both the intervention and evaluation methodology. Method and results: We conducted a scoping review of published qualitative studies undertaken alongside RCTs focusing on illicit drug use. We then used the temporal parallel purpose framework to present key findings to demonstrate how qualitative studies can add value to addiction RCTs by enhancing understanding of the intervention being trialled and/or the RCT itself. In so doing, we highlight the missed opportunities for addiction science when qualitative research is overlooked. We also explain why barriers to combining qualitative research and RCTs are neither inevitable nor insurmountable. Conclusions: The temporal parallel purpose framework provides a tool for assessing when and why to combine qualitative research with addiction treatment and prevention RCTs. Our paper and framework can help researchers formulate key questions that qualitative research can address. This can potentially save resources by reducing the number of poorly designed interventions and trials and prevent morbidity, mortality, and other addiction‐related harms by facilitating the identification and implementation of interventions that are most likely to be effective. [ABSTRACT FROM AUTHOR]

People who are homeless have increased hepatitis C virus (HCV) infection risk, and are less likely to access primary healthcare. We aimed to evaluate HCV RNA prevalence, liver disease burden, linkage to care and treatment uptake and outcomes among people attending a homelessness service in Sydney. Participants were enrolled in an observational cohort study with recruitment at a homelessness service over eight liver health campaign days. Finger‐stick whole‐blood samples for Xpert® HCV Viral Load and venepuncture blood samples were collected. Participants completed a self‐administered survey and received transient elastography and clinical assessment by a general practitioner or nurse. Clinical follow‐up was recommended 2‐12 weeks after enrolment. For participants initiating direct‐acting antiviral (DAA) therapy, medical records were audited retrospectively and treatment outcome data were collected. Among 202 participants (mean age, 48 years), 82% were male (n = 165), 39% (n = 78) reported ever injecting drugs, of whom 63% (n = 49) injected in the previous month. Overall, 23% (n = 47) had detectable HCV RNA and 6% (n=12) had cirrhosis. HCV RNA prevalence among participants with either injecting or incarceration history was 35% (37/105), compared to 4% (3/73) among participants without these risk factors. Among those with detectable HCV RNA, 23 (49%) commenced therapy, of whom 65% (n = 15) achieved sustained virological response, while the remainder had no available treatment outcome. No participant had documented virological failure. HCV DAA treatment uptake among people attending a homelessness service was encouraging, but innovative models of HCV care are required to improve linkage to care and treatment uptake among this highly marginalized population. [ABSTRACT FROM AUTHOR]

