HIV risk behaviors associated with the injection process: multiperson use of drug injection equipment and paraphernalia in injection drug user networks

Assisted injection provider practices and motivations in Los Angeles and San Francisco California 2016-18

BACKGROUND

Assisted injection is a high-risk and common practice among people who inject drugs (PWID) and occurs for diverse reasons according to qualitative research. To develop interventions for reducing assisted injection risks, it is important to understand the practices of PWID who provide injection assistance, including their motivations for providing assistance.

METHODS

Using follow-up data from an efficacy trial among PWID recruited in Los Angeles and San Francisco, CA (n=601), we present descriptive statistics on motivations for providing injection assistance and use multivariable logistic regression modelling to examine factors associated with these motivations.

RESULTS

PWID provided injection assistance most commonly to friends and acquaintances. A quarter provided assistance on a daily basis. The most common motivations for providing assistance were skill and injury prevention. PWID also provided assistance to stop pestering and for compensation in money or drugs. In separate models examining factors associated with the five main motivations, we found injury prevention to be associated with skill injecting others, neck injection, methamphetamine use, and recycling income. Pestering was associated with injury prevention, neck and hand injection, speedball use, and syringe selling. Skill was associated with injury prevention, neck and hand injection, being physically assaulted, and age. Providing assistance for money was associated with providing assistance for food or drugs, armpit injections, being female, and providing assistance more frequently. Providing assistance for drugs was associated with compensation in food or money, goofball injection, selling drugs, and panhandling.

CONCLUSION

Providing injection assistance is associated with injection needs of recipients and drug scene participation. We urgently need new interventions for reducing assisted injection risks. Since injection providers report being motivated by skill and to prevent injury, interventions such as training in safer injection techniques are likely to be met with enthusiasm.

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.

"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.

Changes in Reported Injection Behaviors Following the Public Health Response to an HIV Outbreak Among People Who Inject Drugs: Indiana, 2016

A syringe services program (SSP) was established following the Indiana HIV outbreak among persons who inject drugs (PWID) in Scott County. Among Indiana-based PWID, we examined injection behaviors associated with HIV status, SSP use after its establishment, and changes in injection behaviors after the outbreak response. During 2016, we interviewed 200 PWID and assessed injection behaviors before the response by HIV status. We reported injection behaviors prior to the response and used Fisher's exact Chi square tests (P < 0.05) to assess differences by HIV status. Next, among persons who injected both before (July-December 2014) and after (past 30 days) the response, we (1) reported the proportion of persons who used the SSP to obtain sterile syringes, and assessed differences in SSP use by HIV status using Fisher's exact Chi square tests; and (2) compared distributive and receptive sharing of injection equipment and disposal of syringes before and after the outbreak response, and assessed statistical differences using McNemar's test. We also compared injection behaviors before and after the response by HIV status. Injecting extended release oxymorphone (Opana® ER); receptive sharing of syringes and cookers; and distributive sharing of cookers, filters, or water before the response were associated with HIV infection. SSP use was high (86%), particularly among HIV-positive compared with HIV-negative persons (98% vs. 84%). Injection equipment sharing decreased and safe disposal of used syringes increased after the response, especially among HIV-positive persons. Injection equipment sharing contributed to the outbreak. High SSP use following the response, particularly among HIV-positive persons, contributed to decreased high-risk injection practices.

Reduction of Injection-Related Risk Behaviors After Emergency Implementation of a Syringe Services Program During an HIV Outbreak

OBJECTIVE

To describe injection-related HIV risk behaviors preimplementation and postimplementation of an emergency syringe services program (SSP) in Scott County, Indiana, after an HIV outbreak among persons who inject drugs (PWID).

DESIGN

Mixed methods retrospective pre-post intervention analysis.

METHODS

We analyzed routine SSP program data collected at first and most recent visit among clients with ≥2 visits, ≥7 days apart from April 4 to August 30, 2015, to quantify changes in injection-related risk behaviors. We also analyzed qualitative data collected from 56 PWID recruited in Scott County to understand factors contributing to these behaviors.

RESULTS

SSP clients included in our analysis (n = 148, 62% of all SSP clients) reported significant (P < 0.001) reductions over a median 10 weeks (range 1-23) in syringe sharing to inject (18%-2%) and divide drugs (19%-4%), sharing other injection equipment (eg, cookers) (24%-5%), and number of uses of the same syringe [2 (interquartile range: 1-4) to 1 (interquartile range: 1-1)]. Qualitative study participants described access to sterile syringes and safer injection education through the SSP, as explanatory factors for these reductions. Injection frequency findings were mixed, but overall suggested no change. The number of syringes returned by SSP clients increased from 0 at first visit to median 57. All qualitative study participants reported using sharps containers provided by the SSP.

CONCLUSIONS

Analyses of an SSP program and in-depth qualitative interview data showed rapid reduction of injection-related HIV risk behaviors among PWID post-SSP implementation. Sterile syringe access as part of comprehensive HIV prevention is an important tool to control and prevent HIV outbreaks.

The role of social networks and geography on risky injection behaviors of young persons who inject drugs

BACKGROUND

Little is known about young persons who inject drugs (PWID), who are increasingly from suburban communities and predominantly non-Hispanic white.

METHODS

We conducted a cross-sectional personal network (egocentric) and geographic study of young PWID and their drug-using, sexual, and support network members in 2012-13 in metropolitan Chicago, Illinois, U.S.

RESULTS

We enrolled 164 young (median age=26), mostly male (65%), non-Hispanic white PWID (71%), with a self-reported HCV prevalence of 13%. Many (59%) reported multiple residences (i.e., were transient) in the past year, 45% of whom reported living in both urban and suburban places (i.e., were cross-over transients). In multivariable analyses that adjusted for participant and network member characteristics, (1) large injection networks were more common among homeless participants; and (2) syringe sharing was (a) highest among cross-over transients compared to suburban (OR=4.19 95% CI 1.69-10.35) and urban only residents (OR=2.91 95% CI 1.06-8.03), (b) higher among HCV-unknown compared HCV-negative participants (OR=4.62 95% CI 1.69-10.35), (c) more likely with network members who were cross-over transients compared to urban (OR=4.94, 95% CI 2.17-11.23) and (d) less likely with network members with HCV-unknown compared to HCV-negative status (OR=0.4 95% CI 0.19-0.84).

CONCLUSIONS

We identified homelessness as a significant risk factor for large networks and cross-over transience as a significant risk factor for syringe sharing. Further research is needed to understand the role of geographic factors promoting higher risk among these crossover transient PWID.

Drug injecting and HIV risk among injecting drug users in Hai Phong, Vietnam: a qualitative analysis

BACKGROUND

Hai Phong, located in northern Vietnam, has become a high HIV prevalence province among Injecting Drug Users (IDUs) since the infection shifted from the southern to the northern region of the country. Previous research indicates high levels of drug and sex related risk behaviour especially among younger IDUs. Our recent qualitative research provides a deeper understanding of HIV risk behaviour and highlights views and experiences of IDUs relating to drug injecting and sharing practices.

