The social production of hepatitis C risk among injecting drug users: a qualitative synthesis

Mapping the risk environment for peers with lived-living experience working in the alcohol and other drugs sector in Queensland

INTRODUCTION

Peer workers in the Alcohol and Other Drugs (AOD) sector play a vital role in harm reduction for people who use drugs (PWUDs); however, their experiences are often shaped by complex macro- and micro-risk environments. This study explores these environments and their implications for peer workers, particularly concerning stigma, legal barriers, and organisational culture.

METHODS

Semi-structured interviews were conducted with 18 peers with lived-living experience of illicit drug use. Purposive sampling was employed, leveraging established peer networks and community organisations. Interviews (range = 42-90 mins) were conducted via Microsoft Teams, transcribed, and analysed. The iterative coding process involved deductive codes based on predetermined topics and inductive codes derived from identified themes.

RESULTS

Participants identified key systemic challenges, including peer stigma, limited career prospects, and the complexities of navigating legal frameworks that criminalise drug use, thereby undermining the efficacy of peer work. The interplay between regulatory frameworks and societal attitudes creates barriers to employment, which disproportionately affects people with drug-related offenses. The significance of collective connection as a source of safety and support was also highlighted, particularly through peer supervision, which fosters enabling environments that promote wellbeing.

DISCUSSION

Findings highlight the need for advocacy towards legal reform and the creation of inclusive organisational cultures. Recognising and valuing the LLE of peer workers is essential for enhancing harm reduction initiatives and promoting the wellbeing of PWUDs. Addressing these macro- and micro-risk factors, including the importance of peer supervision, can improve peer workers' efficacy in providing meaningful support within their communities.

Material hardship, forced displacement, and negative health outcomes among unhoused people who use drugs in Los Angeles, California and Denver, Colorado: a latent class analysis

BACKGROUND

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

METHODS

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

RESULTS

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

CONCLUSIONS

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Future destinations: how people cured of hepatitis C using direct acting antiviral drugs progress in a new HCV-free world. A thematic analysis

BACKGROUND

The introduction of Direct-Acting Antivirals (DAAs) transformed Hepatitis C (HCV) treatment, despite this uptake of DAAs remains lower than required to meet the WHO Sustainable Development Goal (3.3). Treatment with interferon was suggested to be able to deliver important outcomes for people who use drugs in addition to a viral cure, such as social redemption, and shift from a stigmatised identity. There is a lack of understanding if DAAs can deliver these transformative outcomes.

METHODS

This recurrent cross-sectional study combines qualitative semi-structured interviews and demographic data of 15 participants receiving DAAs in Tayside, Scotland. A thematic analysis explored the non-clinical outcomes of DAA treatment viewed through the lens of the Social Identity Model of Recovery (SIMOR) to build understanding of the influence DAAs have in a recovery journey from drug use.

RESULTS

Three key themes emerged: identity, relationships and social networks; building recovery capital; and reflecting on re-infection and the shift to DAAs. Concern about the transmission of HCV resulted in self-imposed isolation which weakened support structures. Cure provides a mechanism to strengthen family bonds, however social networks in the wider community remain limited. Participants gained opportunities to undertake activities that build health and wellbeing providing a shift in identity, future plans and aspirations. Social isolation remained for some, revealing unmet need in post-cure support.

CONCLUSION

DAAs may support recovery journeys through the SIMOR, individuals reduced the number of active users within their social network and reconnected with family members, building recovery capital. Individuals, however, remained socially isolated in the context of the wider community. HCV services should support links to community resources to deliver the social inclusion people desire.

Material Hardship, Forced Displacement, and Negative Health Outcomes Among Unhoused People Who Use Drugs in Los Angeles, California and Denver, Colorado: A Latent Class Analysis

Background

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

Methods

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

Results

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

Conclusions

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Understanding Perceptions of Hepatitis C and Its Management Among People with Experience of Incarceration in Quebec, Canada: A Qualitative Study Guided by the Common Sense Self-Regulation Model

Hepatitis C virus (HCV) disproportionately affects certain sub-populations, including people with experience of incarceration (PWEI). Little is known about how perceptions of HCV and treatment have changed despite simplifications in testing and treatment in carceral settings. Nineteen semi-structured interviews were conducted with people living with or having a history of HCV infection released from Quebec provincial prison. Interviews were guided by the Common Sense Self-Regulation Model (CS-SRM) and aimed to explore cognitive and emotional representations of HCV and coping strategies. Among the 19 participants, seven (37%) were diagnosed with HCV in prison and 14 (74%) had previously received HCV treatment. Participants' HCV illness perceptions were influenced by fear (of HCV transmission, death, and the well-being of family) and stigma (related to HCV, injection drug use, and incarceration). While some sought education and social and professional support, others self-isolated or engaged in high-risk behaviors to cope. Despite advances in HCV treatment, PWEI continue to experience various forms of stigma and fear surrounding their HCV diagnosis, resulting in delayed HCV care. These findings provide insights into how prison-based healthcare providers can better utilize HCV illness perceptions to evaluate willingness to engage in HCV care among PWEI.

Syringe Access, Syringe Sharing, and Perceptions of HCV: A Qualitative Study Exploring the HCV Risk Environment in Rural Northern New England, United States

The ongoing hepatitis C virus (HCV) epidemic in the United States disproportionately affects rural people who inject drugs (PWID). This study explores the HCV risk environment in rural northern New England by examining PWID experiences and perceptions of HCV and injection equipment-sharing practices. We performed a thematic analysis on semi-structured interviews conducted with 21 adults with a history of injection drug use from rural New Hampshire, Vermont, and Massachusetts between April 2018 and August 2019. Salient themes included: (1) limited and varied access to sterile syringe sources; (2) syringe scarcity contributing to the use of informal syringe sources (e.g., secondary syringe exchange or syringe sellers who purchased syringes from out-of-state pharmacies); (3) syringe scarcity contributing to syringe sharing; (4) linkages among decisions about syringe sharing and perceptions of HCV risk, HCV status, and interpersonal trust; and (5) confusion and misconceptions about HCV, including difficulty learning one's HCV status, inadequate HCV education, and misconceptions regarding HCV transmission and treatment. Efforts to prevent and eliminate HCV among rural PWID should expand syringe access, increase awareness of HCV as a serious but preventable risk, and acknowledge social connections as potential influences on syringe access and syringe-sharing decisions.

Characterizing Opioid Withdrawal Experiences and Consequences Among a Community Sample of People Who Use Opioids

BACKGROUND

Opioid withdrawal symptoms are a highly salient and consequential health condition experienced by people who use opioids (PWUO). This study utilized qualitative interviews to explore opioid withdrawal experiences and consequences among PWUO in Los Angeles County, USA.

METHODS

Semi-structured qualitative interviews were conducted with 22 PWUO (aged 27-63 years) between May 2021 and May 2022. Participants self-reported opioid and injection drug use in the last 30 days. We employed an inductive thematic approach to systematically code and synthesize textual interview data.

