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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. [ABSTRACT FROM AUTHOR]

Aims: To measure mortality rates and factors associated with mortality risk among participants in the SuperMIX study, a prospective cohort study of people who inject drugs. Design: A prospective observational study using self‐reported behavioural and linked mortality data. Setting: Melbourne, Australia. Participants/cases: A total of 1209 people who inject drugs (67% male) followed‐up between 2008 and 2019 for 6913 person‐years (PY). Measurements We linked participant identifiers from SuperMIX to the Australian National Death Index and estimated all‐cause and drug‐related mortality rates and standardized mortality ratios (SMRs). We used Cox regression to examine associations between mortality and fixed and time‐varying socio‐demographic, alcohol and other drug use and health service‐related exposures. Findings Between 2008 and 2019 there were 76 deaths in the SuperMIX cohort. Of those with a known cause of death (n = 68), 35 (51%) were drug‐related, yielding an all‐cause mortality rate of 1.1 per 100 PY [95% confidence interval (CI) = 0.88–1.37] with an estimated SMR of 16.64 (95% CI = 13.29–20.83) and overall accidental drug‐induced mortality rate of 0.5 per 100 PY (95% CI = 0.36–0.71). Reports of recent use of ambulance services [adjusted hazard ratio (aHR) = 3.77, 95% CI =1.78–7.97] and four or more incarcerations (aHR = 2.78, 95% CI = 1.55–4.99) were associated with increased mortality risk. Conclusions: In Melbourne, Australia, mortality among people who inject drugs appears to be positively associated with recent ambulance attendance and experience of incarceration. [ABSTRACT FROM AUTHOR]

Aims: To estimate incidence of post‐release injecting drug use (IDU) among men who injected drugs before imprisonment and determine factors associated with post‐release IDU frequency. Design, setting, participants: Prospective cohort study of men reporting monthly IDU before a period of sentenced imprisonment in Victoria, Australia, recruited between September 2014 and May 2016 (n = 195). Measurements: Any post‐release IDU and IDU frequency was measured via self‐report at 3‐month follow‐up interview. IDU frequency, measured over the preceding month, was categorised as no IDU, irregular IDU (1–4 days IDU) and regular IDU (≥5 days IDU). Incidence of any IDU was calculated at 3 months post‐release. Factors associated with IDU frequency were estimated using ordinal logistic regression. Findings Most (83%) participants reported post‐release IDU (265 per 100 person‐years, 95% CI, 227–309); with half (48%) reporting regular IDU, 23% irregular IDU and 29% no IDU in the month preceding follow‐up. Poorer psychological well‐being at follow‐up (General Health Questionnaire [GHQ‐12] score; adjusted odds ratio [AOR], 1.18; 95% CI, 1.07–1.29) and post‐release unemployment (AOR, 4.57; 95% CI, 1.67–12.49) were associated with increased IDU frequency. Retention in opioid agonist treatment (AOR, 0.49; 95% CI, 0.24–0.98) was associated with reduced IDU frequency. Non‐linear (inverted‐u) associations between IDU frequency and age (age: AOR, 1.51; 95% CI, 1.17–1.96; age‐squared: AOR, 0.99; 95% CI, 0.99–0.99) and pre‐imprisonment IDU frequency (pre‐imprisonment IDU frequency: AOR, 1.36; 95% CI, 1.15–1.61; pre‐imprisonment IDU frequency‐squared: AOR, 0.99; 95% CI, 0.99–0.99) were found, with odds peaking at age 39 and 19 days IDU, respectively. Longer baseline sentence length was associated with reduced odds of irregular and regular IDU (AOR, 0.99; 95% CI, 0.99–0.99). Conclusion: Among Australian men who inject drugs before imprisonment, resumption of injecting drug use after release from prison appears to be common, with imprisonment seeming to have little impact on reducing injecting drug use behaviour. [ABSTRACT FROM AUTHOR]

It’s difficult to develop infectious disease interventions (such as for HIV) for overlapping high-risk populations such as people who inject drugs, men who have sex with men, and female sex workers, where there are multiple transmission routes. Recent advances in dynamic modelling of coinfection epidemics could disentangle the contributions of different risk groups and behaviours to help develop more efficient and effective prevention interventions.