METHODS

Fifteen IDUs participated in semi-structured interviews conducted in September-October, 2012. Eligible participants were selected from those recruited in a larger scale behavioural research project and identified through screening questions. Interviews were conducted by two local interviewers in Vietnamese and were audiotaped. Ethical procedures, including informed consent and participants' understanding of their right to skip and withdraw, were applied. Transcripts were translated and double checked. The data were categorised and coded according to themes. Thematic analysis was conducted and a qualitative data analysis thematic framework was used.

RESULTS

Qualitative analysis highlighted situational circumstances associated with HIV risks among IDUs in Hai Phong and revealed three primary themes: (i) places for injecting, (ii) injecting drugs in small groups, and (iii) sharing practices. Our results showed that shared use of jointly purchased drugs and group injecting were widespread among IDUs without adequate recognition of these as HIV risk behaviours. Frequent police raids generated a constant fear of arrest. As a consequence, the majority preferred either rail lines or isolated public places for injection, while some injected in their own or a friend's home. Price, a heroin crisis, and strong group norms encouraged collective preparation and group injecting. Risk practices were enhanced by a number of factors: the difficulty in getting new syringes, quick withdrawal management, punitive attitudes, fear of arrest/imprisonment, lack of resources, incorrect self-assessment, and risk denial. Some of the IDU participants emphasised self-care attitudes which should be encouraged to minimise HIV transmission risk.

CONCLUSION

The IDUs' experiences in Hai Phong identified through our data broaden our qualitative understanding about the HIV transmission risk among IDUs and emphasize the need to strengthen harm reduction services in Vietnam.

Outlier populations: individual and social network correlates of solvent-using injection drug users

Objective

We previously identified a high prevalence of Hepatitis C (HCV) amongst solvent-using injection drug users (S-IDU) relative to other injection drug users within the same locality. Here we incorporated social network variables to better characterize some of the behavioural characteristics that may be putting this specific subgroup of IDU at elevated disease risk.

Methods

A cross-sectional survey of at-risk populations was carried out in Winnipeg, Canada in 2009. Individuals reporting any history of injection drug and/or solvent use were included in the study. Associations between subgroup membership, infection with HCV and HIV and individual and social network variables were examined.

Results

In relation to other IDU, S-IDU were more likely to be infected with HCV, to report ever having shared a syringe, and to associate with other IDU. They were further differentiated in terms of their self-reported sexual orientation, ethnicity and in the injection drugs typically used.

Conclusion

Solvent use stands as a proxy measure of numerous other characteristics that put this group of IDU at higher risk of infection. Provision of adequate services to ostracized subpopulations may result in wider population-level benefits.

Uptake of paraphernalia from injecting equipment provision services and its association with sharing of paraphernalia among injecting drug users in Scotland

BACKGROUND

There has been a significant increase in the provision of injecting paraphernalia from Scottish injecting equipment provision (IEP) services. However, there is currently a lack of evidence on whether uptake of paraphernalia has any impact on paraphernalia sharing among injecting drug users (IDU). The aim of this study was to examine the factors associated with paraphernalia sharing; in particular, whether uptake of filters, spoons and sterile water from IEPs is associated with a reduction in the sharing of these items.

METHODS

A cross-sectional voluntary anonymous survey of 2037 IDUs was administered during 2008-2009. Participants were asked whether they had shared filters, spoons or water (paraphernalia) in the previous 6 months, and their uptake of these items from an IEP during an average week in the previous 6 months.

RESULTS

Self-reported uptake of paraphernalia in an average week during the previous 6 months was associated with reduced odds of sharing paraphernalia: (i) uptake of >30 filters was associated with a reduced odds of sharing filters (adjusted odds ratio (AOR) 0.50, 95% confidence interval 0.32-0.79); (ii) uptake of >30 spoons was associated with a reduced odds of sharing spoons (AOR 0.46, 95% confidence interval 0.28-0.74); and (iii) uptake of sterile water was associated with a reduced odds of sharing water (AOR 0.36, 95% confidence interval 0.22-0.61) compared to no uptake of each of these items.

CONCLUSIONS

Uptake of paraphernalia appears to be associated with safer injecting practice. Further research is needed to establish the impact of paraphernalia provision on HCV transmission.

Injection drug users' access to a supervised injection facility in Vancouver, Canada: the influence of operating policies and local drug culture

North America's first supervised injection facility (SIF) was established in Vancouver, Canada, in 2003. Although evaluation research has documented reductions in risk behavior among SIF users, there has been limited examination of the influence of operational features on injection drug users' access to these facilities. We conducted an ethnographic study that included observational research within the SIF, 50 in-depth individual interviews with SIF users, and analysis of the regulatory frameworks governing the SIF. The government-granted exemption allowing the facility to operate legally imposes key operating regulations, as well as a cap on capacity, which results in significant wait times to enter the injecting room. Regulations that prohibit practices that are common in the local drug culture also negatively affect SIF utilization. Restructuring policies that shape the operation of the SIF could enhance access to the facility and permit SIF services to better accommodate local drug use practices.

Comparison of HIV risk by duration of injection drug use

Early studies documented an inverse association between the HIV risk and duration of injection among injection drug users (IDUs). Results from subsequent studies have been inconsistent. To examine this issue, we conducted interviews with 395 street-recruited active IDUs from 38 neighborhoods in New York City during 2005 and 2008. We observed no significant differences in drug or risky sex behaviors by duration of drug use among these IDUs. Despite this, continuing to tailor HIV prevention programs for these recent-onset IDUs is prudent. The study's limitations are noted.

The growing popularity of prescription opioid injection in downtown Montréal: new challenges for harm reduction

Starting in 2007, a 2-year study based on ethnographic methodology was carried out downtown Montréal, Canada. A thematic analysis of observational and interview-based notes was conducted. Illicit prescription opioid (PO) use was widespread among street-based participants. Injection was the main mode of PO administration observed among users. Some injection practices such as "doing a wash" could pose new challenges in terms of prevention of infections. More research is needed to examine the role of illicit PO use in the development of opiate addiction and to better understand drug-using contexts that put PO users at risk of infections. The study's limitations are noted.

Cognitive behavioral theories used to explain injection risk behavior among injection drug users: a review and suggestions for the integration of cognitive and environmental models

Injection drug users (IDUs) are at risk for HIV and viral hepatitis, and risky injection behavior persists despite decades of intervention. Cognitive behavioral theories (CBTs) are commonly used to help understand risky injection behavior. The authors review findings from CBT-based studies of injection risk behavior among IDUs. An extensive literature search was conducted in spring 2007. In total, 33 studies were reviewed- 26 epidemiological and 7 intervention studies. Findings suggest that some theoretical constructs have received fairly consistent support (e.g., self-efficacy, social norms), whereas others have yielded inconsistent or null results (e.g., perceived susceptibility, knowledge, behavioral intentions, perceived barriers, perceived benefits, response efficacy, perceived severity). The authors offer some possible explanations for these inconsistent findings, including differences in theoretical constructs and measures across studies and a need to examine the environmental structures that influence risky behaviors. Greater integration of CBT with a risk environment perspective may yield more conclusive findings and more effective interventions in the future.