RESULTS

Participants experienced withdrawal symptoms frequently, with many going to great lengths to avoid them. Withdrawal pain was described as incapacitating and interfered with PWUO's ability to sustain regular employment and ensure stable housing. Avoiding withdrawal was described as influential in driving decisions to continue using opioids. Mechanisms for managing withdrawal included using other substances to the point of sedation. PWUO who transitioned from heroin to fentanyl use revealed more frequent, painful, and faster onset of withdrawal symptoms. Adverse withdrawal experiences and fear of precipitated withdrawal from buprenorphine were barriers to treatment initiation and continuation.

CONCLUSION

Withdrawal symptoms among PWUO increase health risk. Improved strategies to treat opioid withdrawal are urgently needed. Solutions such as safe supply and intentional opioid withdrawal interventions (educational trainings, withdrawal comfort kits) are needed to improve withdrawal management and reduce opioid-related harm.

"Apparently, you can only be treated once": A qualitative study exploring perceptions of hepatitis C and access to treatment among people who inject drugs visiting a needle and syringe program

BACKGROUND

Access to hepatitis C care within harm reduction community organizations for people who inject drugs is crucial for achieving hepatitis C elimination. However, there is a lack of data on how perceptions of hepatitis C and treatment have changed among individuals visiting these organizations during the era of direct-acting antivirals (DAAs). This study aimed to explore the perceptions of hepatitis C and treatment access for (re)infection among individuals visiting a needle and syringe program in Canada.

METHODS

Eighteen semi-structured interviews were conducted with individuals who recently injected drugs and visited a needle and syringe program. The interviews were guided by the Common-Sense Self-Regulation Model (CS-SRM) and aimed to explore cognitive and emotional representations of hepatitis C, perceptions of treatment, coping strategies and sources of information. Interviews were audio recorded, transcribed, and coded using thematic analysis.

RESULTS

Most of the participants identified as male, were of white ethnicity and had a median age of 45. While most underscored the therapeutic advancements and the effectiveness of DAAs, they expressed confusion regarding the mechanisms of access to treatment, especially in cases of reinfection. Perceptions of the controllability of hepatitis C were significantly influenced by the stigmatizing discourse surrounding treatment access, cost, and public coverage. This influence extended to their intentions for seeking treatment. Participants emphasized the social consequences of hepatitis C, including stigma. Emotional representations of hepatitis C evolved along the care cascade, encompassing initial shock at diagnosis and later fear of reinfection following successful treatment.

CONCLUSION

Nearly a decade after the advent of DAAs, misinformation about treatment access persists. Findings underscore a nexus of internalized and institutionalized stigma associated with hepatitis C, drug use, and the challenges of cost and access to treatment, pointing to a clear need for education and service delivery optimisation in harm reduction community organizations.

Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis

BACKGROUND AND AIMS

Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections.

METHODS

We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes.

RESULTS

We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission).

CONCLUSIONS

Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.

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.

Logics of control and self-management in narratives of people living with HIV, hepatitis C and hepatitis B

In Australia, the response to HIV, hepatitis C and hepatitis B has largely been through the constructed category of 'blood borne viruses' which treats these viruses as an interconnected set of conditions with respect to their mode of transmission. In this paper, we explore how people understand their viral infection, and compare the logics underpinning these different understandings. In-depth interviews were conducted with 61 participants who were either living with a blood borne virus or were the family members of people living with them. Our analysis reveals that the viral infection was often described as 'just a condition that needs to be managed', albeit in potentially exhausting ways. This understanding hinged upon a biomedical logic in which viral invasion was seen as causing illness and in turn necessitating biomedical intervention. In contrast, some participants with hepatitis B presented their infection as a condition unintelligible through Western biomedical logics, defined instead by symptomology - in terms of 'liver disease', and/or 'liver inflammation'. This focus on symptomology calls into question the soundness of prevention and management responses to hepatitis B based in biomedical logics and reveals the extent to which living with a virus involves multiple, sometimes incompatible, cultural logics. The different logics underpinning HIV, hepatitis C and hepatitis B reveal shortcomings of framing these viruses together as a coherent single construct.

Differential risks of syringe service program participants in Central Ohio: a latent class analysis

BACKGROUND

Significant heterogeneity exists among people who use drugs (PWUD). We identify distinct profiles of syringe service program (SSP) clients to (a) evaluate differential risk factors across subgroups and (b) inform harm reduction programming.

METHODS

Latent class analysis (LCA) was applied to identify subgroups of participants (N = 3418) in a SSP in Columbus, Ohio, from 2019 to 2021. Demographics (age, sex, race/ethnicity, sexual orientation, housing status) and drug use characteristics (substance[s] used, syringe gauge, needle length, using alone, mixing drugs, sharing supplies, reducing use, self-reported perceptions on the impact of use, and treatment/support resources) were used as indicators to define latent classes. A five-class LCA model was developed, and logistic regression was then employed to compare risk factors at program initiation and at follow-up visits between latent classes.

RESULTS

Five latent classes were identified: (1) heterosexual males using opioids/stimulants with housing instability and limited resources for treatment/support (16.1%), (2) heterosexual individuals using opioids with stable housing and resources for treatment/support (33.1%), (3) individuals using methamphetamine (12.4%), (4) young white individuals using opioids/methamphetamine (20.5%), and (5) females using opioids/cocaine (17.9%). Class 2 served as the reference group for logistic regression models, and at the time of entry, class 1 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs, with persistently higher odds of sharing supplies and mixing drugs at follow-up. Class 3 was more likely to report history of overdose, sharing supplies, and mixing drugs, but outcomes at follow-up were comparable. Class 4 was the least likely to report history of overdose, HCV, and mixing drugs, but the most likely to report HIV. Class 5 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs at entry, and higher reports of accessing substance use treatment and testing positive for HCV persisted at follow-up.

CONCLUSIONS

Considerable heterogeneity exists among PWUD, leading to differential risk factors that may persist throughout engagement in harm reduction services. LCA can identify distinct profiles of PWUD accessing services to tailor interventions that address risks, improve outcomes, and mitigate disparities.

Accessing hepatitis C direct acting antivirals among people living with hepatitis C: a qualitative study

BACKGROUND

Hepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs.

METHODS

We conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants' accounts.

RESULTS

Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: "being 'worthy' of the cure", "spatially enacted stigma", "countering social and structural vulnerability: the importance of peers", "identity disruption and contagion: attaining a 'social cure'" and "challenging stigma with population-based screening". Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and 'normalizing' hepatitis C among the general population.

CONCLUSIONS

Despite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat.

Transformation of identity in substance use as a pathway to recovery and the potential of treatment for hepatitis C: a systematic review

BACKGROUND AND AIM

People who inject drugs are at high risk of contracting hepatitis C (HCV). The introduction of direct acting antiviral (DAA) drugs to treat HCV has the potential to transform care; however, uptake of DAAs has been slower than anticipated. The strong link between HCV and injecting drug use frames HCV as a shameful, stigmatising disease, reinforcing an 'addict' identity. Linking HCV care to a recovery journey, 'clean' identity and social redemption may provide compelling encouragement for people to engage with treatment and re-evaluate risk and behaviours, reducing the incidence of HCV re-infection. The aim of this review was to identify actions, interventions and treatments that provide an opportunity for a change in identity and support a recovery journey and the implications for HCV care.