Summary: Interactions between the host immune system and the viral variants determine persistence of hepatitis C virus (HCV) infection after the acute phase of infection. This study describes the genetic variability of within‐host HCV viral variants in acute infection and correlates it with host‐ and virus‐related traits and infection outcome. Next generation sequence data (Illumina, MiSeq platform) of viral genomes from 116 incident acute infections (within 180 days of infection) were analysed to determine all the single nucleotide polymorphism (SNP) frequencies above a threshold of 0.1%. The variability of the SNPs for the full open reading frame of the genome as well as for each protein coding region were compared using mean standardized Shannon entropy (SE) values calculated separately for synonymous and nonsynonymous mutations. The envelope glycoproteins regions (E1 and E2) had the highest SE values (indicating greater variability) followed by the NS5B region. Nonsynonymous mutations rather than synonymous mutations were the main contributors to genomic variability in acute infection. The mean difference of Shannon entropy was also compared between subjects after categorizing the samples according to host and virus‐related traits. Host IFNL3 allele CC polymorphism at rs12979860 (vs others) and viral genotype 1a (vs 3a) were associated with higher genomic variability across the viral open reading frame. Time since infection, host gender or continent of origin was not associated with the viral genomic variability. Viral genomic variability did not predict spontaneous clearance. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the cost‐effectiveness of needle and syringe programmes (NSPs) compared with no NSPs on hepatitis C virus (HCV) transmission in the United Kingdom. Design Cost‐effectiveness analysis from a National Health Service (NHS)/health‐provider perspective, utilizing a dynamic transmission model of HCV infection and disease progression, calibrated using city‐specific surveillance and survey data, and primary data collection on NSP costs. The effectiveness of NSPs preventing HCV acquisition was based on empirical evidence. Setting and participants: UK settings with different chronic HCV prevalence among people who inject drugs (PWID): Dundee (26%), Walsall (18%) and Bristol (45%) Interventions: Current NSP provision is compared with a counterfactual scenario where NSPs are removed for 10 years and then returned to existing levels with effects collected for 40 years. Measurements HCV infections and cost per quality‐adjusted life year (QALY) gained through NSPs over 50 years. Findings Compared with a willingness‐to‐pay threshold of £20 000 per QALY gained, NSPs were highly cost‐effective over a time‐horizon of 50 years and decreased the number of HCV incident infections. The mean incremental cost‐effectiveness ratio was cost‐saving in Dundee and Bristol, and £596 per QALY gained in Walsall, with 78, 46 and 40% of simulations being cost‐saving in each city, respectively, with differences driven by coverage of NSP and HCV prevalence (lowest in Walsall). More than 90% of simulations were cost‐effective at the willingness‐to‐pay threshold. Results were robust to sensitivity analyses, including varying the time‐horizon, HCV treatment cost and numbers of HCV treatments per year. Conclusions: Needle and syringe programmes are a highly effective low‐cost intervention to reduce hepatitis C virus transmission, and in some settings they are cost‐saving. Needle and syringe programmes are likely to remain cost‐effective irrespective of changes in hepatitis C virus treatment cost and scale‐up. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Mortality studies of people who inject drugs (PWID) are mostly of older people and drug treatment cohorts. We estimate mortality rates, describe causes of death, and years of potential life lost in a community-recruited cohort of young PWID characterised by high incidence of hepatitis C virus (HCV) infection.Design and Methods: Participant identifiers of 215 PWID from the south-western Sydney sub-cohort of the HCV Cohort were linked to National Death Index records from 1999 to 2010 and crude mortality rates and standardised mortality ratios estimated. Australian life tables were used to calculate years of potential of life lost.Results: Fifteen participants died (7.0%) in 2095 person years (PY) of follow-up. Median age at death was 30.6 years (interquartile range 24.9-32.2). The crude mortality rate was 0.72 per 100PY (95% confidence interval 0.29-0.79) with a standardised mortality ratio of 11.09 (95% confidence interval 6.68-18.39). One-third of deaths were due to accidental drug overdose (5/15) and one-fifth were suicides (3/15). All deaths from defined causes (13/15) were potentially avoidable. Decedents lost on average 49.8 years of potential life.Discussion and Conclusions: Mortality and potential life lost further highlight the impact of accidental overdose deaths and suicide among young PWID. Integration of overdose and suicide prevention into youth-orientated outreach, including innovation in online and mobile technology should be evaluated. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Increasing treatment uptake among people who inject drugs (PWID) with chronic hepatitis C virus (HCV) infection is integral to eliminating viral hepatitis. This study explored the role of community-based outreach in engaging and retaining Australian PWID in the testing component of the HCV care cascade.Design and Methods: Semi-structured interviews were conducted with 28 PWID, including new initiates to injecting and those from culturally and linguistically diverse (CALD) backgrounds, who acquired HCV infection while enrolled in a community-based prospective observational study of hepatitis C vaccine preparedness in Sydney. Participants were interviewed at diagnosis and 12 months later. Transcripts were thematically analysed using constant comparative techniques.Results: Community-based outreach was effective in engaging newly infected participants in HCV monitoring and decision-making about seeking interferon-based treatment. Key factors in the acceptability of outreach were privacy and discretion, and opportunities to build trust with non-judgmental staff. Retaining participants in the HCV cascade of care required more than a one-off session of post-test counselling. Ongoing discussions with staff enabled paced and tailored delivery of information about HCV prevention, testing and treatment. Increased understanding of the role of HCV ribonucleic acid viremia in determining the need for treatment, and access to this testing, was pivotal in making HCV monitoring salient for participants.Discussion and Conclusions: Outreach is an effective strategy for engaging new initiates to injecting and CALD PWID in HCV testing and decision-making about treatment. Findings highlight the need to increase availability and access to HCV ribonucleic acid testing for PWID. [ABSTRACT FROM AUTHOR]