Background and Aims: People who have recently injected drugs are a priority population in efforts to achieve hepatitis C virus (HCV) elimination. This study estimated the prevalence and number of people with recent injecting drug use living with HCV, and the proportion of people with recent injecting drug use among all people living with HCV infection at global, regional and country‐levels. Methods: Data from a global systematic review of injecting drug use and HCV antibody prevalence among people with recent (previous year) injecting drug use were used to estimate the prevalence and number of people with recent injecting drug use living with HCV. These data were combined with a systematic review of global HCV prevalence to estimate the proportion of people with recent injecting drug use among all people living with HCV. Results: There are an estimated 6.1 million [95% uncertainty interval (UI) = 3.4–9.2] people with recent injecting drug use aged 15–64 years living with HCV globally (39.2% viraemic prevalence; UI = 31.6–47.0), with the greatest numbers in East and Southeast Asia (1.5 million, UI = 1.0–2.1), eastern Europe (1.5 million, UI = 0.7–2.4) and North America (1.0 million, UI = 0.4–1.7). People with recent injecting drug use comprise an estimated 8.5% (UI = 4.6–13.1) of all HCV infections globally, with the greatest proportions in North America (30.5%, UI = 11.7–56.7), Latin America (22.0%, UI = 15.3–30.4) and eastern Europe (17.9%, UI = 8.2–30.9). Conclusions: Although, globally, 39.2% of people with recent injecting drug use are living with hepatitis C virus (HCV) and 8.5% of all HCV infections occur globally among people with recent injecting drug use, there is wide variation among countries and regions. [ABSTRACT FROM AUTHOR]

An editorial is presented which examines the authors' views about a variation in global statistics regarding the prevalence of injecting (intravenous) and opioid drug abuse, and it mentions how some studies use alternative information sources and give value to unreferened country estimates. The 2017 World Drug Report and a Global Burden of Disease (GBD) study are examined, along with cocaine and methamphetamine abuse.

Background and aims In Scotland, hepatitis B virus (HBV) vaccination for all prisoners was introduced in 1999; here, we examine the impact of this programme among people who inject drugs (PWID) in the community. This study aimed to compare rates of HBV vaccine uptake before and after implementation of the prison programme and to estimate the determinants of vaccine uptake, the levels of ever/current HBV infection and the associations between vaccine uptake and ever/current HBV infection. Design Data collected via serial cross-sectional surveys were used to compare the proportion who reported being vaccinated over time. For the 2013-14 survey, rates of ever/current HBV infection were calculated and the associations between vaccine uptake and ever/current HBV infection were examined using logistic regression. Setting Services providing injecting equipment and drug treatment and street sites in Glasgow (1993-2002) and throughout Scotland (2008-14). Participants More than 10 000 PWID in total were recruited in the surveys. Measurements Participants completed a questionnaire (all years) to ascertain self-reported vaccine uptake and provided a blood spot (in 2013-14), tested for HBV core antibodies (anti-HBc) and surface antigen (HBsAg). Findings Among recent-onset PWID in Glasgow, vaccine uptake increased from 16% in 1993 to 59% in 2008-14 ( P < 0.001). Among all PWID in Scotland, uptake increased further from 71% in 2008-09 to 77% in 2013-14 ( P < 0.001) and was associated with incarceration [adjusted odds ratio (aOR) = 2.91, 95% confidence interval (CI) = 2.23-3.79]. The prevalence of anti-HBc and HBsAg in Scotland was 2.6 and 0.3%, respectively, among PWID who had commenced injecting in the decade since the programme's introduction. Vaccination was associated with reduced odds of ever (aOR = 0.60, CI = 0.37-0.97) and current (aOR = 0.40, CI = 0.16-0.97) HBV infection. Conclusions In Scotland, uptake of hepatitis B virus (HBV) vaccination among people who inject drugs (PWID) in the community has increased since the 1999 introduction of universal prison vaccination, and current levels of HBV infection among PWID are low compared with other European countries. [ABSTRACT FROM AUTHOR]

