Preventing transitions into injection drug use: A call for gender-responsive upstream prevention

"If you're strung out and female, they will take advantage of you": A qualitative study exploring drug use and substance use service experiences among women in Boston and San Francisco

BACKGROUND

Significant disparities in substance use severity and treatment persist among women who use drugs compared to men. Thus, we explored how identifying as a woman was related to drug use and treatment experiences.

METHODS

The study recruited participants for a qualitative interview study in Boston and San Francisco from January-November 2020. Self-identified women, age ≥ 18 years, with nonprescribed opioid use in the past 14 days were eligible for inclusion. The study team developed deductive codes based on intersectionality theory and inductive codes generated from transcript review, and identified themes using grounded content analysis.

RESULTS

The study enrolled thirty-six participants. The median age was 46; 58 % were White, 16 % were Black, 14 % were Hispanic, and 39 % were unstably housed. Other drug use was common with 81 % reporting benzodiazepine, 50 % cocaine, and 31 % meth/amphetamine use respectively. We found that gender (i.e., identifying as a woman) intersected with drug use and sex work practices and exacerbated experiences of marginalization. Violence was ubiquitous in drug use environments. Some women reported experiences of gender-based violence in substance use service settings that perpetuated cycles of trauma and reinforced barriers to care. Substance use services that were women-led, safe, and responsive to women's needs were valued and sought after.

CONCLUSION

Women reported a cycle of trauma and drug use exacerbated by oppression in substance use services settings. In addition to increasing access to gender-responsive care, our study highlights the need for greater research and examination of practices within substance use service settings that may be contributing to gender-based violence.

Gender, sexual orientation identity, and initiation of amphetamine injecting among people who inject drugs: Examination of an expanding drug era in Montreal, Canada, 2011-19

BACKGROUND

Amphetamine injection is expanding in North America and has been associated with male homosexuality among people who inject drugs (PWID). Applying subcultural evolution theory, we examined overall and gender-stratified trends in amphetamine injection and assessed sexual orientation as a gender-specific predictor of initiation among PWID in Montreal, Canada.

METHODS

Data were from HEPCO, an open prospective cohort of PWID. Gender and sexual orientation were self-identified at enrolment. Interviewer-administered questionnaires at three-monthly (HCV RNA-negative participants) or yearly (RNA-positive) intervals captured past three-month amphetamine injection and covariates. Annual prevalence and linear trends in amphetamine injection were estimated using GEE. Incidence was computed among naïve individuals and hazard ratios for initiation estimated using gender-stratified, time-varying Cox regression models.

RESULTS

803 participants contributed 8096 observations between March 2011 and December 2019. Annual prevalence of amphetamine injecting increased from 3.25% [95%CI: 2.06-4.43%] to 12.7% [9.50-16.0] (trend p<0.001). Bivariate Cox regression models suggested similar and divergent predictors of initiation by gender. Incidence was 3.27 per 100 person-years [95%CI: 2.51-4.18] among heterosexual men, 7.18 [3.50-13.2] among gay/bisexual men, 1.93 [0.78-4.02] among heterosexual women and 5.30 [1.69-12.8] among gay/bisexual women. Among men, gay/bisexual identity doubled risk of initiation after adjusting for age, ethnicity, calendar year (aHR 2.16 [1.07-4.36]) and additional covariates (2.56 [1.24-5.30]). Among women, evidence for an association with gay/bisexual identity was inconclusive (aHR 2.63 [0.62-11.2]) and sample size precluded further adjustment CONCLUSIONS: Prevalence of amphetamine injection among PWID increased four-fold from 2011 to 2019, with elevated risk of initiation in gay and bisexual men.

Context and correlates of providing assistance with someone's first injection in the AIDS linked to the IntraVenous Experience cohort, Baltimore, MD

BACKGROUND

The social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual's first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID.

METHODS

Participants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019-2020 about assisting with another person's first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics.

RESULTS

At baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1-4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4-4.6]), syringe sharing (2.2 [1.2-3.9]), and injecting ≥3 times per day (2.0 [1.2-3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person's lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury.

CONCLUSION

PWID with a history of assisting with another person's first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.

Exploring the impact of the COVID-19 pandemic on healthcare and substance use service access among women who inject drugs: a qualitative study

BACKGROUND

The COVID-19 pandemic disrupted healthcare and substance use services engagement, including primary and mental health services as well as residential and outpatient drug treatment. Women who inject drugs (WWID) face known barriers to healthcare and substance use service engagement, which pre-date the COVID-19 pandemic. The impact of COVID-19 on WWID's engagement with healthcare and substance use services, however, remains understudied.