March marks the second anniversary of the passing of globally esteemed drug reform advocate Jude Byrne. Identifying unapologetically as a person who injects drugs for over 40 years, Jude's living experience drove her human rights perspectives on drug use, law and health. Whether it was a high-level committee on national HIV prevention or a small, locally led health initiative to encourage hepatitis C testing, Jude provided advocacy and leadership. [Extracted from the article]

Background and Aims: North America's overdose epidemic is increasingly driven by fentanyl and fentanyl‐adulterated drugs. Supervised consumption sites, including low‐threshold models (termed overdose prevention sites; OPS), are now being debated in the United States and implemented in Canada. Despite evidence that gendered and racialized violence shape access to harm reduction among women who use drugs (WWUD), this has not been examined in relation to OPS and amid the overdose epidemic. This study explores how overlapping epidemics of overdose and gendered and racialized violence in Vancouver's Downtown Eastside, one of North America's overdose epicenters, impacts how marginalized WWUD experience OPS. Design Qualitative analysis using rapid ethnographic fieldwork. Data collection included 185 hours of naturalistic observation and in‐depth interviews; data were analyzed thematically using NVivo. Setting: Vancouver, Canada. Participants: Thirty‐five WWUD recruited from three OPS. Measurements Participants' experiences of OPS and the public health emergency. Findings The rapid onset and severity of intoxication associated with the use of fentanyl‐adulterated drugs in less regulated drug use settings not only amplified WWUD's vulnerability to overdose death but also violence. Participants characterized OPS as safer spaces to consume drugs in contrast to less regulated settings, and accommodation of assisted injections and injecting partnerships was critical to increasing OPS access among WWUD. Peer‐administered injections disrupted gendered power relations to allow women increased control over their drug use; however, participants indicated that OPS were also gendered and racialized spaces that jeopardized some women's access. Conclusion: Although women who use drugs in Vancouver, Canada appear to feel that overdose prevention sites address forms of everyday violence made worse by the overdose epidemic, these sites remain 'masculine spaces' that can jeopardize women's access. [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]

Abstract: Aims: To estimate the impact of existing high‐coverage needle and syringe provision (HCNSP, defined as obtaining more than one sterile needle and syringe per injection reported) and opioid substitution therapy (OST) on hepatitis C virus (HCV) transmission among people who inject drugs (PWID) in three UK settings and to determine required scale‐up of interventions, including HCV treatment, needed to reach the World Health Organization (WHO) target of reducing HCV incidence by 90% by 2030. Design: HCV transmission modelling using UK empirical estimates for effect of OST and/or HCNSP on individual risk of HCV acquisition. Setting and participants: Three UK cities with varying chronic HCV prevalence (Bristol 45%, Dundee 26%, Walsall 19%), OST (72–81%) and HCNSP coverage (28–56%). Measurements: Relative change in new HCV infections throughout 2016–30 if current interventions were stopped. Scale‐up of HCNSP, OST and HCV treatment required to achieve the WHO elimination target. Findings: Removing HCNSP or OST would increase the number of new HCV infections throughout 2016 to 2030 by 23–64 and 92–483%, respectively. Conversely, scaling‐up these interventions to 80% coverage could achieve a 29 or 49% reduction in Bristol and Walsall, respectively, whereas Dundee may achieve a 90% decrease in incidence with current levels of intervention because of existing high levels of HCV treatment (47–58 treatments per 1000 PWID). If OST and HCNSP are scaled‐up, Walsall and Bristol can achieve the same impact by treating 14 or 40 per 1000 PWID annually, respectively (currently two and nine treatments per 1000 PWID), while 18 and 43 treatments per 1000 PWID would be required if OST and HCNSP are not scaled‐up. Conclusions: Current opioid substitution therapy and high‐coverage needle and syringe provision coverage is averting substantial hepatitis C transmission in the United Kingdom. Maintaining this coverage while getting current drug injectors onto treatment can reduce incidence by 90% by 2030. [ABSTRACT FROM AUTHOR]