Aims To estimate adherence and response to therapy for chronic hepatitis C virus (HCV) infection among people with a history of injecting drug use. A secondary aim was to identify predictors of HCV treatment response. Design Prospective cohort recruited between 2009 and 2012. Participants were treated with peg-interferon alfa-2a/ribavirin for 24 (genotypes 2/3, G2/3) or 48 weeks (genotype 1, G1). Setting Six opioid substitution treatment (OST) clinics, two community health centres and one Aboriginal community-controlled health organization providing drug treatment services in New South Wales, Australia. Participants Among 415 people with a history of injecting drug use and chronic HCV assessed by a nurse, 101 were assessed for treatment outcomes (21% female). Measurements Study outcomes were treatment adherence and sustained virological response (SVR, undetectable HCV RNA >24 weeks post-treatment). Findings Among 101 treated, 37% ( n = 37) had recently injected drugs (past 6 months) and 62% ( n = 63) were receiving OST. Adherence ≥ 80% was 86% ( n = 87). SVR was 74% (75 of 101), with no difference observed by sex (males: 76%, females: 67%, P = 0.662). In adjusted analysis, age < 35 (versus ≥ 45 years) [adjusted odds ratio (aOR) = 5.06, 95% confidence interval (CI) = 1.47, 17.40] and on-treatment adherence ≥ 80% independently predicted SVR (aOR = 19.41, 95% CI = 3.61, 104.26]. Recent injecting drug use at baseline was not associated with SVR. Conclusions People with a history of injecting drug use and chronic hepatitis C virus attending opioid substitution treatment and community health clinics can achieve adherence and responses to interferon-based therapy similar to other populations, despite injecting drugs at baseline. Younger age and adherence are predictive of improved response to hepatitis C virus therapy. [ABSTRACT FROM AUTHOR]

Aims To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods). Design A prospective cohort study. Setting Oslo, Norway. Participants A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004. Measurements Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated. Findings Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period. Conclusions Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods. [ABSTRACT FROM AUTHOR]

Background and Aims Treatment of injecting drug users (IDU) for hepatitis C virus (HCV) infection may prevent onward transmission. Treating individuals who often share injecting equipment is most likely to prevent new infections. However, these high-risk IDU are also more likely to become re-infected than low-risk IDU. We investigated to which group treatment is best targeted. Design We modelled the expected benefits per treatment of one chronically HCV-infected IDU in a population of low- and high-risk IDU. The benefits of treating one low- or one high-risk IDU were compared. Measurements Benefits included the probability for the treated IDU to become and remain uninfected, as well as the expected number of prevented infections to others (i.e. we quantified the total expected decrease in chronic infections). Findings We found a threshold in HCV-RNA prevalence above which treating low-risk IDU, and below which treating high-risk IDU, resulted in the greatest benefits. This threshold was at 50% of exchanged syringes being HCV contaminated. When 42% of IDU engaged in high-risk behaviour (borrowing and lending out syringes 7.3 times more frequently than low-risk IDU), the corresponding threshold of HCV-RNA prevalence among IDU was at 32%. Larger-risk heterogeneity led to a lower corresponding threshold among IDU. A combination of HCV treatment and 50% risk reduction was best directed at high-risk IDU for prevalence among syringes up to 59%. The threshold was marginally sensitive to changes in disease and treatment variables. Conclusions When more than half of all exchanged syringes in a population of injecting drug users (IDU) are contaminated by hepatitis C virus, it is most efficient to treat low-risk IDU first. Below this threshold, it is most efficient to treat high-risk IDU first. [ABSTRACT FROM AUTHOR]