METHODS

Databases (MEDLINE, EMBASE, PsycINFO, ProQuest Public Health, ProQuest Sociological Abstracts, CINAHL and Web of Science) were searched following our published strategy and a grey literature search conducted. A narrative synthesis was undertaken to collate themes and identify common threads and provide an explanation of the findings.

RESULTS

Thirty-two studies fulfilled the inclusion criteria. The narrative synthesis of the studies identified five over-arching analytical themes: social factors in substance use and recovery, therapeutic communities, community treatment, online communities, and finally women and youth subsets. The change from an 'addict' identity to a 'recovery' identity is described as a key aspect of a recovery journey, and this process can be supported through social support and turning point opportunities.

CONCLUSIONS

Recovery from addiction is a socially mediated process. Actions, interventions and treatments that support a recovery journey provide social connections, a recovery identity and citizenship (reclaiming a place in society). There is a gap in current literature describing how pathways of care with direct acting antivirals can be designed to promote recovery, as part of hepatitis C care.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States

BACKGROUND

Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois.

METHODS

Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses.

RESULTS

We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care.

CONCLUSION

The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection

BACKGROUND AND AIMS

Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID).

DESIGN

A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews.

SETTING

Baltimore City, MD, USA.

PARTICIPANTS

Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021).

MEASUREMENTS

Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone.

FINDINGS

Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces.

CONCLUSIONS

WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

Future destinations and social inclusion scoping review: how people cured of hepatitis C (HCV) using direct- acting antiviral drugs progress in a new HCV-free world

BACKGROUND

There has been a paradigm shift in the treatment of Hepatitis C (HCV) from the interferon-era to direct-acting antiviral (DAA) drugs. Cure of HCV for the key risk group, those with a history of injecting drug use, may provide a range of benefits to an individual's quality of life that can be additional to that of a clinical cure. The interferon-era provided evidence that cure of HCV can be a turning point for those who use drugs, supporting a recovery journey. There remains a question if DAAs can provide the same opportunity.

METHODS

We employed a scoping review methodology to consider the additional non-clinical benefits that HCV cure may provide. We used the theoretical construct of recovery capital to consider how these benefits may support a recovery journey in the DAA-era.

RESULTS

Our search provided 2095 articles, from which 35 were included in the analysis. We developed a thematic synthesis of the non-clinical outcomes identified based on the four over-arching themes of recovery capital: physical, cultural, social and human capital. Our review suggests that identity change is a constituent part of each of the recovery capital domains in relation to HCV treatment.

CONCLUSION

We identified Social Identity Model Of Recovery (SIMOR) as a mechanism through which DAAs may provide non-clinical outcomes to increase recovery capital domains. Further research is required to develop an understanding of the impact a cure of HCV with DAAs may have on identity, overall health and wellbeing and social inclusion to support recovery journeys.

A rapid ethnographic study of risk negotiation during the COVID-19 pandemic among unstably housed people who use drugs in Rhode Island

BACKGROUND

The COVID-19 pandemic has greatly exacerbated the United States' overdose crisis. However, the overlapping impacts of COVID-19 and the overdose crisis have not been experienced equally, with unstably housed people who use drugs (PWUD) disproportionately impacted. Amid these changes, there is a need to understand how risk is experienced and managed among unstably housed PWUD to address health and social needs more effectively.

METHODS

This project draws on ethnographic research conducted from June 2020 to April 2021 in Rhode Island. Data include 39 in-depth interviews with unstably housed PWUD and approximately 50 h of ethnographic fieldwork conducted alongside street-based outreach workers.

RESULTS

COVID-19 risks were primarily contextualized in relation to participants' prior experiences of overdose events and adverse health outcomes. However, participants had varying levels of risk tolerance that were managed in ways that allowed them to reassert control and agency within the uncertainty of overlapping public health crises. Given participants' level of structural vulnerabilities, COVID-19 risk was managed alongside meeting their basic needs to survive.

CONCLUSIONS

Findings demonstrate how COVID-related public health measures (e.g., stay-at-home orders, service closures) reinforced participants' structural vulnerabilities in ways that increased their risk of health and social harms. Implementing and scaling up programs that meet the basic needs of individuals, including permanent housing, social supports, and overdose prevention interventions (e.g., supervised consumption sites) is critically needed to address intersecting risks faced by unstably housed PWUD.

Transformation of identity in substance use as a pathway to recovery and the potential of treatment for hepatitis C: a systematic review protocol

INTRODUCTION

Hepatitis C virus (HCV) is a strongly stigmatised disease as it is framed within the context of injecting substance use. HCV provides the identity of 'dirty' or 'junky', with perceptions by others being beyond the control of the individual. People who experience problematic substance use are often viewed as being outside acceptable social behaviours, thus viewed as having tainted identities or second-class citizens. It is suggested that to recover from substance use, people should move towards social networks where substance use is not the norm and there is greater recovery support. The social identity model of recovery advocates that the mechanism to do this is by developing a new identity. It is unclear what catalysts provide this change in identity. This systematic review aims to describe actions, interventions and treatments that provide the opportunity for new identities and considers evidence that supports the hypothesis that curing HCV with direct acting antivirals may provide this opportunity.

METHODS AND ANALYSIS

Methods are informed by the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Seven electronic peer-reviewed and four grey literature sources were identified and preliminary searches have been conducted. The inclusion and exclusion criteria are broad to capture activities that result in a change in identity, recovery from substance use, quality of life, life satisfaction or the opportunity for the individual to reclaim their place in society (citizenship). Qualitative and quantitative literature are eligible. Papers will be assessed against standardised criteria and checked independently and in duplicate. A narrative synthesis of the findings will be reported, structured around intervention type, population context and outcomes.

ETHICS AND DISSEMINATION

This systematic review will be based on studies that have already been conducted and therefore no ethical approvals are required. The resulting findings will be submitted to an international peer-reviewed journal and disseminated at relevant research conferences.

PROSPERO REGISTRATION NUMBER

CRD42020209447.

Becoming posthuman: hepatitis C, the race to elimination and the politics of remaking the subject

Hepatitis C has long been a public health problem in Australia. 'Revolutionary' new drugs with the potential to cure hepatitis C have now emerged. The Australian government has invested heavily in them, and has an ambitious goal to eliminate hepatitis C by 2030. Numerous shifts in policy and practice are required if the elimination agenda is to be realised. This paper explores the significance of these shifts. We ask: what is the race to elimination doing with the subject? We argue that the race to elimination can be understood, simultaneously, as a product of posthuman forces, capable of being analysed using the theoretical tools made available via the posthuman turn; producing an intervention in what it means to be human; and generating a dilemma for people who use (or used) drugs, people with hepatitis C, and posthuman scholarship. In drawing out these issues, we aim to: trace the significant developments underway in hepatitis C medicine and raise awareness of them; encourage reflection on the consequences of these developments; and invite reflections on what might be lost when the human is remade by hepatitis C medicine.