Introduction and Aims: There is a current epidemic of pharmaceutical opioid (PO) misuse, particularly fentanyl and fentanyl analogues, globally. Fentanyl is a highly potent synthetic opioid with rapid onset and significantly higher risk of overdose compared with other opioids. Contexts and correlates of fentanyl use among people who inject drugs (PWID) in Australia are under-researched.Design and Methods: The Australian Needle Syringe Program Survey is conducted annually. Consenting PWID complete a self-administered questionnaire and provide a capillary dried blood spot for human immunodeficiency virus and hepatitis C virus antibody testing. Bivariate and multivariate logistic regressions determined correlates of recent (last 6 months) fentanyl injection in 2014.Results: Recent fentanyl injection was reported by 8% (n = 193) of the total sample. Among the 848 PWID who recently injected POs, 23% injected fentanyl. Compared with PO injectors who had not injected fentanyl, those who had injected fentanyl were significantly more likely to identify as Indigenous Australian [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04, 2.51; P = 0.034], inject daily or more frequently (AOR 1.92; 95% CI 1.30, 2.83; P = 0.005), inject in public (AOR 1.43; 95% CI 1.01, 2.02; P = 0.042) and to have overdosed in the past year (AOR 2.16; 95% CI 1.48, 3.13; P < 0.001), but were significantly less likely to receptively share syringes (AOR 0.56; 95% CI 0.36, 0.87; P = 0.010).Discussion and Conclusions: Fentanyl injectors in Australia are significantly more likely to identify as Indigenous, report frequent injection, inject in public and experience overdose. Increased access to harm reduction interventions, including naloxone distribution, wheel filters and supervised injection facilities, are likely to benefit this population. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To estimate the effects of needle and syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of hepatitis C virus (HCV) in people who inject drugs (PWID). Methods: Systematic review and meta‐analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within the last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥ 100% coverage (receiving sufficient or greater number of needles and syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non‐randomized studies tool. Random‐effects models were used in meta‐analysis. Results: We identified 28 studies (n = 6279) in North America (13), United Kingdom (five), Europe (four), Australia (five) and China (one). Studies were at moderate (two), serious (17) critical (seven) and non‐assessable risk of bias (two). Current OST is associated with 50% [risk ratio (RR) =0.50, 95% confidence interval (CI) = 0.40–0.63] reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I2 = 0, P = 0.889). Weaker evidence was found for high NSP coverage (RR = 0.79, 95% CI = 0.39–1.61) with high heterogeneity (I2 = 77%, P = 0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR = 0.44, 95% CI = 0.24–0.80) with low heterogeneity (I2 = 12.3%, P = 0.337), but not in North America (RR = 1.58, I2 = 89.5%, P = < 0.001). Combined OST/NSP is associated with a 74% reduction in HCV acquisition risk (RR = 0.26, 95% CI = 0.07–0.89, I2 = 80% P = 0.007). According to Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria, the evidence on OST and combined OST/NSP is low quality, while NSP is very low. Conclusions: Opioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle and syringe programmes (NSP). There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe. [ABSTRACT FROM AUTHOR]