Aims To assess systematically the risk of HIV acquisition by type of drug injected across different settings. Methods A systematic review and meta-analysis were conducted. Databases were searched for studies of HIV incidence in people who inject different drugs (PWID). Pooled HIV incidence rate ratio (IRR) was used to compare HIV risk between injecting and not-injecting a given drug, when possible, or otherwise with those reported not to have injected the substance. Pooled estimates of crude IRR were derived using random-effects models. Variations in IRR were assessed in subgroup analyses, by drug and geographical region. Results Of 5779 studies screened, 15 were included. HIV incidence was reported for people injecting cocaine (eight: North America, Europe), amphetamine-type stimulants (ATS) (four: Western and Eastern Europe, Asia), heroin (11: all settings), opiate-stimulants (four: North America, Western and Eastern Europe) and opiates-sedatives (five: Europe, Asia). HIV risk in cocaine injectors was 3.6 times 95% confidence interval (CI) = 2.8-4.7, I2 = 0%; n = 4) that of non-injectors and 3.0 for ATS injectors (95% CI = 2.2-4.1, I2 = 0%; n = 2). Higher sexual risk was reported in cohorts injecting stimulants. Compared to not-injecting, HIV IRR was 2.8 (95% CI = 1.7-4.7, I2 = 77%; n=6) for all heroin injectors and 3.5 (95% CI = 2.3-5.2, I2 = 40%; n=5) for heroin injectors in Asia and Europe. Conclusion The risk of HIV acquisition in people who inject drugs appears to vary by drug type but differences are not statistically significant, precluding conclusive grading of risk. [ABSTRACT FROM AUTHOR]

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

The authors reflect on ethical, economic, and evidential aspects concerning early treatment of Hepatitis C virus and prevention of infection for injection drug users. It considers the cost effectiveness of providing new hepatitis C virus treatments for people with early stages of liver disease who inject drugs. It talks about the lack of ethical grounds in denying treatment to drug users with moderate or severe liver disease.

Aims To examine changes in causes of death in a cohort treated for opioid dependence, across time and age; quantify years of potential life lost ( YPLL); and identify avoidable causes of death. Design People in New South Wales ( NSW) who registered for opioid substitution therapy ( OST), 1985-2005, were linked to a register of all deaths in Australia. Setting NSW, Australia. Measurements Crude mortality rates ( CMRs), age-sex-standardized mortality rates ( ASSRs) and standardized mortality ratios ( SMRs) across time, sex and age. Years of potential life lost ( YPLL) were calculated with reference to Australian life tables and by calculating years lost before the age of 65 years. Findings There were 43 789 people in the cohort, with 412 216 person-years of follow-up. The proportion of the cohort aged 40+ years increased from 1% in 1985 to 39% in 2005. Accidental opioid overdoses, suicides, transport accidents and violent deaths declined with age; deaths from cardiovascular disease, liver disease and cancer increased. Among men, 89% of deaths were potentially avoidable; among women, 86% of deaths were avoidable. There were an estimated 160 555 YPLL in the cohort, an average of 44 YPLL per decedent and an average of 29 YPLL before age 65 years. Conclusions Among a cohort of opioid-dependent people in New South Wales, 1985-2005, almost nine in 10 deaths in the cohort were avoidable. There is huge scope to improve mortality among opioid-dependent people. [ABSTRACT FROM AUTHOR]

Aims In Amsterdam, HIV prevalence has nearly halved among injecting drug users ( IDU) since 1990. Hepatitis C virus ( HCV) prevalence also declined; HIV and HCV incidence dropped to nearly zero. We examined possible explanations for these time trends, among which the implementation of harm reduction measures aimed at reducing the risk behaviour of IDU. Design We used individual-based modelling of the spread of HIV and HCV. Information about demographic parameters was obtained from the Amsterdam Cohort Study ( ACS) among drug users. The model included changes in inflow of new IDU and death rates over time, the latter dependent on age and time since HIV seroconversion. We considered different scenarios of risk behaviour. Setting IDU in Amsterdam. Measurements Simulated HIV and HCV incidence and prevalence were compared with ACS data. Findings Assuming that harm reduction measures had led to a strong decrease in risk behaviour over time improved the model fit (squared residuals decreased by 30%). However, substantial incidence and HIV prevalence decline were already reproduced by incorporating demographic changes into the model. In particular, lowered disease spread might be a result of depletion of high-risk IDU among those at risk for disease, and a decrease in the number of high-risk individuals in the population due to HIV-related mortality. Conclusions Marked decreases in HIV and HCV in Amsterdam since 1990 could be due partly to harm reduction measures; however, they may also be attributable largely to changes in the IDU population. Future research aimed at quantifying the benefits of interventions should not neglect the impact of natural epidemic progression and demographic changes. [ABSTRACT FROM AUTHOR]