The provision of non-needle/syringe drug injecting paraphernalia in the primary prevention of HCV among IDU: a systematic review

BACKGROUND

Sharing drug injecting paraphernalia other than needles and syringes (N/S) has been implicated in the transmission of Hepatitis C virus (HCV) among injecting drug users (IDU). We aimed to determine whether the provision of sterile non-N/S injecting paraphernalia reduces injecting risk behaviours or HCV transmission among IDU.

METHODS

A systematic search of seven databases and the grey literature for articles published January 1989-February 2010 was undertaken. Thirteen studies (twelve observational and one non-randomized uncontrolled pilot intervention) were identified and appraised for study design and quality by two investigators.

RESULTS

No studies examined the association between the provision of non-N/S injecting paraphernalia and incident HCV infection. One cross-sectional study found that individuals who frequently, compared to those who infrequently, used sterile cookers and water, were less likely to report prevalent HCV infection. Another found no association between the uptake of sterile non-N/S injecting paraphernalia and self-reported sharing of this paraphernalia. The remaining observational studies used attendance at needle and syringe exchange programmes (NSP) or safer injection facilities (SIF) that provided non-N/S injecting paraphernalia as a proxy measure. Eight studies presented adjusted odds ratios, ranging from 0.3 to 0.9, suggesting a reduced likelihood of self-reported sharing of non-N/S injecting paraphernalia associated with use of NSP or SIF. There was substantial uncertainty associated with these estimates however. Three unadjusted studies reported a reduction in the prevalence of sharing of non-N/S injecting paraphernalia over time among NSP users. Only one study reported an adjusted temporal trend in the prevalence of sharing non-N/S injecting paraphernalia, finding higher rates among non-NSP users than NSP users at each time point, and a greater reduction in sharing among non-NSP than NSP users over time. Study limitations included the use of convenience samples, self-reported exposure and outcome measures, flawed classification of the exposed and unexposed groups, and inadequate adjustment for potential confounding variables.

CONCLUSIONS

The evidence to demonstrate that the provision of sterile non-N/S injecting paraphernalia reduces HCV transmission or modifies injecting risk behaviours is currently limited by an insufficient volume and quality of studies. Further research is required to inform practice and policy in this area.

Correlates of seeking injection assistance among injection drug users in Tijuana, Mexico

Assisted injection among injection drug users (IDUs) remains understudied. We recruited 1,056 IDUs using respondent-driven sampling in Tijuana, Mexico. Participants underwent HIV and syphilis testing and structured interviews. One-quarter (25%) sought injection assistance in the past 6 months. Seeking injection assistance was independently associated with being female (adjusted odds ratio [AOR]= 2.59; 95% confidence interval [CI]= 1.73-3.90), being born outside Baja California (AOR = 1.75; CI = 1.26-2.42), having recent abscesses (AOR = 2.59; CI = 1.93-3.47), using syringes previously used by others in the past 6 months (AOR = 1.99; CI = 1.45-2.71), and ever being arrested for carrying sterile syringes (AOR = 1.55; CI = 1.15-2.09).

Hepatitis C virus risk behaviors within the partnerships of young injecting drug users

AIMS

Young injection drug users (IDU) are at high risk for hepatitis C virus (HCV). We sought to determine whether perceiving one's injecting partner to be HCV positive was associated with decreased odds of engaging in receptive needle/syringe sharing (RNS) or ancillary equipment sharing (AES) with that partner.

DESIGN

Cross sectional study.

SETTING

2003 to 2007 in San Francisco.

PARTICIPANTS

212 young (under age 30) IDU who were HCV antibody negative reported on 492 injecting partnerships.

MEASUREMENTS

Self-reported RNS and AES within injecting partnerships.

FINDINGS

RNS and AES (in the absence of RNS) occurred in 23% and 64% of injecting partnerships in the prior month. The odds of engaging in RNS were significantly lower for relationships in which the participant reported that his/her partner was HCV positive (odds ratio [OR] 0.49; 95% confidence interval [CI] 0.25-0.95). This association was attenuated when adjusted for reusing one's own needle/syringe (adjusted OR 0.57; 95% CI 0.28-1.15). The odds of engaging in AES were lower for participants who did not know the HCV status of their partner, only among non-sexual partnerships (OR 0.47; 95% CI 0.29-0.76).

CONCLUSIONS

Because perceiving one's partner to be HCV positive was associated with decreased RNS, increased HCV testing and partner disclosure may be warranted. AES was common and was decreased only among non-sexual partnerships in which the HCV status of the partner was not known. This suggests that interventions to reduce AES in young IDU must be widespread.

Giving away used injection equipment: missed prevention message?

Background

Our objective was to examine factors associated with distributive injection equipment sharing and how needle exchange programs (NEPs) can help reduce distributive sharing among injection drug users (IDUs).

Methods

145 English speaking Canadian IDUs ages 16 years and over who had injected in the past 30 days were recruited for a cross-sectional survey. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, social support, drug treatment readiness, program satisfaction, health and social service use and NEP drug use. Bivariate statistics and logistic regression were used to characterize the population and examine correlates of sharing behaviour.

Results

More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. Factors associated with giving away used water included: male, injected methadone, injected other stimulants and moved 3+ times in the past 6 months. Factors associated with giving away used filters included: injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included: an ASI mental health score indicative of a mental health problem, and HCV negative status.

Conclusions

Our findings show that more IDUs give away cookers than needles or other injection equipment. While the results showed that correlates of sharing differed by piece of equipment, each point to distributive sharing by the most marginalized IDUs. Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission.

Bundling occupational safety with harm reduction information as a feasible method for improving police receptiveness to syringe access programs: evidence from three U.S. cities

Introduction

In light of overwhelming evidence that access to sterile injection equipment reduces incidence of injection-attributable bloodborne disease without encouraging drug use, many localities have authorized sterile syringe access programs (SAPs), including syringe exchange and pharmacy-based initiatives. Even where such interventions are clearly legal, many law enforcement officers are unaware of the public health benefits and legal status of these programs and may continue to treat the possession of injection equipment as illegal and program participation as a marker of illegal behavior. Law enforcement practice can impede SAP utilization and may increase the risk of needlestick injury (NSI) among law enforcement personnel. Many SAPs conduct little or no outreach to law enforcement, in part because they perceive law enforcement actors as unreceptive to health-promotion programs targeting drug users.

Case description

We report on a brief training intervention for law enforcement personnel designed to increase officer knowledge of and positive attitudes towards SAPs by bundling content that addresses officer concerns about infectious disease and occupational safety with information about the legality and public health benefits of these programs. Pilot trainings using this bundled curriculum were conducted with approximately 600 officers in three US cities.