Background and aims This narrative review aims to highlight key insights from qualitative research on drug use and drug users by profiling a selection of classic works. Methods Consensus methods were used to identify and select four papers published in 1938, 1969, 1973 and 1984 considered to be classics. Results These landmark qualitative studies included the first account of addiction as a social process, demonstrating that people have meaningful responses to drug use that cannot be reduced to their pharmacological effects; the portrayal of inner-city heroin users as exacting, energetic and engaged social agents; identification of the interactive social learning processes involved in becoming a drug user; the application of the 'career' concept to understanding transitions and trajectories of drug use over time; and the articulation of a framework for understanding drug use that incorporates the interaction between pharmacology, psychology and social environments. Conclusions These classic sociological and anthropological studies deployed qualitative research methods to show how drug use is shaped by complex sets of factors situated within social contexts, viewing drug users as agents engaged actively in social processes and worlds. Their findings have been used to challenge stereotypes about drug use and drug users, develop a deeper understanding of drug use among hidden, hard-to-research and under-studied populations, and provide the foundations for significant developments in scientific knowledge about the nature of drug use. They continue to retain their relevance, providing important correctives to biomedical and behaviourist paradigms, reminding us that drug use is a social process, and demonstrating how the inductive approach of qualitative research can strengthen the way we understand and respond to drug use and related harms. [ABSTRACT FROM AUTHOR]

Hepatitis C virus ( HCV) transmission is high in prisons. This study investigated trends in HCV incidence and associated factors among a cohort of prisoners with a history of injecting drug use in New South Wales, Australia. Data were available from the Hepatitis C Incidence and Transmission Study-prisons ( HITS-p) from 2005 to 2014. Temporal trends in HCV incidence were evaluated. Factors associated with time to HCV seroconversion among people with ongoing injecting was assessed using Cox proportional hazards. Among 320 antibody-negative participants with a history of injecting drug use (mean age 26; 72% male), 62% (n=197) reported injecting drug use during follow-up. Overall, 93 infections were observed. HCV incidence was 11.4/100 person-years in the overall population and 6.3/100 person-years among the continually imprisoned population. A stable trend in HCV incidence was observed. Among the overall population with ongoing injecting during follow-up, ≥weekly injecting drug use frequency was independently associated with time to HCV seroconversion. Among continuously imprisoned injectors with ongoing injecting during follow-up, needle/syringe sharing was independently associated with time to HCV seroconversion. This study demonstrates that prison is a high-risk environment for acquisition of HCV infection. Needle and syringe sharing was associated with HCV infection among continually imprisoned participants, irrespective of frequency of injecting or the type of drug injected. These findings highlight the need for the evaluation of improved HCV prevention strategies in prison, including needle/syringe programmes and HCV treatment. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Patient attrition is common among people enrolled in methadone maintenance treatment (MMT) programs and most pronounced during the first year of treatment. However, the experiences of patients initiating MMT have been overlooked in the literature. This study explores experiences of MMT initiation among MMT patients, focusing on contextual influences on MMT initiation and perceptions of MMT and their subsequent influence on treatment retention.Design and Methods: Semi-structured qualitative interviews were conducted with 39 MMT patients in Vancouver, Canada. Individuals reporting enrolment in MMT were recruited from within two ongoing cohort studies comprised of people who use drugs. Interview transcripts were analysed using an inductive and iterative approach.Results: Two groups of MMT initiators were identified: (i) 'crisis initiators' prescribed methadone following critical transition events, such as incarceration or pregnancy; and (ii) 'everyday initiators' enrolled in MMT as part of routine healthcare utilisation. While most 'crisis initiators' and some 'everyday initiators' described experiencing coercion during MMT initiation, 'crisis initiators' were further subjected to the coercive leveraging of their vulnerability to motivate 'consent' for MMT. 'Crisis initiators' developed negative views towards MMT and were more likely to discontinue treatment. Long-standing patient-provider relationships and open dialogue were associated with more positive views regarding MMT, regardless of the circumstances of initiation.Discussion and Conclusion: Findings underscore the need for clear and effective communication regarding treatment regimens and expectations during MMT initiation. Furthermore, training in trauma-informed care may help reduce perceptions of coercion and rates of early treatment termination. [Damon W, Small W, Anderson S, Maher L, Wood E, Kerr T, McNeil R. Crisis' and 'everyday' initiators: A qualitative study of coercion and agency in the context of methadone maintenance treatment initiation. Drug Alcohol Rev 2017;36:253-260]. [ABSTRACT FROM AUTHOR]