Aims To investigate the impact of scaling-up opiate substitution therapy ( OST) and high coverage needle and syringe programmes (100% NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users ( IDUs). Design Hepatitis C virus HCV transmission modelling using UK estimates for effect of OST and 100% NSP on individual risk of HCV infection. Setting Range of chronic HCV prevalent (20/40/60%) settings with no OST/100% NSP, and UK setting with 50% coverage of both OST and 100% NSP. Participants Injecting drug users. Measurements Decrease in HCV prevalence after 5-20 years due to scale-up of OST and 100% NSP to 20/40/60% coverage in no OST/100% NSP settings, or from 50% to 60/70/80% coverage in the UK setting. Findings For 40% chronic HCV prevalence, scaling-up OST and 100% NSP from 0% to 20% coverage reduces HCV prevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100% NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100% NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ≥80%. Conclusions Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims We explored social factors affecting access to antiretroviral HIV treatment (ART) among people who inject drugs (PWID) in a Russian city with a large HIV burden. Design Qualitative interview study. Setting Community settings in Ekaterinburg, Russian Federation. Participants 42 PWID living with HIV and 11 health practitioners. Measurements Thematic analyses of in-depth qualitative interviews. Findings Access to ART was felt by participants to be contingent upon their capacity to demonstrate a commitment to becoming 'drug free'. We identify, across interview accounts, a treatment access narrative of 'treat drugs before HIV'. This narrative is upheld by ART providers' concerns to maximize clinical outcome in the face of adherence doubts, as well as by would-be patients' perceptions of expectations placed upon them by the treatment system and their own doubts regarding treatment engagement. This has the effect of reproducing a habit of ART delay and disengaging people from the treatment system. Difficulties accessing ART, and the perceived rationing of treatment on account of untreated drug use, were experienced as 'moral discipline' for falling short of treatment 'deservedness'. Participants describe a 'Catch 22' system, where they are invited to treat their drug use in a setting where effective drug treatment was perceived as unavailable. Conclusions Inadequate drug treatment practices act as structural obstacles to realizing HIV treatment. Evidence internationally suggests that effective drug treatment, including opioid substitution therapy, improves access and adherence to antiretroviral treatment among people who inject drugs. Policy shifts are urgently needed in this setting to enable systemic improvements to drug treatment, especially given large HIV treatment demand. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim To explore the facilitators of long-term hepatitis C avoidance among people who inject drugs. Design We employed a qualitative life history design. Setting Recruitment took place through low-threshold drug services and drug user networks in South East and North London. Participants were interviewed at the recruitment services or in their homes. Participants The sample comprised 35 people who inject drugs, 20 of whom were hepatitis C antibody-negative. Participants' average injecting trajectory was 19 years (6-33), with 66% primarily injecting heroin, and 34% a crack and heroin mix. Nine (26%) of the sample were female and the average age was 39 years (23-53). Measurements Two interviews were conducted with each participant, with the second interview incorporating reference to a computer-constructed life history time-line. Interview accounts were audiorecorded, transcribed verbatim and analysed thematically. Findings Hepatitis C risk awareness was recent and deprioritized by the majority of participants. The facilitation of venous access and care was an initial and enduring rationale for safe injecting practices. Difficult venous access resulted in increased contamination of injecting environments and transitions to femoral injecting. Participants expressed an unmet desire for non-judgemental venous access information and advice. Conclusions Harm reduction interventions which attend to the immediate priorities of people who inject drugs, such as venous access and care, have the potential to re-engage individuals who are jaded or confused by hepatitis C prevention messages. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims We conducted a systematic review of studies reporting seroincidence of hepatitis C infection (HCV) in relation to shared syringes and drug preparation equipment among injection drug users (IDUs). We identified published and unpublished studies that met inclusion criteria. Design We estimated the relative contributions of shared syringes and drug preparation equipment to HCV transmission using random-effects meta-analysis, and analyzed potential sources of heterogeneity of effects among studies. Findings Syringe sharing was associated with HCV seroconversion [pooled risk ratio (PRR) = 1.94, 95% confidence interval (CI) 1.53, 2.46], as was sharing drug preparation containers (PRR = 2.42, 95% CI 1.89, 3.10), filters (PRR = 2.61, 95% CI 1.91, 3.56), rinse water (PRR = 1.98, 95% CI 1.54, 2.56), combinations of this equipment (PRR = 2.24, 95% CI 1.28, 3.93) and 'backloading', a syringe-mediated form of sharing prepared drugs (PRR = 1.86, 95% CI 1.41, 2.44). Meta-regression results showed that the association between syringe sharing and seroconversion was modified by HCV seroprevalence in the IDU populations. Conclusions The risk of hepatitis C infection through shared syringes is dependent upon hepatitis C infection seroprevalence in the population. The risk of hepatitis C infection through shared drug preparation equipment is similar to that of shared syringes. Because the infection status of sharing partners is often unknown, it is important for injection drug users to consistently avoid sharing unsterile equipment used to prepare, divide or inject drugs and avoid backloading with an unsterile syringe. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims The hepatitis C virus (HCV) disease burden among injecting drug users (IDUs) is determined by HCV incidence, the long latency period of HCV, competing mortality causes, presence of co-infection and HCV treatment uptake. We examined the effect of these factors and estimated the HCV disease burden in Amsterdam. Design A Markov model was developed, incorporating HCV and human immunodeficiency virus (HIV), and parameterized with data from the Amsterdam Cohort Studies, surveillance studies and literature. Setting IDU population of Amsterdam. Measurements HCV infection simulated from its acute phase to HCV-related liver disease (i.e. decompensated cirrhosis and hepatocellular carcinoma). Findings The HCV prevalence among IDUs in Amsterdam increased to approximately 80% in the 1980s. From 2011 to 2025, the HCV-related disease prevalence will accordingly rise by 36%, from 57 cases (95% range 33-94) to 78 (95% range 43-138), respectively. In total, 945 (95% range 617-1309) individuals will develop HCV-related liver disease. This burden would have been 33% higher in the absence of HIV, resulting in 1219 cases (95% range 796-1663). In Amsterdam, 25% of HIV-negative IDUs receive successful HCV treatment, reducing the cumulative disease burden by 14% to 810 (95% range 520-1120). Further reduction of 36% can be achieved by improving treatment, resulting in 603 cases (95% range 384-851). Conclusions The hepatitis C virus burden among injecting drug users in Amsterdam has been reduced by a high competing mortality rate, particularly caused by HIV infection, and to a smaller extent by hepatitis C virus treatment. Improved hepatitis C virus treatment is expected to contribute to reduce the future hepatitis C virus disease burden. [ABSTRACT FROM AUTHOR]