Discussion and evaluation

Law enforcement officers were generally receptive to receiving information about SAPs through the bundled curriculum. The trainings led to better communication and collaboration between SAP and law enforcement personnel, providing a valuable platform for better harmonization of law enforcement and public health activities targeting injection drug users.

Conclusion

The experience in these three cities suggests that a harm reduction training curriculum that bundles strategies for increasing officer occupational safety with information about the legality and public health benefits of SAPs can be well received by law enforcement personnel and can lead to better communication and collaboration between law enforcement and harm reduction actors. Further study is indicated to assess whether such a bundled curriculum is effective in changing officer attitudes and beliefs and reducing health risks to officers and injection drug users, as well as broader benefits to the community at large.

HIV and HCV discordant injecting partners and their association to drug equipment sharing

Our objective was to examine the association between HIV and HCV discordant infection status and the sharing of drug equipment by injection drug users (IDUs). IDUs were recruited from syringe exchange and methadone treatment programmes in Montreal, Canada. Characteristics of participants and their injecting partners were elicited using a structured questionnaire. Among 159 participants and 245 injecting partners, sharing of syringes and drug preparation equipment did not differ between concordant or discordant partners, although HIV-positive subjects did not share with HIV-negative injectors. Sharing of syringes was positively associated with discordant HIV status (OR=1.85) and negatively with discordant HCV status (OR=0.65), but both results were not statistically significant. Sharing of drug preparation equipment was positively associated with both discordant HIV (OR=1.61) and HCV (OR=1.18) status, but both results were non-significant. Factors such as large injecting networks, frequent mutual injections, younger age, and male gender were stronger predictors of equipment sharing. In conclusion, IDUs do not appear to discriminate drug equipment sharing partners based at least on their HCV infection status. The results warrant greater screening to raise awareness of infection status, post-test counselling to promote status disclosure among partners, and skill-building to avoid equipment sharing between discordant partners.

Access to sterile injecting equipment is more important than awareness of HCV status for injection risk behaviors among drug users

Awareness of hepatitis C virus (HCV) infection status is expected to influence risk behaviors. In 2004-2005, injection drug users (IDUs) recruited from syringe exchange programs (SEPs) and methadone clinics in Montreal, Canada, were interviewed on drug use behaviors (past 6 months) and HCV testing. Subjects (n = 230) were classified as low/intermediate risk (20.4% borrowed drug preparation equipment only) and high risk (19.6% borrowed syringes), and 54.5% reported being HCV positive. Logistic regression modeling showed that compared to no risk (60% borrowed nothing), low/intermediate risk was associated with fewer noninjecting social network members, poor physical health, and problems obtaining sterile injecting equipment. High risk was associated with all of these factors except social networks. HCV status was not associated with any level of risk. Improved access to sterile injecting equipment may be more important than knowledge of HCV status in reducing injection risks among this IDU population. The study limitations are noted and recommendations discussed.

Reflections on 40 Years of Ethnographic Drug Abuse Research: Implications for the Future

This paper focuses on past, present, and potential future contributions of ethnographic research to describing and understanding “street cultures” of drug use and the implications these have for informing various interventions. The first section provides an overview of ethnography and drug abuse research. This is followed by a historical perspective on the ethnography of street cultures. Next, the significance of ethnographic drug abuse research is highlighted, with a focus on its methodology. Ethnographic contributions to the development, implementation, and evaluation of interventions are discussed, including ethical issues. Subsequently, the interdisciplinary nature of ethnographic drug abuse research is described. Methodological challenges emerged over time as the definition of street cultures and drug trends shifted. These are illustrated with examples, including the use of prescription drugs, new heroin users, and rural drug and methamphetamine use. The final sections focus on career opportunities for ethnographers and opportunities and barriers for the future. We address training needs for interdisciplinary inquiry, the potential role of ethnographers in prevention and treatment research, and the link to studies on the brain and genetics. The future of ethnographic research on drug use will be influenced by the funding structure. We conclude with a summary of reflections on the past and aspirations for the future.

Identifying heterogeneity among injection drug users: a cluster analysis approach

OBJECTIVES

We used cluster analysis to subdivide a population of injection drug users and identify previously unknown behavioral heterogeneity within that population.

METHODS

We applied cluster analysis techniques to data collected in a cross-sectional survey of injection drug users in Winnipeg, Manitoba. The clustering variables we used were based on receptive syringe sharing, ethnicity, and types of drugs injected.

RESULTS

Seven clusters were identified for both male and female injection drug users. Some relationships previously revealed in our study setting, such as the known relationship between Talwin (pentazocine) and Ritalin (methylphenidate) use, injection in hotels, and hepatitis C virus prevalence, were confirmed through our cluster analysis approach. Also, relationships between drug use and infection risk not previously observed in our study setting were identified, an example being a cluster of female crystal methamphetamine users who exhibited high-risk behaviors but an absence or low prevalence of blood-borne pathogens.

CONCLUSIONS

Cluster analysis was useful in both confirming relationships previously identified and identifying new ones relevant to public health research and interventions.

Risk of hepatitis C virus transmission through drug preparation equipment: a systematic and methodological review

The use of blood-contaminated drug preparation equipment is believed to be associated with the transmission of hepatitis C virus (HCV) among injection drug users (IDUs), but the extent of HCV infection risk is unclear. The objective of this review was to appraise the evidence regarding HCV incidence associated with the use of drug preparation equipment such as drug mixing containers, filters and water. In June 2007, cohort and case-control studies examining the association of HCV incidence with the sharing of drug preparation equipment were identified by searching electronic reference databases as well as the reference lists of published papers. Ten studies (seven cohort and three nested case-control) met the inclusion criteria for the review. The relative risk of HCV infection associated with drug preparation equipment were mainly between 2.0 and 5.9; however, the precision of the estimates from individual studies were marked by wide confidence intervals. Few studies exist to allow an adequate assessment of the individual contributions of containers, filters and water to HCV incidence. The major methodological limitations of reviewed studies were short follow-up times, inadequate control of confounders and lack of exclusion of periods when IDUs were not at risk for HCV infection through drug injection. Current evidence implicating the association of drug preparation equipment with HCV incidence is limited by several methodological concerns.

Injecting drug users' experiences of policing practices in two Mexican-U.S. border cities: public health perspectives

BACKGROUND

Previous research has identified the impact of law enforcement practices on the behaviours and health of injection drug users (IDUs). We undertook a qualitative study of IDUs' experiences of policing practices in two Mexican cities on the U.S. border.

METHODS

In 2004, two teams of Mexican interviewers conducted in-depth interviews with IDUs residing in Tijuana and Ciudad Juarez (Cd. Juarez), Mexico, who had injected drugs at least once in the prior month. Topics included types of drug used, injection settings, access to sterile needles and experiences with police. Field notes and transcribed interviews were analysed to identify emergent themes.