Injecting drug use remains the major risk factor for hepatitis C ( HCV) transmission. A minority of long-term injecting drug users remain seronegative and aviraemic, despite prolonged exposure to HCV - termed highly exposed seronegative subjects. Natural killer (NK) cells have been implicated in this apparent protection. A longitudinal nested, three group case-control series of subjects was selected from a prospective cohort of seronegative injecting drug users who became incident cases ( n = 11), remained seronegative ( n = 11) or reported transient high-risk behaviour and remained uninfected ( n = 11). The groups were matched by age, sex and initial risk behaviour characteristics. Stored peripheral blood mononuclear cells were assayed in multicolour flow cytometry to enumerate natural killer cell subpopulations and to assess functional activity using Toll-like receptor ligands before measurement of activation, cytokine production and natural cytotoxicity receptor expression. Principal components were derived to describe the detailed phenotypic characteristics of the major NK subpopulations (based on CD56 and CD16 co-expression), before logistic regression analysis to identify associations with exposed, seronegative individuals. The CD56dim CD16+ ( P = 0.05, OR 6.92) and CD56dim CD16− ( P = 0.05, OR 6.07) principal components differed between exposed, seronegative individuals and pre-infection samples of the other two groups. These included CD56dim CD16+ and CD56dim CD16− subsets with CD56dim CD16+ IFN- γ and TNF- α on unstimulated cells, and CD56dim CD16− CD69+, CD107a+, IFN- γ and TNF- α following TLR stimulation. The cytotoxic CD56dim NK subset thus distinguished highly exposed, seronegative subjects, suggesting NK cytotoxicity may contribute to protection from HCV acquisition. Further investigation of the determinants of this association and prospective assessment of protection against HCV infection are warranted. [ABSTRACT FROM AUTHOR]

Introduction: HIV infections and the use of amphetamine-type stimulants (ATS) among men who have sex with men (MSM) have been increasing internationally, but the role of ATS use as a co-factor for HIV infection remains unclear. We aimed to summarize the association between ATS use and HIV infection among MSM. Methods: We conducted a systematic search of MEDLINE, EMBASE, GLOBAL HEALTH and PsycINFO for relevant English, peerreviewed articles of quantitative studies published between 1980 and 25 April 2013. Pooled estimates of the association - prevalence rate ratios (PRR, cross-sectional studies), odds ratio (OR, case-control studies) and hazard ratio (HR, longitudinal studies), with 95% Confidence Intervals (CI) - were calculated using random-effects models stratified by study design and ATS group (meth/amphetamines vs. ecstasy).We assessed the existence of publication bias in funnel plots and checked for sources of heterogeneity using meta-regression and subgroup analysis. Results: We identified 6710 article titles, screened 1716 abstracts and reviewed 267 full text articles. A total of 35 publications were eligible for data abstraction and meta-analysis, resulting in 56 records of ATS use. Most studies (31/35) were conducted in high-income countries. Published studies used different research designs, samples and measures of ATS use. The pooled association between meth/amphetamine use and HIV infection was statistically significant in all three designs (PRR = 1.86; 95% CI: 1.57-2.17; OR = 2.73; 95% CI: 2.16-3.46 and HR = 3.43; 95% CI: 2.98-3.95, respectively, for cross-sectional, case-control and longitudinal studies). Ecstasy use was not associated with HIV infection in cross-sectional studies (PRR = 1.15; 95% CI: 0.88-1.49; OR = 3.04; 95% CI: 1.29-7.18 and HR = 2.48; 95% CI: 1.42-4.35, respectively, for cross-sectional, case-control and longitudinal studies). Results in cross-sectional studies were highly heterogeneous due to issues with ATS measurement and different sampling frames. Conclusions: While meth/amphetamine use was significantly associated with HIV infection among MSM in high-income countries in all study designs, evidence of the role of ecstasy in HIV infection was lacking in cross-sectional studies. Crosssectional study design, measurement approaches and source populations may also be important modifiers of the strength and the direction of associations. Event-specific measure of individual drug is required to establish temporal relationship between ATS use and HIV infection. HIV prevention programmes targeting MSM should consider including interventions designed to address meth/amphetamine use. [ABSTRACT FROM AUTHOR]