To evaluate the efficacy, safety and adherence to hepatitis C (HCV) therapy in patients attending tertiary hepatitis clinics who are receiving opioid replacement therapy. A non-randomized, open-label study. Participants were treated with pegylated interferon alpha-2a and weight-based ribavirin for 24 weeks (genotype non-1, n = 31) or 48 weeks (genotype 1, n = 22). Four tertiary hospital hepatitis clinics in Australia. Fifty-three patients with chronic HCV who were receiving opioid replacement therapy Patients were monitored for virological response, adverse events and adherence. They were also screened for psychiatric illness prior to and throughout the study utilizing two validated instruments: the Mini International Neuropsychiatric Interview (MINI) and Beck Depression Interview (BDI)-II. The overall sustained virological response (SVR) rate was 57% (71% genotype non-1 versus 36% genotype 1), and was similar in active injectors (63%) and non-injectors (53%). The psychological profile of patients based on validated instruments did not change on therapy. The pattern and frequency of adverse effects were comparable to non-opioid replacement patients. Eighty-five per cent of patients were adherent to therapy by 80/80/80 criteria and only two patients who had an end-of-treatment response relapsed, one of whom was not an active injector. Patients on opioid replacement therapy, even if they continue to inject actively, can achieve comparable sustained virological response rates to other populations with pegylated interferon alpha-2a and ribavirin therapy, suffer no excess rates of adverse effects or psychological complications and have good adherence to therapy. [ABSTRACT FROM AUTHOR]