RESULTS

Amongst the 43 participants, most reported that it is common for IDUs to be arrested and detained for 36h for carrying sterile or used syringes. Most reported that they or someone they knew had been beaten by police. Interviews suggested five key themes relating to police influence on the risk environment: (1) impact of policing practices on accessibility of sterile syringes, (2) influence of police on choice of places to inject drugs (e.g., shooting galleries), (3) police violence, (4) police corruption and (5) perceived changes in policing practices.

CONCLUSION

Findings suggest that some behaviour of police officers in Tijuana and Cd. Juarez is inconsistent with legal norms and may be negatively influencing the risk of acquiring blood-borne infections amongst IDUs. Implementing a comprehensive and successful HIV prevention programme amongst IDUs requires interventions to influence the knowledge, attitudes and practices of law enforcement officers.

Prevalence and correlates of indirect sharing practices among young adult injection drug users in five U.S. cities

BACKGROUND

Sharing of drug paraphernalia to prepare, measure and divide drugs for injection remains an important residual risk factor for hepatitis C and other blood-borne infections among injection drug users (IDUs) especially as sharing of syringes for injection decreases.

METHODS

We analyzed data from five U.S. cities to determine the prevalence and independent correlates of non-syringe paraphernalia-sharing (NSPS) and syringe-mediated drug-splitting (SMDS) among 15-30-year-old IDUs who reported not injecting with others' used syringes (receptive syringe-sharing, RSS).

RESULTS

NSPS was reported by 54% of IDUs who did not practice RSS and was independently associated (p<0.05) with having > or =5 injection partners, injecting with sex partners or regular injection partners, injecting in shooting galleries, peers' sharing behaviors, lower self-efficacy for avoiding NSPS, and less knowledge of HIV and HCV transmission. SMDS was reported by 26% of IDUs who did not practice RSS, and was independently associated with having > or =5 injection partners, injecting in shooting galleries, and inversely associated with unknown HIV status.

CONCLUSIONS

NSPS and SMDS were common among young adult IDUs. Increased efforts to prevent these risky practices should address social and environmental contexts of injection and incorporate knowledge and skills building, self-efficacy, and peer norms.

Determinants of injection drug user (IDU) syringe sharing: the relationship between availability of syringes and risk network member characteristics in Winnipeg, Canada

AIMS

Despite the establishment of syringe exchange programmes, syringe-sharing behaviour remains common among some injection drug users (IDU). Previous studies have identified several individual- and social network-level variables associated with syringe sharing. We examine the extent to which each of these variables is related independently to this behaviour within a diverse study population.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey of 435 IDU conducted between December 2003 and September 2004 in Winnipeg, Canada.

MEASUREMENTS

Individual and social-network variables were obtained from a survey instrument administered through a personal interview. Syringe sharing was defined as receptive syringe sharing in the last 6 months. Logistic regression analysis with generalized estimating equations was used to determine simultaneously the role of individual-level and risk network member-level variables on the odds of syringe sharing.

FINDINGS

Individuals' relationship to a risk network member (sex partner, OR: 15.3 95% CI: 7.6-30.8; family member, OR: 3.4 95% CI: 1.3-9.0) and difficulty of access to syringes (OR: 3.6 95% CI: 1.3-9.9) were predictive of syringe sharing. Dyads who 'often' pooled resources to obtain drugs were at 4.9 times (95% CI: 2.1-11.6) the odds of syringe sharing, while those who 'sometimes' pooled resources were at 2.8 times (95% CI: 1.1-6.7) the odds, compared to those who 'never' pooled resources together.

CONCLUSIONS

Syringe sharing in this population depended on both the availability of clean syringes and social network relationships. Adopting interventions that take into account relationships and behaviours that shape social norms present in networks/dyads would be a necessary prevention strategy alongside the provision of clean syringes.

Multiperson Use of Syringes Among Injection Drug Users in a Needle Exchange Program

Syringe-sharing behaviors among injection drug users (IDUs) are typically based on self-reports and subject to socially desirable responding. We used 3 short tandem repeat (STR) genetic biomarkers to detect sharing in 2,512 syringes exchanged by 315 IDUs in the Baltimore needle exchange program (NEP; 738 person-visits). Demographic characteristics as well as direct and indirect needle-sharing behaviors corresponding to the closest AIDS Link to Intravenous Experience (ALIVE) study visits were examined for association with multiperson use (MPU) of syringes. Overall, 56% of the syringes exchanged at the Baltimore NEP had evidence of MPU. Less MPU of syringes (48% vs. 71%; P < 0.0001) was seen with more rapid syringe turnaround (<3 days). IDUs always exchanging their own syringes ("primary" syringes) were less likely to return syringes with evidence of MPU (52%) than those who exchanged syringes for others ("secondary" syringes; 64%; P = 0.0001) and those exchanging primary and secondary syringes (58%; P = 0.004). In a multivariate analysis restricted to primary exchangers, MPU of syringes was associated with sharing cotton (adjusted odds ratio [AOR] = 2.06, 95% confidence interval [CI]: 1.30 to 3.28), lending syringes (AOR = 1.70, 95% CI: 1.24 to 2.34), and injecting less than daily (AOR = 0.64, 95% CI: 0.43 to 0.95). These findings support additional public health interventions such as expanded syringe access to prevent HIV and other blood-borne infections. Testing of STRs represents a promising approach to examining and accessing complex behavioral data, including syringe sharing.

Demographic, risk behaviour and personal network variables associated with prevalent hepatitis C, hepatitis B, and HIV infection in injection drug users in Winnipeg, Canada

Background

Previous studies have used social network variables to improve our understanding of HIV transmission. Similar analytic approaches have not been undertaken for hepatitis C (HCV) or B (HBV), nor used to conduct comparative studies on these pathogens within a single setting.

Methods

A cross-sectional survey consisting of a questionnaire and blood sample was conducted on injection drug users in Winnipeg between December 2003 and September 2004. Logistic regression analyses were used to correlate respondent and personal network data with HCV, HBV and HIV prevalence.

Results

At the multivariate level, pathogen prevalence was correlated with both respondent and IDU risk network variables. Pathogen transmission was associated with several distinct types of high-risk networks formed around specific venues (shooting galleries, hotels) or within users who are linked by their drug use preferences. Smaller, isolated pockets of IDUs also appear to exist within the larger population where behavioural patterns pose a lesser risk, unless or until, a given pathogen enters those networks.

Conclusion

The findings suggest that consideration of both respondent and personal network variables can assist in understanding the transmission patterns of HCV, HBV, and HIV. It is important to assess these effects for multiple pathogens within one setting as the associations identified and the direction of those associations can differ between pathogens.