METHODS

To explore the impact of the COVID-19 pandemic on service-seeking and utilization, we conducted in-depth interviews with 27 cisgender WWID in Baltimore, Maryland, in April-September 2021. Iterative, team-based thematic analysis of interview transcripts identified disruptions and adaptations to healthcare and substance use services during the COVID-19 pandemic.

RESULTS

The COVID-19 pandemic disrupted service engagement for WWID through service closures, pandemic safety measures restricting in-person service provision, and concerns related to contracting COVID-19 at service sites. However, participants also described various service adaptations, including telehealth, multi-month prescriptions, and expanded service delivery modalities (e.g., mobile and home delivery of harm reduction services), which overwhelmingly increased service engagement.

CONCLUSION

To build upon service adaptations occurring during the pandemic and maximize expanded access for WWID, it is vital for healthcare and substance use service providers to continue prioritizing expansion of service delivery modality options, like telehealth and the provision of existing harm reduction services through alternative platforms (e.g., mobile services), that facilitate care continuity and increase coverage.

Gender and the first-time provision of injection initiation assistance among people who inject drugs across two distinct North American contexts: Tijuana, Mexico and Vancouver, Canada

INTRODUCTION

Injection drug use initiation is commonly facilitated by other people who inject drugs (PWID). We investigated how the gender of PWID influences their risk of providing initiation assistance to others across two distinct geo-cultural settings.

METHODS

Data were drawn from two prospective cohorts in Tijuana, Mexico and Vancouver, Canada which conducted semi-annual interviews within the PReventing Injecting by Modifying Existing Responses (PRIMER) study. Participants consisted of PWID who had reported never providing injection initiation assistance at baseline. We then conducted site-specific discrete-time survival analyses assessing the relationship between gender and other relevant covariates (e.g. age and past 6-month sex work) on the risk of the first reported instance of providing initiation assistance.

RESULTS

Of 1988 PWID (Tijuana: n = 596; Vancouver: n = 1392), 256 (43%) and 511 (36.7%) participants were women, and 42 (1.7%) and 78 (1.6%) reported recent injection initiation assistance across a median of three and two follow-up visits, respectively. Women had a lower risk of providing injection initiation assistance for the first time in Tijuana (adjusted hazard ratio = 0.52, 95% confidence interval 0.27-0.99), but not in Vancouver. Gendered pathways, like sex work, were associated with providing initiation assistance for the first time in Vancouver (adjusted hazard ratio = 1.97, 95% confidence interval 1.08-3.61).

DISCUSSION AND CONCLUSIONS

Women in Tijuana, but not Vancouver, were less likely to provide first-time initiation assistance among PWID. These results can inform gender- and site-specific prevention efforts aimed at reducing transitions into drug injecting across geographic contexts.

Gender Dynamics in Substance Use and Treatment: A Women's Focused Approach

Gender impacts substance use initiation, substance use disorder development, engagement with treatment, and harms related to drug and alcohol use. Using the biopsychosocial model of addiction, this review provides a broad summary of barriers and facilitators to addiction services among women. It also reviews substance use among pregnant and parenting women and approaches to care. Given the increasing rates of substance use among women, there is a need to implement and scale-up gender-responsive addiction programming and pursue advocacy at the policy level that addresses the root drivers of substance use inequities among women.

Vulnerabilidades associadas à violência contra a mulher antes do ingresso no sistema prisional

RESUMO Objetivo: analisar as vulnerabilidades individuais e sociais de mulheres privadas de liberdade para violência sofrida antes da entrada no sistema prisional. Método: estudo transversal analítico, realizado com 272 internas de uma unidade prisional feminina, na Região Metropolitana de Fortaleza, Ceará. Foram aplicados dois instrumentos: formulário para análise de informações sociodemográficas e da violência sofrida previamente à entrada no presídio e o Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), que analisou o histórico do uso de substâncias psicoativas. Resultados: 44,5% das mulheres sofreram violência. A maior parte da amostra total apresentava idade entre 18 e 29 anos, com filhos, baixa escolaridade e renda, início precoce da vida sexual e histórico de uso de drogas ilícitas. A idade entre 18 e 29 anos mostrou ser fator protetor da violência (OR = 0,632). Uso de cocaína e crack (p = 0,002), anfetaminas e êxtase (p = 0,018) aumenta a chance de violência de 2,2 a 3,3 vezes. Conclusão: aspectos das dimensões individuais e sociais da vulnerabilidade estão associadas à ocorrência de violência em mulheres internas do sistema prisional feminino. Estratégias efetivas necessitam ser traçadas com base nas vulnerabilidades, para prevenir violência contra a mulher.