To examine the self-reported personal wellbeing of a sample of Australian injecting drug users (IDU) using a standardized instrument and determine the key correlates of variations in self-reported personal wellbeing. Cross-sectional survey of 881 Australian IDU. Self-reported personal wellbeing collected using the Personal Wellbeing Index (PWI). IDU scored significantly lower than the general Australian population on the PWI and all subscales. Lower PWI scores were associated with a range of socio-demographic, drug use and other health and social characteristics. Across all PWI subscales, lower personal wellbeing scores were associated with unemployment, past 6-month mental health problems and more frequent injecting (all P < 0.05). The PWI is sufficiently sensitive to distinguish between IDU and the general population, and to identify key correlates of PWI among IDU. Some domains canvassed within the scale, such as health, standard of living and life achievements, are well within the scope of current intervention strategies, such as pharmacotherapy maintenance treatment and housing and employment support services. This suggests that the PWI could be useful in clinical settings by allowing structured identification of the areas of a person's life to be addressed as a part of a treatment regimen. In order to inform targeted prevention and intervention efforts, longitudinal studies of PWI and its correlates among IDU are required. [ABSTRACT FROM AUTHOR]

Aims To illustrate the impact of different proportions of injecting drug users (IDUs) sharing high dead-space syringes (HDSS) or low dead-space syringes (LDSS) on the probability of human immunodeficiency virus (HIV) transmission; and thus the impact on injection-related HIV prevalence and incidence. Design A stochastic mathematical model was used to evaluate the impact of HDSS use in high- and low-risk IDU populations. Model parameters were obtained from peer-reviewed publications. Analytical solutions of a simplified deterministic model were obtained to explain the effect of HDSS on HIV endemic states. Findings Simulation analysis shows that the HIV epidemic could be sustained even when a small percentage of sharing (10%) involved HDSS. The effect is much stronger in high-risk compared with low-risk populations. Steady state HIV prevalence increases with the proportion of HDSS, and for high- and low-risk populations reaches around 80% and 20%, respectively. For low-risk populations, the use of LDSS could result in the virtual elimination of HIV. These results are dependent upon an evidence-supported assumption of a significant difference in HIV transmission risk associated with HDSS versus LDSS. Conclusions Our models suggest that injection-related HIV epidemics may not occur when most (e.g. 95% or more) IDUs use LDSS. While these results are based on indirect risk measures and a number of simplifying assumptions, the effect of blood retained in high dead-space syringes on HIV prevalence seems to be very strong, even using relatively conservative assumptions. The findings have potential implications for needle exchange programs and the types of syringes produced and distributed world-wide. [ABSTRACT FROM AUTHOR]

Aims Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy. Design Ecological study of patterns in ambulance attendances at opioid-related overdoses, before and after the opening of a SIF in Sydney, Australia. Setting A SIF opened as a pilot in Sydney's ‘red light’ district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses. Measurements A total of 20 409 ambulance attendances at opioid-related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid-related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW). Results The burden on ambulance services of attending to opioid-related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity. Conclusions By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community. [ABSTRACT FROM AUTHOR]