Detection of HIV-1 in injection paraphernalia: risk in an era of heightened awareness

Links between AIDS and self-injection of drugs were first recognized more than 20 years ago, but identification of a specific pathogen and ways to neutralize it has not led to complete success in preventing transmission of HIV-1 infection among injecting drug users (IDUs). A street ethnographer identified active risk locales (places where IDUs go to inject drugs) and recruited their proprietors into a study of contaminated injection paraphernalia. Collected paraphernalia from locales were analyzed for contamination by HIV-1 using real-time polymerase chain reaction (PCR). Proprietors and clientele of 16 risk locales participated by contributing used paraphernalia and/or agreeing to a blood test (0.5-1 mL drawn by finger stick). Realtime PCR was the primary measure used to determine contamination of injection paraphernalia and blood samples with HIV-1. Of 130 samples collected at baseline, a total of 8 were found to have evidence of HIV-1 contamination by detection of either HIV-1 RNA or DNA. The most serious contamination (up to 600,000 copies per milliliter) was found in ancillary paraphernalia, rather than needle/syringe (N/S) specimens. Only 4 of 74 N/S specimens had any evidence of HIV-1 contamination at all (with very low viral loads), and none had both HIV-1 DNA and RNA. Although IDUs in risk locales in Miami/Dade appear to be taking care of their N/S with regard to contamination by HIV-1, important evidence of contamination in ancillary paraphernalia, especially cookers and cottons, indicates that IDUs may still incur serious risk regardless of how well they care for their N/S. Our observations indicated that IDUs rinsed their N/S before returning them to the proprietors, from whom we eventually collected them, and this rinsing would have masked the contamination to which they were exposed through use of unrinsed cookers and reused cottons.

The dynamics of injection drug users' personal networks and HIV risk behaviors

AIMS

While studies of the social networks of injection drug users (IDUs) have provided insight into how the structures of interpersonal relationships among IDUs affect HIV risk behaviors, the majority of these studies have been cross-sectional. The present study examined the dynamics of IDUs' social networks and HIV risk behaviors over time.

DESIGN

Using data from a longitudinal HIV-intervention study conducted in Baltimore, MD, this study assessed changes in the composition of the personal networks of 409 IDUs. We used a multi-nomial logistic regression analysis to assess the association between changes in network composition and simultaneous changes in levels of injection HIV risk behaviors. Using the regression parameters generated by the multi-nomial model, we estimated the predicted probability of being in each of four HIV risk behavior change groups.

FINDINGS

Compared to the base case, individuals who reported an entirely new set of drug-using network contacts at follow-up were more than three times as likely to be in the increasing risk group. In contrast, reporting all new non-drug-using contacts at follow-up increased the likelihood of being in the stable low-risk group by almost 50% and decreased the probability of being in the consistently high-risk group by more than 70%.

CONCLUSIONS

The findings from this study show that, over and above IDUs' baseline characteristics, changes in their personal networks are associated with changes in individuals' risky injection behaviors. They also suggest that interventions aimed at reducing HIV risk among IDUs might benefit from increasing IDUs' social contacts with individuals who are not drug users.

Changes in the "get-off": social process and intervention in risk locales

Because of ongoing resistance in Florida's legislature to interventions involving exchanges of sterile syringes for contaminated ones, Miami/Dade County's population of injection drug users (IDUs) reduce risk of HIV and hepatitis C infection by buying illegal syringes, participating in illegal syringe exchanges, or decontaminating their paraphernalia. Although it is completely legal, wherewithal for decontamination of injection paraphernalia, including sodium hypochlorite (laundry bleach), water, and cotton for filtering drugs, only appears sporadically in Miami/Dade's risk locales (called "get-off" houses). To ensure consistent decontamination, our intervention instituted regular delivery of these goods to known risk locales. In addition, personnel in half of the locales received training in techniques for optimal decontamination. RNA polymerase chain reaction measured impact of this intervention in terms of viral load found on harvested paraphernalia. Regular delivery of cleansing paraphernalia provided opportunities for observation and characterization of adaptations among people who run risk locales. These people may lead highly stable lives or highly changeable ones, but in most cases their roles as regular hosts of injection activities continue with only brief hiatuses due to incarceration, eviction, or familial dissolution. Proprietors of risk locales maintain their roles as facilitators of self-injection because they use that role to make money or to obtain opportunities to inject drugs and also because their clientele demands they continue.

Cultural approach to HIV/AIDS harm reduction in Muslim countries

Muslim countries, previously considered protected from HIV/AIDS due to religious and cultural norms, are facing a rapidly rising threat. Despite the evidence of an advancing epidemic, the usual response from the policy makers in Muslim countries, for protection against HIV infection, is a major focus on propagating abstention from illicit drug and sexual practices. Sexuality, considered a private matter, is a taboo topic for discussion. Harm reduction, a pragmatic approach for HIV prevention, is underutilized. The social stigma attached to HIV/AIDS, that exists in all societies is much more pronounced in Muslim cultures. This stigma prevents those at risk from coming forward for appropriate counseling, testing, and treatment, as it involves disclosure of risky practices. The purpose of this paper is to define the extent of the HIV/AIDS problem in Muslim countries, outline the major challenges to HIV/AIDS prevention and treatment, and discuss the concept of harm reduction, with a cultural approach, as a strategy to prevent further spread of the disease. Recommendations include integrating HIV prevention and treatment strategies within existing social, cultural and religious frameworks, working with religious leaders as key collaborators, and provision of appropriate healthcare resources and infrastructure for successful HIV prevention and treatment programs in Muslim countries.

Elicitation of salient beliefs related to drug preparation practices among injection drug users in Puerto Rico

Even when IDUs use their own syringes, the common use of drug preparation materials can expose them to blood-borne pathogens. Notwithstanding the accumulated evidence about the riskiness of drug preparation practices (DPPs), the factors that lead IDUs to engage in DPPs have remained understudied. We conducted 80 semi-structured interviews to elicit salient beliefs about engaging in low-risk DPPs. Data were content analyzed for consequences, normative influences, and barriers. For the most part respondents described positive consequences of engaging in low-risk DPPs. The majority of respondents mentioned IDU peers as a major source of pressure to engage in high-risk DPPs. Lack of access to clean materials and the need to carry materials on oneself were the most salient barriers elicited. The results suggest that preventive interventions need to address the preference for re-using filters, help develop skills to fend off pressures from peers, and increase the accessibility of materials in ways that do not require IDUs to carry additional items.

Injecting shared drugs: an observational study of the process of drug acquisition, preparation, and injection by Puerto Rican drug users

The practice of injecting shared drugs, in which drug users prepare, divide and inject portions of a drug solution, is a means of transmitting HIV, HCV, and other blood-borne pathogens. This study examined the process of injecting shared drugs among drug users in San Juan, Puerto Rico, through detailed observations of 25 episodes of the injection of shared drugs, and by informal interviewing of episode participants. The ways in which price and packaging of drugs, access to drug preparation materials, and social and economic relations between drug-sharing "partners" influence the process of injecting shared drugs are explored. Because differential power relations, and in turn, injection drug users' exposure to HIV and HCV, are apparent in some drug-sharing partnerships, a key objective of this study was to extend our understanding of contributions or "investments" made by different drug-sharing partners, the benefits and costs that different partners experience, and the extent to which IDUs assume different partner roles. The findings of this small, in-depth qualitative study provide insight into drug users' motivations for injecting shared drugs, and suggest reasons why certain standardized, countrywide HIV/HCV intervention efforts have not been entirely successful in preventing the devastating illnesses that disproportionately affect injection drug users.