Love & hate in the Downtown Eastside of Vancouver: features of an unusual drug scene

Purpose

According to conventional research and political conceptions, illicit drug scenes are often characterised by cultures of crime, violence and deceit and customarily met by repressive law enforcement. However, a growing body of research demonstrates the very diverse nature of drug subcultures. This paper aims to explore this diversity and thereby investigates the psychosocial and socio-spatial features people selling and/or using drugs in the Downtown Eastside of Vancouver (DTES) attribute to the local drug scene.

Design/methodology/approach

Qualitative in-depth interviews were conducted with 23 persons with drug selling and/or using experiences in the DTES. Interviews were analysed and interpreted according to grounded theory.

Findings

Participants represent the social fabric of the DTES drug scene as comprising complexly interwoven facets and structures including frequent, brutal violence on the one hand and sincere, heart-rending compassion, care and even love on the other.

Originality/value

Police and social and health services can cooperate constructively with the overriding aim of individual and social harm reduction. Thereby, the existing social network and prosocial orientations of a drug scene can be used in effective approaches such as participatory policy strategies and peer-driven interventions.

Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV and hepatitis C virus (HCV) infection and also have high levels of homelessness and unstable housing. We assessed whether homelessness or unstable housing is associated with an increased risk of HIV or HCV acquisition among PWID compared with PWID who are not homeless or are stably housed.

METHODS

In this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies published between Jan 1, 2000, and June 13, 2017. Using the same strategy as for this existing database, we searched MEDLINE, Embase, and PsycINFO for studies, including conference abstracts, published between June 13, 2017, and Sept 14, 2020, that estimated HIV or HCV incidence, or both, among community-recruited PWID. We only included studies reporting original results without restrictions to study design or language. We contacted authors of studies that reported HIV or HCV incidence, or both, but did not report on an association with homelessness or unstable housing, to request crude data and, where possible, adjusted effect estimates. We extracted effect estimates and pooled data using random-effects meta-analyses to quantify the associations between recent (current or within the past year) homelessness or unstable housing compared with not recent homelessness or unstable housing, and risk of HIV or HCV acquisition. We assessed risk of bias using the Newcastle-Ottawa Scale and between-study heterogeneity using the I2 statistic and p value for heterogeneity.

FINDINGS

We identified 14 351 references in our database search, of which 392 were subjected to full-text review alongside 277 studies from our existing database. Of these studies, 55 studies met inclusion criteria. We contacted the authors of 227 studies that reported HIV or HCV incidence in PWID but did not report association with the exposure of interest and obtained 48 unpublished estimates from 21 studies. After removal of duplicate data, we included 37 studies with 70 estimates (26 for HIV; 44 for HCV). Studies originated from 16 countries including in North America, Europe, Australia, east Africa, and Asia. Pooling unadjusted estimates, recent homelessness or unstable housing was associated with an increased risk of acquiring HIV (crude relative risk [cRR] 1·55 [95% CI 1·23-1·95; p=0·0002]; I2= 62·7%; n=17) and HCV (1·65 [1·44-1·90; p<0·0001]; I2= 44·8%; n=28]) among PWID compared with those who were not homeless or were stably housed. Associations for both HIV and HCV persisted when pooling adjusted estimates (adjusted relative risk for HIV: 1·39 [95% CI 1·06-1·84; p=0·019]; I2= 65·5%; n=9; and for HCV: 1·64 [1·43-1·89; p<0·0001]; I2= 9·6%; n=14). For risk of HIV acquisition, the association for unstable housing (cRR 1·82 [1·13-2·95; p=0·014]; n=5) was higher than for homelessness (1·44 [1·13-1·83; p=0·0036]; n=12), whereas no difference was seen between these outcomes for risk of HCV acquisition (1·72 [1·48-1·99; p<0·0001] for unstable housing, 1·66 [1·37-2·00; p<0·0001] for homelessness).

INTERPRETATION

Homelessness and unstable housing are associated with increased risk of HIV and HCV acquisition among PWID. Our findings support the development of interventions that simultaneously address homelessness and unstable housing and HIV and HCV transmission in this population.

FUNDING

National Institute for Health Research, National Institute on Drug Abuse, National Institute of Allergy and Infectious Diseases, and Commonwealth Scholarship Commission.

"Stigma is where the harm comes from": Exploring expectations and lived experiences of hepatitis C virus post-treatment trajectories among people who inject drugs

BACKGROUND

The advent of direct-acting antiviral (DAA) medications has facilitated opportunities to treat hepatitis C virus (HCV) among people who inject drugs (PWID). However, there remains a need for data about how to optimally support PWID throughout DAA post-treatment trajectories, including with regard to re-infection prevention. The objective of this study is therefore to identify how PWID with lived experience of HCV describe their expectations and experiences related to health and social outcomes, contexts, and substance use practices following completion of DAA treatment.

METHODS

We thematically analyzed data from in-depth, semi-structured interviews, conducted between January and June 2018, in Vancouver, Canada, with a purposive sample (n = 50) of PWID at various stages of DAA treatment (e.g., pre, peri, post).

RESULTS

Our analysis yielded three themes. First, while participants had hoped to experience holistic enhancements in wellbeing following HCV cure, discussions of actual post-treatment experiences tended to be located in physical health (e.g., increased energy). Second, participants often pointed to the ways in which HCV-related and other stigmas had restricted opportunities for health and healthcare access. Participants therefore identified stigma-reduction as a key motivator of HCV cure, and while reductions in internalized stigma were sometimes achieved, participants underscored that other forms of enacted stigma (e.g., related to: substance use, HIV, poverty) had continued to feature prominently in their post-treatment lives. Third, participants described considerable knowledge about how to prevent HCV re-infection following cure, but they also expressed apprehensiveness about how socio-structural barriers, including stigma and criminalization, could interfere with harm reduction and re-infection prevention efforts.

CONCLUSIONS

DAAs are transforming the health and wellbeing of some PWID. Yet, HCV-related policy must extend beyond the scale-up of DAAs to include concerted public health investments, including anti-stigma efforts and improvements to the social welfare system, to meaningfully advance equity in PWID's post-treatment trajectories and outcomes.

Social network predictors of recent and sustained injection drug use cessation: findings from a longitudinal cohort study

BACKGROUND AND AIMS

The US opioid crisis has led to increases in overdose fatalities and the incidence of HIV, hepatitis C and other infections. This analysis examines social network predictors of recent (self-report injection followed by non-injection) and sustained (self-report non-injection at two consecutive visits among those who previously injected) injection cessation in Appalachian Kentucky.

DESIGN

Data were collected through bi-annual longitudinal assessments for Social Networks among Appalachian People (SNAP; 2008-17). Using logistic regression with generalized estimating equations that clustered on individuals, we regressed non-injection status on the number of social network members who (a) did not inject and (b) recently stopped injecting and tested for interactions between each social network exposure and prior non-injection status. Social network exposures were self-reported.