Vulnerabilities associated with violence against women before entering the prison system

OBJECTIVE

to analyze the individual and social vulnerabilities of women deprived of their liberty for violence suffered before entering the prison system.

METHOD

an analytical crosssectional study, carried out with 272 inmates of a female prison unit, in the Metropolitan Region of Fortaleza, Ceará. We applied two instruments: a form to analyze sociodemographic information and the violence suffered prior to entering the prison and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), which analyzed the history of psychoactive substance use.

RESULTS

44.5% of women suffered violence. Most of the total sample was between 18 and 29 years old, with children, low education and income, early onset of sexual life and history of illicit drug use. Age between 18 and 29 years proved to be a protective factor against violence (OR = 0.632). Cocaine and crack use (p =0.002), amphetamines and ecstasy (p =0.018) increase the chance of violence by 2.2 to 3.3 times.

CONCLUSION

aspects of the individual and social dimensions of vulnerability are associated with the occurrence of violence in women in the female prison system. Effective strategies need to be designed based on vulnerabilities to prevent violence against women.

HCV communication within ego-centric networks of men and women who inject drugs

INTRODUCTION

Leveraging interpersonal communication among social networks of people who inject drugs (PWID) may be an innovative strategy to increase awareness and access to hepatitis C (HCV) care. However, little is known about HCV communication patterns among PWID and if these patterns vary by gender.

METHODS

Egocentric network data collected at baseline from HCV-infected PWID enrolled in a randomized HCV treatment intervention trial in Baltimore, Maryland were analyzed. Logistic generalized estimating models were conducted to identify predictors of HCV communication.

RESULTS

Among 227 PWID, the mean age was 43.8 (SD=10.3), 28.2% (n = 64) were women and 71.8% (n = 163) were men. Female participants reported 516 dyadic relationships and male participants 1139 dyadic relationships. While there were significant gender differences based on socio-demographics, risk behavior and network composition, there were few differences in HCV communication patterns. Both men and women had increased odds of HCV communication with alters who are currently enrolled in drug treatment (AOR 1.7, 95% CI: 1.3-2.4), alters with whom participants share drug preparation equipment (AOR 3.0, 95% CI: 1.9-4.6), alters who are sex partners compared to kin (AOR 3.0; 95% CI: 1.9-4.9) and alters with whom respondents have increased trust (AOR 1.1; 95% CI: 1.11.2) and daily/weekly interactions (AOR 1.7; 95% CI 1.3-2.1).

CONCLUSION

PWID engaged with trusted alters about HCV disclosure and information, highlighting the important role network interventions could play in this vulnerable population.

Shared injection experiences: Interpersonal involvement in injection drug practices among women

BACKGROUND

Many women who inject drugs are aware of the associated risks, however social influences play a part in their behavioral decisions. Incorporation of others in drug use behaviors may be common practice among women who use drugs. The aim of this study was to gain an in-depth understanding of women's injection drug use experiences with a focus on interpersonal involvement. Methods: Venue-based recruitment was conducted in collaboration with a harm reduction program. A group of 30 women, ages 18 and older, who reported injecting drugs within the past 30 days took part in a demographic survey and semi-structured interview to gain an understanding of their injection practices. In vivo coding and thematic analysis were conducted. Results: Three main themes that relate to incorporating others into injection drug behaviors surfaced, including: (1) injection practices described as we and not I, (2) partnered purchase and drug preparation, and (3) assisted injection. This group of women most often incorporated sexual and/or romantic partners (same and other-gender), friends, or family members into their injection drug use behaviors. Some women described a lack of ability to inject themselves and require assistance every time they use. Women also reported helping other women during drug use behaviors. Conclusions: Our primary themes indicate that a variety of relationship partners are important conceptual links in theoretical frameworks explaining drug use behaviors among women. Findings suggest same gender assistance during drug use behaviors, including injection, that may reduce harm. The interpersonal nature of injection drug use among women may indicate the expansion of treatment options designed for couples or other relationship partners, such as family, together.