Aims To document the relationships between injecting drug use, imprisonment and hepatitis C virus ( HCV) infection. Design Prospective cohort study. Setting Multiple prisons in New South Wales, Australia. Participants HCV seronegative prisoners with a life-time history of injecting drug use ( IDU) were enrolled and followed prospectively ( n = 210) by interview and HCV antibody and RNA testing 6-12-monthly for up to 4 years when in prison. Measurements HCV incidence was calculated using the person-years method. Cox regression was used to identify predictors of incident infection using time-dependent covariates. Results Almost half the cohort reported IDU during follow-up (103 subjects; 49.1%) and 65 (31%) also reported sharing of the injecting apparatus. There were 38 HCV incident cases in 269.94 person-years (py) of follow-up with an estimated incidence of 14.08 per 100 py [confidence interval ( CI) = 9.96-19.32]. Incident infection was associated independently with Indigenous background, injecting daily or more and injecting heroin. Three subjects were RNA-positive and antibody-negative at the incident time-point, indicating early infection, which provided a second incidence estimate of 9.4%. Analysis of continuously incarcerated subjects ( n = 114) followed over 126.73 py, identified 13 new HCV infections (10.26 per 100 py, CI = 5.46-17.54), one of which was an early infection case. Bleach-cleansing of injecting equipment and opioid substitution treatment were not associated with a significant reduction in incidence. Conclusions In New South Wales, Australia, imprisonment is associated with high rates of hepatitis C virus transmission. More effective harm reduction interventions are needed to control HCV in prison settings. [ABSTRACT FROM AUTHOR]

The article focuses on the Hepatitis C Incidence and Transmission Study-community (HITS-c), a community-based prospective observational study designed to inform future trials of candidate hepatitis C virus (HCV) vaccines, which found that opioid substitution therapy protects against HCV acquisition in people who inject drugs (PWID). It notes that HCV is highly prevalent globally among PWID. Figures are revealed on the percentage of people affected by HCV globally.

Commentary is provided regarding the article "Prevalence and correlates of receptive syringe‐sharing among people who inject drugs in rural Appalachia" by R. White Hamilton, A. O'Rourke, and others which appears in the same issue of the journal. Harm reduction initiatives and outbreaks of HIV in rural American communities are examined, along with stable housing assistance, hepatitis C risks, and drug injecting patterns and practices.

Although the levels of injecting drug use among lesbian, gay, bisexual and transgender ( LGBT) populations are high, we know little about their experiences of injecting drugs or living with hepatitis C virus ( HCV) infection. The loss of traditional family and cultural ties means connection to community is important to the well-being of LGBT populations. Although some kinds of drug use are normalised within many LGBT communities, injecting drug use continues to be stigmatised. This exploratory qualitative study of people with newly acquired HCV used semi-structured interviews to explore participants' understandings and awareness of HCV, seroconversion, testing, diagnosis and treatment. We present a secondary thematic analysis of eight LGBT participants of the experience of injecting drugs, living with HCV and having a marginalised sexual or gender identity. Community was central to the participants' accounts. Drug use facilitated connection to a chosen community by suppressing sexual or gender desires allows them to fit in to the mainstream; enacting LGBT community norms of behaviour; and connection through shared drug use. Participants also described feeling afraid to come out about their drug use to LGBT peers because of the associated stigma of HCV. They described a similar stigma associated with HIV within the people who inject drugs ( PWID) community. Thus, the combination of being LGBT/living with HIV (a gay disease) and injecting drugs/living with HCV (a junkie' s disease) left them in a kind of no-man's-land. Health professionals working in drug and HCV care services need to develop capacity in providing culturally appropriate health-care for LGBT PWID. [ABSTRACT FROM AUTHOR]