SETTING

Rural eastern Kentucky, USA.

PARTICIPANTS

Participants entered the analysis only after reporting recent injection and had to have had at least two consecutive study visits (n = 326).

MEASUREMENTS

Interviewer-administered surveys collected individual-level socio-demographics, recent (past 6 months) drug use behaviors and the names of recent social support, sex and drug-use partners.

FINDINGS

After adjusting for confounders, the number of non-injecting social network members was positively associated with recent/sustained injection cessation (adjusted odds ratio = 1.27; 95% confidence interval = 1.13-1.42) and having more social network members was associated with reduced odds of recent/sustained injection cessation. The number of previously injecting social network members who had recently stopped injecting was not statistically significantly associated with injection cessation. Neither of the interactions we tested for was statistically significant, suggesting that the relationships may be similar for those who recently stopped injecting versus had not injected for at least 1 year.

CONCLUSIONS

For each additional network member who did not inject drugs, there was an increased odds of recent and sustained injection cessation among people with a history of injection drug use in Appalachian Kentucky.

Hepatitis C testing and treatment uptake among young people who use opioids in New York City: A cross-sectional study

Young people who use drugs have a rising hepatitis C (HCV) incidence in the United States, but they may face barriers to testing and treatment adoption due to stigma. We conducted a cross-sectional study of New York City residents aged 18-29 years who reported non-medical prescription opioid and/or heroin use in the past 30 days. Participants were recruited from the community between 2014-2016 via respondent-driven sampling. Participants completed an in-person structured survey that included questions about HCV testing and treatment and received HCV antibody testing. There were 539 respondents: 353 people who inject drugs (PWID) and 186 non-PWID. For PWID, median age was 25 years, 65% were male and 73% non-Hispanic White. For non-PWID, median age was 23 years, 73% were male and 39% non-Hispanic White. 20% of PWID and 54% of non-PWID had never been tested for HCV (P < .001). Years since first injection (aOR 1.16, CI: 1.02-1.32, P = .02) and history of substance use treatment (aOR 3.17, CI: 1.53-6.61, P = .02) were associated with prior testing among PWID. The seroprevalence of HCV among PWID was 25%, adjusted for sampling weights. Of the 75 who were aware of their HCV-positive status, 53% had received HCV-related medical care, and 28% had initiated treatment. HCV prevalence among young PWID is high, and many have never been tested. Injection experience and treatment engagement is associated with testing. Interventions to increase testing earlier in injection careers, and to improve linkage to HCV treatment, will be critical for young PWID.

Upscaling HIV and hepatitis C testing in primary healthcare settings: stigma-sensitive practice

Increasing testing for viral hepatitis and HIV is central to meeting World Health Organization and Australian targets to eliminate blood-borne viruses as public health priorities by 2030. In this paper we draw on findings and recommendations from a Victorian consultation with 40 health and community practitioners engaged with blood-borne virus testing. The consultation focused on identifying what constitutes best practice in pre- and post-testing discussion in the current era of highly effective treatments for HIV and hepatitis C. Overall, the consultation found that the pre- and post-test discussion remains an important feature of testing, but, given that stigma continues to impact the lives of people affected by these viruses, sensitivity to this issue needs to inform how these discussions take place. We describe how primary healthcare settings can support the goal of upscaling HIV and hepatitis C testing in a way that delivers safe and stigma-free testing encounters. We offer the notion of 'stigma-sensitive practice' as a term to describe this approach to pre- and post-test discussions.

Novel Routes of Potential Hepatitis C Virus Transmission among People Who Inject Drugs: Secondary Blood Exposures Related to Injection Drug Use

BACKGROUND

The US is in the midst of a national Hepatitis C Virus (HCV) epidemic that appears to be driven by new cases among people who inject drugs (PWID). While HCV transmission among PWID is believed to occur mostly through direct sharing of syringes, some infections may be spread via secondary processes and materials involved in injecting.

OBJECTIVES

Here, we present the prevalence of secondary blood exposures on clothing and nearby surfaces after injection episodes and examine the correlations of these exposures to lifetime HCV infection among a targeted sample of 553 PWID in Los Angeles and San Francisco, California in 2016-18.

RESULTS

In multivariate logistic regression models, higher odds of blood on clothing in the last 30 days was significantly (p < 0.05) associated with lifetime positive HCV status, opioids as primary drug, injecting with others, sharing cookers, and receptive syringe sharing. Higher adjusted odds of blood on nearby surfaces in the last 30 days was significantly associated with lifetime positive HCV status, sharing cookers, and receptive syringe sharing. Native American race was associated with significantly lower adjusted odds of both outcome variables. Conclusions/Importance: Results indicate the relevance of physical and social micro-environments to the potential for blood exposures secondary to injection episodes. Individuals with chronic HCV seropositivity are potentially more likely to expose others to blood due to decreases in the blood's ability to clot. This highlights the need for increased HCV testing at harm reduction sites and increased supply of first aid and wound-care materials to help stop potential blood exposures after injection episodes.

Housing Stability and Hepatitis C Infection for Young Adults Who Inject Drugs: Examining the Relationship of Consistent and Intermittent Housing Status on HCV Infection Risk

Housing status affects drug using behaviors, but less is known about the relationship between housing patterns and hepatitis C virus (HCV) infection. HCV-negative young people who inject drugs (PWID) were enrolled into a prospective cohort (2003-2019) with quarterly study visits. We used Cox regression to estimate the independent association of recent housing status (housed vs. unhoused, housing stability, and housing trajectory) on HCV incidence. Among 712 participants, 245 incident HCV infections occurred over 963.8 person-years (py) (cumulative incidence 24.4/100 py). An inverse relationship between time housed and HCV incidence was observed (always unhoused 45.0/100 py, 95% confidence interval (CI) 37.1, 54.5; variably housed 18.0/100 py, 95% CI 15.0, 21.3; and always housed 7.0/100 py, 95% CI 3.0, 17.3). In Cox regression models controlling for confounders, those unhoused versus housed at baseline had a 1.9-fold increased infection risk (95% CI 1.4, 2.6). Those always unhoused versus always housed had a 1.5 times greater risk of HCV (95% CI 1.0, 2.3), and those spending a portion of time in stable housing a lower risk (adjusted relative hazard 0.05, 95% CI 0.3, 0.9) with a similar trend for those being housed for less time. Young adult PWID experiencing both recent and chronic states of being unhoused are at elevated risk for HCV infection. Importantly for this group of PWID, our findings indicate that some frequency of residential housing significantly reduces HCV infection risk.

"Caballo": risk environments, drug sharing and the emergence of a hepatitis C virus epidemic among people who inject drugs in Puerto Rico

BACKGROUND

Sharing drug injection equipment has been associated with the transmission of HCV among PWID through blood contained in the cooker and cotton used to prepare and divide up the drug solution. While epidemiologists often subsume this practice under the sharing of "ancillary equipment," more attention should be paid to the fact that indirect sharing takes place within the process of joint drug acquisition and preparation.