Drug sharing among heroin networks: implications for HIV and hepatitis B and C prevention

Qualitative and quantitative findings from the baseline survey of a longitudinal, socially-focused blood-borne disease intervention study among 611 heroin IDU in Denver indicate that high risk injection practices-the sharing of contaminated drug solution in particular-often occur as a consequence of how heroin is obtained, the quantity obtained and the setting where it is injected. Contamination occurs if a contaminated syringe is used to liquefy and apportion the shared drug. In our cohort of 304 heroin injecting networks there was at least one member who, when asked to describe their last injection, reported dividing the drug as a liquid (82%), using a reservoir of water that syringes had been rinsed in to mix drugs (67%), using a common cooker (86%)-a proxy for drug sharing-and beating a shared cotton filter (58%). In contrast, only 22% reported syringe sharing. Variables associated with various injection practices included location of the last injection episode, quantity of drug injected, dope sickness, and years injecting. When compared to those who injected in a safe setting, those in an unsafe location had almost three times the odds (OR = 2.9; 95% CI: 1.9, 4.6) of being part of an injection episode where there was cooker sharing; and the smaller the quantity of heroin (< or =1/4 gram v. > 1/4 gram) present at the episode, the greater the odds that cooker sharing occurred (OR = 1.8; 95% CI: 1.2, 2.6). Use of a used, unbleached syringe to prepare shared drugs had twice the odds of occurring in "unsafe" v. safe settings (OR = 2.2; 95% CI: 1.3, 4.0) and in episodes in which a participant was dopesick (OR = 2.1; 95% CI: 1.2, 3.6). In summary, risky injection practices occur within an injection process that is, in part, a response to a structurally imposed risk environment. Lessening the blood-borne disease risks embedded within this process requires interventions designed to mitigate the environmental factors that influence it, including syringe accessibility, law enforcement strategies and the settings where IDU inject drugs.

Changes in the sharing of drug injection equipment among street-recruited injection drug users in Chicago, Illinois, 1994--1996

This study examines changes in the multi-person use of drug injection paraphernalia during the mid-1990s, a time of increasing awareness of HIV transmission modes and availability of prevention programs. Beginning in 1994, 794 street-recruited injection drug users in Chicago were interviewed and followed at 6 and 12 months postbaseline. Random-effects, pattern-mixture logistic regression models were used to determine correlates of five injection-equipment sharing practices, while accounting for repeated measurement and study attrition. At baseline, 45.7% of participants reported receptive syringe sharing in the previous 6 months. Syringe-mediated sharing was reported by 28.7% of participants and the sharing of cookers (65.1%), cotton filters (55.7%), and rinse water (46.9%) was common. During follow-up, the proportion of all sharing behaviors decreased significantly, especially receptive syringe sharing. Participation in a syringe exchange program was associated with reductions in receptive syringe sharing and syringe-mediated sharing, but not the sharing of cookers.

Hepatitis C and its risk management among drug injectors in London: renewing harm reduction in the context of uncertainty

AIM

Recognizing the dearth of qualitative research on hepatitis C virus (HCV) infection associated with injecting drug use in the UK, this paper summarizes qualitative insights from a study exploring the social relations of HCV risk management among drug injectors in London.

METHOD

Adopting an inductive approach to data collection and analysis, 59 depth tape-recorded qualitative interviews were undertaken in 2001 with drug injectors recruited via drug user networks.

RESULTS

While access to injecting equipment was reportedly good, needle and syringe sharing continued in exceptional circumstances and in the context of 'trust relationships'. Analyses of drug injectors' accounts of variations of 'I never share' showed that this construction denoted less a descriptor of actual risk behaviour than presentation of perceived risk status. Paraphernalia sharing, including spoons and filters, was common. There was much confusion and uncertainty concerning HCV knowledge, including its medical and transmission risks. Injectors were aware of the provisionality and partiality of their HCV knowledge. Confusion also surrounded the meaning of HCV antibody test results, with some feeling that their positive diagnosis had been 'trivialized' by their experiences of HCV testing. Injectors tended to make sense of HCV risk in relation to HIV. With most viewing HCV prevalence as high and HCV transmission as an inevitable consequence of injecting, HCV risk was perceived as ubiquitous and unavoidable.

CONCLUSIONS

There is an urgent need to renew UK policies of harm reduction in order to support perceptions that HCV is avoidable and preventable.

Addressing the "risk environment" for injection drug users: the mysterious case of the missing cop

Ecological models of the determinants of health and the consequent importance of structural interventions have been widely accepted, but using these models in research and practice has been challenging. Examining the role of criminal law enforcement in the "risk environment" of injection drug users (IDUs) provides an opportunity to apply structural thinking to the health problems associated with drug use. This article reviews international evidence that laws and law enforcement practices influence IDU risk. It argues that more research is needed at four levels--laws; management of law enforcement agencies; knowledge, attitudes, beliefs, and practices of frontline officers; and attitudes and experiences of IDUs--and that such research can be the basis of interventions within law enforcement to enhance IDU health.

Social network correlates of self-reported non-fatal overdose

The leading cause of death among heroin users is drug overdose. The present study examined the relationship between history of self-reported drug overdoses and social network characteristics among cocaine and opiate users. Data were from cross-sectional surveys administered from March 2001 through February 2003 as part of follow-up of an experimental network oriented HIV prevention intervention. A total of 838 participants with histories of cocaine and opiate use completed the survey. Several social network variables were found to be significantly associated with drug overdose in the prior 2 years, including larger number of network members who were injection drug users and a larger number of conflictual ties among the network members. Even after controlling for age, gender, frequency of injection drug and alcohol use, and health status, network variables continued to have a strong association with history of recent overdose. These data suggest that large drug networks should be targeted for drug overdose prevention interventions.

Treatment of methamphetamine abuse: research findings and clinical directions

Over the past few years, methamphetamine has appeared in mass quantities, in part, because of the ease and cost efficiency of manufacturing. With this increase in availability, the use of methamphetamine has increased significantly. The purpose of this article is to describe the existing treatment options for methamphetamine abuse and provide recommendations for practitioners and researchers. Methamphetamine abuse adversely impacts physical functioning, brain functioning and cognition, social support and social networks, and behavioral functioning. Negative consequences have also been documented to the environment and communities. In the studies reviewed on effective treatments, interventions consisted of aversion therapy, medication, psychosocial treatment, and case management. Each specific treatment is described as connected with an overall drug treatment program. If methamphetamine abuse continues to increase and the consequences continue to be so devastating, researchers and clinicians could advance the field by particular focus on the treatment of this type of drug use.