ABSTRACT A series of radiocarbon dates from two Epipalaeolithic sites - Kharaneh IV and Ayn Qasiyya - in the Azraq Basin of eastern Jordan provide a new perspective on the chronology and settlement patterns of this part of southwest Asia during the Late Pleistocene. We discuss the implications to our understanding of the chronology of Late Pleistocene lithic industries, particularly in regard to current hypotheses for the abandonment of eastern Jordan's 'mega-sites', Kharaneh IV and Jilat 6. Modelling a series of accelerator mass spectrometry dates from Kharaneh IV indicates a much shorter span of occupation for the site than previously assumed by the size and density of its deposits. Given the high density of material accumulated over a relatively short time span, we show that Kharaneh IV was an aggregation site occupied intensively by a significant number of people, providing new perspectives on the east Jordanian phenomenon of Epipalaeolithic 'mega-sites'. [ABSTRACT FROM AUTHOR]

Aims To assess heroin injectors' perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses. Design Semi-structured qualitative interviews. Setting Vancouver, Canada. Participants Eighteen active heroin injectors. Measurements Semi-structured interview guide focussing on heroin injectors' perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations. Findings Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages. Conclusions Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk. [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]

ABSTRACT National surveillance data indicate marked differences between Indigenous and other Australians in the prevalence of many sexually transmitted infections (STIs). Young Indigenous people bear a particularly high burden of these infections. A collaboration of university researchers, Indigenous health workers and young Indigenous people conducted 45 field interviews to examine how young Indigenous Australians keep themselves healthy and protected against STIs. Our findings emphasise the complexity of health behaviours, where individuals are rarely always 'risky' or always 'safe', as well as subtle gender differences in health practices. Preventive strategies employed by the young people were contingent on beliefs and knowledge about sexual partners, the type of relationship, the context of the sexual encounter and access to condoms. Tangible strengths such as young Indigenous people's commitments to condoms and STI screening should be celebrated and bolstered to enhance their ability to protect themselves against adverse health outcomes and enhance their resilience against STIs. Focusing on strengths helps to counter the deficit model of health commonly deployed in Indigenous health research and draws attention to health issues facing young Indigenous people and their communities, without reinforcing negative stereotypes or focusing solely on individual risk behaviour. We provide concrete recommendations for health promotion and education. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Few cultural developments have taken on as much archeological significance as when people began living in villages and producing their own food. The economic, social, technological, and ideological transformations immediately preceding and following these changes were profound. Early models of culture change associated with pre-agricultural societies of the Levant focused on the sudden, late origin of settled farming villages triggered by climate change. Accompanying this new economic and living situation was durable stone-built architecture; intensified plant and animal use; a flourishing of art and decoration; new mortuary traditions, including marked graves and cemeteries; elaborate ritual and symbolic behavior-a new way of life. This new life style arguably had a slow start, but really took off during the Epipaleolithic period (EP), spanning more than 10,000 years of Levantine prehistory from c. 23,000-11,500 cal BP. The last EP phase, immediately preceding the Neolithic, is by far the best-studied in terms of its cultural and economic contributions to questions on the origins of agriculture.1-4 Recently, archeologists have considered the earlier parts of the EP to be more culturally dynamic and similar to the later phase (Natufian) than was previously thought.3-10 The earlier EP is increasingly seen as demonstrating the behavioral variability and innovations that help us to understand the economic, technological, and social changes associated with complex hunter-gatherers of the Natufian and farmers of the Neolithic. This paper traces the cultural and biological developments of the EP period leading up to the Natufian and considers the long-term trajectory of culture change, social complexity, and village life in the Near East. © 2012 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]