METHODS

We employed an ethnographic approach observing active PWID (N = 33) in four rural towns in Puerto Rico in order to document drug sharing arrangements involved in "caballo", as this practice is locally known. We explored partners' motivation to engage in drug sharing, as well as its social organization, social roles and existing norms.

FINDINGS

Findings suggest that drug sharing, is one of the main drivers of the HCV epidemic in this population. Lack of financial resources, drug packaging, drug of choice and the desire to avoid the painful effects of heroin withdrawal motivates participants' decision to partner with somebody else, sharing injection equipment-and risk-in the process. Roles are not fixed, changing not only according to caballo partners, but also, power dynamics.

CONCLUSION

In order to curb the HCV epidemic, harm reduction policies should recognize the particular sociocultural contexts in which people inject drugs and make decisions about risk. Avoiding sharing of injection equipment within an arrangement between PWID to acquire and use drugs is more complex than assumed by harm reduction interventions. Moving beyond individual risk behaviors, a risk environment approach suggest that poverty, and a strict drug policy that encourage users to carry small amounts of illicit substances, and a lack of HCV treatment among other factors, contribute to HCV transmission.

Engagement in the Hepatitis C care continuum among people who use drugs

Despite high rates of Hepatitis C virus (HCV) infection among people who use drugs (PWUDs), access to the HCV care continuum combined with the receipt of medications for addiction treatment in primary care settings remains suboptimal. A qualitative study was conducted among adults admitted for inpatient detoxification for opioid use disorder (OUD) in New York City (n=23) to assess barriers and facilitators with HCV prevention, screening, treatment, interactions with primary care providers, and experiences with integrated care approaches. Study findings yielded six major themes related to HCV care. Major gaps persist in knowledge regarding HCV harm reduction strategies, voluntary HCV testing services, and eligibility for HCV treatment. Treatment coordination challenges reinforce the importance of enhancing linkages to HCV care in key access-points utilized by PWUDs (e.g., emergency rooms, specialty addiction treatment settings). Peer networks combined with frequent patient-physician communication were elicited as important factors in facilitating linkage to HCV care. Additional care coordination needs in primary care settings included access to integrated treatment of HCV and OUD, and administrative support for enrollment in Medicaid, subsidized housing, and access to transportation vouchers.

Understanding ‘risk’ in families living with mixed blood-borne viral infection status: The doing and undoing of ‘difference’

‘Risk’ has long been at the centre of expert and popular perceptions of transmissible and stigmatised blood-borne viral infections, such as HIV and viral hepatitis. There is a substantial body of research on transmission risk among couples with mixed viral infection status (serodiscordance). But we know very little about how families affected by HIV and viral hepatitis engage with understandings of infectiousness and how these shape family relationships in different ways. Guided by cultural theories of risk that build on Mary Douglas’ work, we draw on qualitative interviews to explore the ‘performativity’ of risk in serodiscordant families in Australia. We show how the ‘doing’ of risk could be constitutive of difference, which unsettled the family connection or deepened existing fault lines. Conversely, the ‘undoing’ of risk enabled the preservation of the family bond by rejecting difference and reframing risk as an external threat to the family in the form of stigma. We conclude that risk in the context of serodiscordant families had relational implications far beyond viral transmission and consider what our findings might mean for service provision and health promotion campaigns related to blood-borne viruses.

Migration to the US among rural Puerto Ricans who inject drugs: influential factors, sources of support, and challenges for harm reduction interventions

BACKGROUND

While PWID of Puerto Rican origin have been migrating to the US for decades, the range of factors influencing their migration to the US and the resources they draw on to do so are not well understood. This is particularly true for rural Puerto Rican PWID, and the present study is the first empirical research to document migration patterns among this population. The specificities of their migration raise important challenges that need to be documented in order to implement more effective harm reduction policies at home (Puerto Rico) and abroad (US).

METHODS

This paper draws from data obtained employing a modified NHBS survey which was administered to (N =296) PWID in four rural municipalities of Puerto Rico with participants 18 years or older. The primary dependent variables for this paper are the number of times a person has lived in the continental US, and if they are planning on moving to the continental US in the future.

RESULTS

Findings suggest that 65% of the sample reported ever lived in the US and that 49% are planning on moving in the future. The number of times living in the US is associated with higher education and older age, but not with self-reported positive HIV or HCV statuses. Planning to move to the US is associated with knowing PWID who have moved or plan to move, negatively associated with age, and is not associated with HIV or HCV status. Around one third of those that lived in the US reported having some sort of support, with the majority receiving support from family sources. No participant received help to enter HIV/HCV treatment.

CONCLUSIONS

A multi-region approach to prevention is required to make a dent in curbing HIV/HCV transmission in this population. Understanding PWID migration patterns, risk behaviors, and health care needs in the US is now more important than ever as natural disasters prompted by human-made climate change will only increase in the future, raising demands not only for service providers but also harm reduction policies to cope with an increasing influx of "climate refugees" as PWID move across national borders.

Maintaining the healthy body: Blood management and hepatitis C prevention among men who inject performance and image-enhancing drugs

Australia's ambitious aim to 'eliminate' hepatitis C as a public health concern by 2030 requires researchers, policy makers and health practitioners to engage with populations rarely identified as a priority. Men who inject performance and image-enhancing drugs (PIEDs) are one such population, yet research suggests they have low rates of knowledge about hepatitis C. Although rates of needle-sharing in this group are thought to be low, other risks of blood-to-blood contact exist due to the use of large-gauge needles, intramuscular injecting, hard-to-reach injection sites, repeated injecting and peer-to-peer injecting. How should health initiatives engage people who might not customarily consider themselves vulnerable to hepatitis C? Drawing on the work of body theorist Margrit Shildrick, this article considers how men who inject PIEDs understand their bodies, with a particular focus on injecting practices, blood awareness and infection control, in order to inform hepatitis C prevention efforts. In our analysis, we draw on qualitative interviews with 60 men who inject PIEDs, which we conducted for an Australian Research Council-funded project focused on better understanding PIED injecting to improve health and minimise hepatitis C transmission. The interviews suggest that men who inject PIEDs closely monitor potential external infection risks, such as dirt and bacteria that might intrude upon the 'purity and security' of the body. However, less attention appears to be paid to what might be transferred out of the body and potentially to others, such as blood. Notions of trust and cleanliness, and normative perceptions of intravenous drug use, also shaped injecting practices and cursory attention to blood management. While environmental transmission poses a smaller transmission risk than needle-sharing, educating PIED consumers about it is nevertheless warranted. Focusing targeted health promotion materials on environmental blood as a potential route of hepatitis C transmission may help engage this population in prevention, and encourage more frequent hepatitis C testing.