Hepatitis-associated knowledge is low and risks are high among HIV-aware injection drug users in three US cities

AIMS

Injection drug use is a major risk factor for HIV and hepatitis infections. Whereas programs to prevent new infections have focused on HIV, they have generally neglected hepatitis B and C. This study was designed to examine the interrelationships among HIV and hepatitis knowledge, risky drug preparation and injection practices, and participation in syringe exchange programs (SEPs).

DESIGN

Surveys of injection drug users (IDUs) collected data on socio-demographics, medical history, drug use and injection practices, and HIV- and hepatitis-related knowledge.

SETTING

Inner-city US neighborhoods in Chicago, IL, Hartford, CT and Oakland, CA.

PARTICIPANTS

The study population was a convenience sample of 493 IDUs recruited using street outreach and snowball sampling strategies.

MEASUREMENTS

HIV and hepatitis knowledge, injection-related risks for virus transmission, associations between the two, and with SEP use.

FINDINGS

HIV knowledge was significantly higher than hepatitis knowledge among SEP customers and non-customers alike. Elevated hepatitis knowledge was associated with a history of substance abuse treatment, hepatitis infection, hepatitis B vaccination and injection practices that reduced contact with contaminated blood or water but not with SEP use. SEP customers were consistently less likely to engage in risk behaviors, with the notable exception of safely staunching blood postinjection.

CONCLUSION

Increased hepatitis awareness among IDUs is necessary for reducing hepatitis transmissions. Although SEPs continue to effectively disseminate HIV prevention messages-as evidenced by lowered risk behaviors among their customers-they must do more to prevent hepatitis transmissions.

Drug-scene roles and HIV risk among Puerto Rican injection drug users in East Harlem, New York and Bayamón, Puerto Rico

This article describes and compares distributions of drug-scene roles, frequency of engaging in role behaviors, and relationships of role-holding to high-risk behaviors and sexual partnerships among Puerto Rican injection drug users in New York and Puerto Rico. For this study 561 street-recruited injection drug users in East Harlem, New York, and 312 in Bayamón, Puerto Rico were asked the number of days (in the last 30) in which they earned money or drugs in each of seven drug-scene roles; and about behaviors and egocentric risk partner characteristics in the last 30 days. East Harlem subjects were more likely to get resources by selling drugs and syringes, and buying drugs for someone else; Bayamón subjects were more likely to be "hit doctors," buy needles for others, operate a shooting gallery, or escort others to shooting galleries. All roles were part-time except shooting gallery management in East Harlem. About 27% of respondents at each site engaged in two or more roles. Many roles were associated with increased odds of injecting more than twice a day, receptive syringe sharing, distributive syringe sharing, receptive paraphernalia sharing, and having a drug-injecting sex partner. Drug-scene role structures vary between cities. Most roles are part-time pursuits. Role-holders have higher-risk behaviors and sexual partnerships than other drug injectors. Although further research is needed, drug-scene role-holders should be targeted for interventions to affect their own risk and their communications with others.

Social factors related to syringe sharing among injecting partners: a focus on gender

The study of social networks has become an increasingly utilized method of examining the relationship between injection drug users' social environment and risk of HIV. This study examined relational aspects of two injection drug users (IDUs) within a single social network as they relate to sharing syringes. Data presented in this study were derived from baseline interviews of 508 IDUs from Baltimore, MD. Analyses were performed separately for male and female participants in an effort to understand gender differences in social aspects of syringe sharing. Among this sample, women shared syringes with a significantly higher percentage of injecting partners compared to men. In separate multilevel logistic regression models, significant variables associated with males' and females' syringe sharing were: sharing drugs daily with female injecting partners, injecting partners' provision of drugs when indexes' were withdrawing, being sexual partners, and injecting partners' injecting speedballs. Factors associated with male injecting dyads sharing of syringes were: being kin, injecting partners' injection of heroin and daily drug use, and drinking alcohol together. Results from this study demonstrate the usefulness of examining relationship characteristics of injecting dyads related to syringe sharing as they differ between men and women.

Residential status and HIV risk behaviors among Puerto Rican drug injectors in New York and Puerto Rico

This article investigates the association between residential status and human immunodeficiency virus (HIV) risk behaviors among island and New York Puerto Rican injection drug users (IDUs). We assigned 561 subjects from New York City and 312 from Puerto Rico to five residential status categories: living in parent's home, living in own home, living in other's home, living in temporary housing (hotel, single-room occupancy [SRO] hotels), and homeless (living in streets/shelters). Dependent variables included injection- and sex-related risk behaviors (sharing syringes, sharing other injection paraphernalia, shooting gallery use, and having paid sex). Chi square, t tests, and multivariate logistic analysis tests were performed separately by site. About one-quarter of the sample in each site was homeless. Island Puerto Ricans were more likely to live with their parents (44% vs. 12%, p < .001), and more New York IDUs lived in their own home (30% vs. 14%, p < .001). In New York, gallery use and paid sex were associated with living in other's home, living in parent's home, and being homeless. Sharing paraphernalia was related to living in other's home, living in temporary housing, and being homeless. In Puerto Rico, having paid sex was associated with homelessness. High-risk behaviors were more likely among homeless IDUs in both sites. Programs to provide housing and target outreach and other prevention programs for homeless IDUs would be helpful in reducing HIV risk.

A Cohort Study of Syringe Exchangers and Nonexchangers in San Francisco

This paper presents a cohort study of injection drug users (n=229) who did and did not use syringe exchange in San Francisco in 1993. Participants were interviewed at baseline, six months (49%), and 12 months (57%). At baseline, exchangers were less likely than nonexchangers to share syringes (21% vs. 37%), have multiple sharing partners (7% vs. 19%), and reuse their syringes (73% vs. 90%). These differences persisted in multivariate analysis adjusting for gender, age, race, education, and injection frequency. For the subset of participants who provided data at all three time points (n=101), rates of syringe sharing, syringe reuse, and indirect sharing decreased over time for both exchangers and nonexchangers. Nonetheless, levels of indirect sharing remained high among exchangers in this study (>45%) and decreased significantly less than nonexchanger levels over time. The implications of these Findings for syringe exchange programs and research are discussed.

Needle exchange program attendance and injection risk in Providence, Rhode Island

Needle sharing has long been recognized as a primary route of HIV infection. However, recent research has shown that HIV antibody is also detectable in injection supplies other than needles. In this study we tested frequency of attendance at a Providence, Rhode Island, needle exchange program (NEP) as a correlate of injection risk indicators including not just sharing needles but also sharing cookers, sharing cotton filters, cleaning the skin before injecting, and using bleach as a needle disinfectant. Results showed that drug users who attended the NEP less frequently were more likely to report needle sharing, less likely to report always cleaning their skin, and more likely to report sharing cookers. The Providence NEP is one at which alcohol swabs and cookers are distributed along with clean needles. Our results suggest that NEPs represent a valuable and underexploited opportunity to promote risk reduction efforts beyond the avoidance of needle sharing. NEPs should be distributing risk reduction supplies in addition to clean needles and should adopt strategies (e.g., outreach and more days/hours of operation) to encourage frequent attendance.