Injecting-related trust, cooperation, intimacy, and power as key factors influencing risk perception among drug injecting partnerships

Sharing of injection drug use paraphernalia is a dyadic process linked to the transmission of HIV and hepatitis C virus (HCV). Despite this, limited research exists identifying specific dyadic interpersonal factors driving injecting partners' engagement in needle/syringe and ancillary injecting equipment sharing among young adults. Using semi-structured in-depth interview data collected between 2014 and 2015 from twenty-seven people who inject drugs (PWID), we applied an inductive approach to identify key injection drug-related interpersonal factors and developed a conceptual model integrating the findings based on interdependence theory. Interactions between injecting partners resulted in varying levels of injecting-related trust, cooperation, intimacy, and power. These factors interacted to collectively influence the type and level of risk perceived and enacted by injecting partners. The relationship between these injecting-related interpersonal factors, on the one hand, and risk perception on the other was dynamic and fluctuated between actions that protect the self (person-centered) and those that protect the partnership (partnership-centered). These findings indicate that the interpersonal context exerts substantial influence that shapes risk perception in all types of injecting partnerships. Partnership-focused prevention strategies should consider the dynamics of trust, cooperation, intimacy, and power, in characterizing dyadic risk perceptions and in understanding risky injecting practices among PWID.

Understanding how, why, for whom, and under what circumstances opt-out blood-borne virus testing programmes work to increase test engagement and uptake within prison: a rapid-realist review

BACKGROUND

Prisons represent a unique opportunity to diagnose blood-borne viruses. Opt-out testing is receiving increasing interest, as a result of mounting evidence to suggest that the manner in which a test offer is delivered, affects test uptake. Although the effectiveness of opt-out testing within the prison setting has been established, robust explanations are required for the variation in outcomes reported.

METHODS

Rapid-realist review methodology was used to synthesise the literature on prison-based opt-out testing. The review was carried out in three phases. Phase one: An expert panel provided literature relevant to the implementation of opt-out testing within the English prison estate. Unstructured searches were also conducted to identify other social programmes where "opt-out" had been used to increase uptake. Phase two: a systematic search of six peer-review and five grey literature databases was carried out to identify empirical data on opt-out testing within the prison setting. Phase three: Additional non-exhaustive searches were carried out to identify literature that reinforced emergent concepts. The development of programme theory took place with each iteration and was validated in consultation with stakeholders.

RESULTS

Programme theory was constructed for two outcomes: the proportion of intake offered a test and the proportion offered that accepted testing. The proportion of intake offered testing was influenced by the timing of the test offer, which was often delayed due to barriers to prisoner access. The decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a prisoner's personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer.

CONCLUSIONS

This review identified important implementation considerations that moderate the effectiveness of opt-out testing programmes. It also highlighted a lack of appreciation for the theoretical underpinnings of opt-out programmes and tension around how to implement testing in a manner that adheres to both default theory and informed consent. It is anticipated that results will be used to inform the design and implementation of subsequent versions of these programmes, as well as catalyse further in-depth analysis into their operation within the unique context of prison.

REVIEW REGISTRATION

CRD42017068342 .

Establishing trust in HIV/HCV research among people who inject drugs (PWID): Insights from empirical research

BACKGROUND

The establishment of trust between researchers and participants is critical to advance HIV and HCV prevention particularly among people who inject drugs (PWID) and other marginalized populations, yet empirical research on how to establish and maintain trust in the course of community health research is lacking. This paper documents ideas about trust between research participants and researchers amongst a sub-sample of PWID who were enrolled in a large, multi-year community health study of social networks and HIV/HCV risk that was recently conducted in rural Puerto Rico.

METHODS

Qualitative research was nested within a multi-year Social Network and HIV/HCV Risk study involving N = 360 PWID > 18 years of age living in four small, rural Puerto Rican communities. Semi-structured interviews were conducted between March 2017 and April 2017 with a subset of 40 active PWID who had been enrolled in the parent study. Interview questions invited participants to draw upon their recent experience as research participants to better understand how PWID perceive and understand participant-researcher trust within the context of HIV/HCV-related epidemiological research.

RESULTS

Fear of police, stigma and concerns regarding confidentiality and anonymity were identified as structural factors that could compromise participation in HIV/HCV-related research for PWID. While monetary compensation was an important motivation, participants also valued the opportunity to learn about their HIV/HCV status. During their participation in the study, gaining knowledge of safe injection practices was perceived as a valuable benefit. Participant narratives suggested that PWID may adopt an incremental and ongoing approach in their assessment of the trustworthiness of researchers, continuously assessing the extent to which they trust the research staff throughout the course of the research. Trust was initially generated through peer Respondent Driven Sampling recruitment. Research staff who maintained a presence in the community for the entire duration of the prospective study reinforced trust between participants and the research team.

CONCLUSION

Although PWID face numerous structural barriers to research-related trust in HIV/HCV research, we found that using a peer-based recruitment method like RDS, and employing a research staff who are knowledgeable about the targeted population, culturally sensitive to their needs, and who maintain a long-term presence in the community may help mitigate many of these barriers. The reputation of the research is built incrementally as participants join the study. This contributes to a "street reputation" that grows as current or former participants vouch for the study. Establishing trust was identified as only the first step towards building a collaborative relationship with participants, and our findings suggest that steps to address criminalization and stigmatization also are necessary to support research trust.

Evaluating a Dyadic Intervention on Risk Reduction Among People Who Inject Drugs

Among 100 people who inject drugs enrolled in a peer mentorship intervention aiming to promote injection-related risk reduction behavior change, we evaluated the role of participation in a dyad session on reducing sharing of syringes and cookers in the past 6 months. Dyad participants (n = 69) invited an injection, sex partner, or family member to the study site to reinforce learnt behavior change tools by practicing communication skills and risk reduction lessons. In all, 31 participants did not participate in the dyad session. We descriptively assessed changes in sharing injection equipment between the 2 time points of pre- and postintervention using the tests of proportions by dyad participation. Multivariable logistic regression adjusted for sex was used with an interaction term (time points × dyad participation) to evaluate the dyad effect. Dyad participants reported reduced syringe and cooker sharing at postintervention (sharing syringe: 17% versus 39%, P < .05 and cooker: 32% versus 59%, P < .01). There was no difference between the dyad group's sharing injection equipment behavior after the intervention (sharing syringes: adjusted odds ratio [aOR] 0.76; 95% confidence interval [CI] 0.1-3.9 and cookers: aOR 0.72; 95% CI 0.1-3.5). The role of the dyad session alone on risk taking was not effective. With a small sample size, it is important to continue to evaluate the nature of peer-based dyadic experiences in future studies.

A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK

Background

Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK.

Methods

A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants’ responses.

Results

We report an overarching theme of ‘tension’ in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation.

Conclusions

The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.

Injection Partners, HCV, and HIV Status among Rural Persons Who Inject Drugs in Puerto Rico

BACKGROUND

The prevalence of hepatitis C (HCV) and HIV among persons who inject drugs (PWID) and the ability of these diseases to spread through injection networks are well documented in urban areas. However, less is known about injection behaviors in rural areas.

OBJECTIVES

This study focuses on the association between the number of self-reported injection partners with the PWID's self-reported HCV and HIV status. Injection networks provide paths for infection and information to flow, and are important to consider when developing prevention and intervention strategies.

METHODS

Respondent driven sampling was used to conduct 315 interviews with PWID in rural Puerto Rico during 2015. Negative binomial regression was used to test for associations between the number of self-reported injection partners and self-reported HCV and HIV statuses. Multinomial logistic regression was used to test for associations with the participant's self-reported HCV and HIV statuses.

RESULTS

Self-reported HCV status is significantly associated with injection risk network size. Injection partner networks of self-reported HCV- respondents are half what is reported by those with a positive or unknown status. Self-reported HIV statuses are not associated with different numbers of injection partners.

CONCLUSIONS

Smaller injection networks among those who self-report a HCV- status suggests that those who believe their status to be negative may take protective action by reducing their injection network compared to those have a self-reported HCV+ or an unknown status. Although the cross-sectional design of the study makes it difficult verify, such behavior has implications for prevention programs attempting to prevent HCV transmission.

Who goes first? Understanding hepatitis C risk among injecting networks in the prison setting

BACKGROUND

Hepatitis C (HCV) is a blood-borne virus that is most commonly transmitted through shared injecting equipment. Due to the criminalisation of injecting drug use, HCV is highly prevalent among those incarcerated. Using a risk environment framework, this qualitative study sought to understand the role of HCV risk within injecting networks in the prison setting.

METHODS

Thirty-two adult prisoners (n=24 men; n=8 women) with a history of injecting drug use participated in this qualitative sub-study. Participants were recruited across four correctional centres.

RESULTS

Social, economic, and environmental risk factors contributed to injecting practices within prison. Commonly, the person supplying the drugs injected first, with the person who owns the injecting equipment going next. HCV did not regularly factor into determining order of injection within networks (i.e., first, second, third), although it was reported that some prisoners claimed not to have HCV in efforts to "jump the queue".

CONCLUSION

Social, economic, and environmental risk factors contribute to negotiation of injecting order among people who inject drugs in prison. Risk of HCV exposure rarely influenced the injecting order. Harm reduction strategies should consider the social factors influencing injecting drug use in the prison setting especially to optimise the population benefits of the roll-out of highly effective HCV treatments.

High-Risk Geographic Mobility Patterns among Young Urban and Suburban Persons who Inject Drugs and their Injection Network Members

Young people in the USA who inject drugs, particularly those at a risk of residence instability, experience the highest incidence of hepatitis C (HCV) infections. This study examined associations between geographic mobility patterns and sociodemographic, behavioral, and social network characteristics of 164 young (ages 18-30) persons who inject drugs (PWID). We identified a potential bridge sub-population who reported residence in both urban and suburban areas in the past year (crossover transients) and higher-risk behaviors (receptive syringe sharing, multiple sex partners) compared to their residentially localized counterparts. Because they link suburban and urban networks, crossover transients may facilitate transmission of HIV and HCV between higher and lower prevalence areas. Interventions should address risk associated with residential instability, particularly among PWID who travel between urban and suburban areas.

Barriers and facilitators towards fertility preservation care for cancer patients: a meta-synthesis

Infertility is a potential late-effect of cancer treatment, which negatively impact on young cancer survivors' quality of life. This paper aims to synthesise factors that influence patients', carers' and healthcare professionals' decision to engage in fertility preservation programmes at the time of cancer diagnosis. Four databases and grey literature were systematically searched to identify qualitative and mixed-method studies published between 2000 and 2015. Thematic framework and synthesis were used to analyse and synthesise the data. Thirty-seven papers were selected and represented. Factors that affect engagement of patients, carers and healthcare providers in fertility preservation care can be grouped as intrinsic and extrinsic. Intrinsic factors include patients' attitudes, health beliefs and health literacy; clinicians' approaches and skills; as well as doctor-patient relationships. Extrinsic factors include fertility preservation care resources and institutional characteristics. We conclude that existing qualitative literature highlights the complex convergences of intrinsic and extrinsic factors that impede successful engagement in fertility preservation care. Addressing these factors could help cancer survivors achieve better health outcomes and improve their wellbeing. Potential solutions include attitudinal changes and organisational skill reforms across the health community that will help ensure a person's goals are always at the centre of their cancer care.

Hepatitis C in a new therapeutic era: Recontextualising the lived experience

AIMS AND OBJECTIVES

To explore the experience of adults living with hepatitis C in a new era of interferon-free treatment.

BACKGROUND

Hepatitis C is a leading cause of morbidity and mortality worldwide, posing a significant challenge to global public health. Historically, the treatment of hepatitis C was poorly efficacious and highly demanding; however, more effective and tolerable therapies have become available in high-income nations in recent years. This is the first study to explore how these significant developments in the treatment of hepatitis C may have influenced the experience of those living with the virus, and their understanding of the disease.

DESIGN

A qualitative study underpinned by social phenomenological theory.

METHODS

Data were generated through semi-structured interviews with a purposive sample of 20 hepatitis C positive adults living in a large city in Scotland.

RESULTS

Thematic analysis identified three overriding themes. "Positioning hepatitis C" illustrated how the disease was understood within wider sociocultural, medical and politico-economic contexts. "Beyond a physical burden" emphasised the emotional aspect of infection, and "a new uncertainty" revealed participants' cautious response to the advances in hepatitis C therapy.

CONCLUSIONS

Interthematic discourse portrayed the new era of hepatitis C treatment as holding little sway over constructions of the illness, as narratives resonated with previous studies. Such unmoving "lay" understandings of hepatitis C may pose potential barriers to the new therapeutic era from reaching its full potential.

RELEVANCE TO CLINICAL PRACTICE

How people living with the virus perceive and understand hepatitis C can have an adverse impact on their engagement with care and treatment. Whilst global medical discourse eulogises the arrival of a new era of therapy, there remain significant challenges for nurses engaging those with hepatitis C in therapeutic pathways.

Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection.

Risk behaviour determinants among people who inject drugs in Stockholm, Sweden over a 10-year period, from 2002 to 2012

BACKGROUND

People who inject drugs (PWID) frequently engage in injection risk behaviours exposing them to blood-borne infections. Understanding the underlying causes that drive various types and levels of risk behaviours is important to better target preventive interventions.

METHODS

A total of 2150 PWID in Swedish remand prisons were interviewed between 2002 and 2012. Questions on socio-demographic and drug-related variables were asked in relation to the following outcomes: Having shared injection drug solution and having lent out or having received already used drug injection equipment within a 12 month recall period.

RESULTS

Women shared solutions more than men (odds ratio (OR) 1.51, 95% confidence interval (CI) 1.03; 2.21). Those who had begun to inject drugs before age 17 had a higher risk (OR 1.43, 95% CI 0.99; 2.08) of having received used equipment compared to 17-19 year olds. Amphetamine-injectors shared solutions more than those injecting heroin (OR 2.43, 95% CI 1.64; 3.62). A housing contract lowered the risk of unsafe injection by 37-59% compared to being homeless.

CONCLUSIONS

Women, early drug debut, amphetamine users and homeless people had a significantly higher level of injection risk behaviour and need special attention and tailored prevention to successfully combat hepatitis C and HIV transmission among PWID.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier, NCT02234167.