Objectives To estimate the impact of injecting drug use (IDU) on mortality in HIV-infected patients in the highly active antiretroviral therapy (HAART) era. Design Population-based, nation-wide prospective cohort study in Denmark (the Danish HIV Cohort Study). Methods A total of 4578 HIV-infected patients were followed from 1 January 1997 or date of HIV diagnosis. We calculated mortality rates stratified on IDU. One-, 5- and 10-year survival probabilities were estimated by Kaplan–Meier methods, and Cox regression analyses were used to estimate mortality rate ratios (MRR). Results Of the patients, 484 (10.6%) were categorized as IDUs and 4094 (89.4%) as non-IDUs. IDUs were more likely to be women, Caucasian, hepatitis C virus (HCV) co-infected and younger at baseline; 753 patients died during observation (206 IDUs and 547 non-IDUs). The estimated 10-year survival probabilities were 53.2% [95% confidence interval (CI): 48.1–58.3] in the IDU group and 82.1% (95% CI: 80.7–83.6) in the non-IDU group. IDU as route of HIV infection more than tripled the mortality in HIV-infected patients (MRR: 3.2; 95% CI: 2.7–3.8). Adjusting for potential confounders did not change this estimate substantially. The risk of HIV-related death was not increased in IDUs compared to non-IDUs (MRR 1.1; 95% CI 0.7–1.7). Conclusions Although Denmark's health care system is tax paid and antiretroviral therapy is provided free of charge, HIV-infected IDUs still suffer from substantially increased mortality in the HAART era. The increased risk of death seems to be non-HIV-related and is due probably to the well-known risk factors associated with intravenous drug abuse. [ABSTRACT FROM AUTHOR]

Background Human immunodeficiency virus (HIV) outbreaks occur among injecting drug users (IDUs), but where HIV is low insight is required into the future risk of increased transmission. The relationship between hepatitis C virus (HCV) and HIV prevalence among IDUs is explored to determine whether HCV prevalence could indicate HIV risk. Methods Systematic review of IDU HIV/HCV prevalence data and regression analysis using weighted prevalence estimates and time–series data. Results HIV/HCV prevalence estimates were obtained for 343 regions. In regions other than South America/sub-Saharan Africa (SAm/SSA), mean IDU HIV prevalence is likely to be negligible if HCV prevalence is <30% (95% confidence interval 22–38%) but increases progressively with HCV prevalence thereafter [linearly (β = 0.39 and R2 = 0.67) or in proportion to cubed HCV prevalence (β = 0.40 and R2 = 0.67)]. In SAm/SSA, limited data suggest that mean HIV prevalence is proportional to HCV prevalence (β = 0.84, R2 = 0.99), but will be much greater than in non-SAm/SSA settings with no threshold HCV prevalence that corresponds to low HIV risk. At low HCV prevalences (<50%), time–series data suggest that any change in HIV prevalence over time is likely to be much smaller (<25%) than the change in HCV prevalence over the same time-period, but that this difference diminishes at higher HCV prevalences. Conclusions HCV prevalence could be an indicator of HIV risk among IDUs. In most settings, reducing HCV prevalence below a threshold (30%) would reduce substantially any HIV risk, and could provide a target for HIV prevention. [ABSTRACT FROM AUTHOR]

Objective To assess trends in injecting and non-injecting drug use after implementation of large-scale syringe exchange in New York City. The belief that implementation of syringe exchange will lead to increased drug injecting has been a persistent argument against syringe exchange. Methods Administrative data on route of administration for primary drug of abuse among patients entering the Beth Israel methadone maintenance program from 1995 to 2007. Approximately 2000 patients enter the program each year. Results During and after the period of large-scale implementation of syringe exchange, the numbers of methadone program entrants reporting injecting drug use decreased while the numbers of entrants reporting intranasal drug use increased ( P < 0.001). Conclusion While assessing the possible effects of syringe exchange on trends in injecting drug use is inherently difficult, these may be the strongest data collected to date showing a lack of increase in drug injecting following implementation of syringe exchange. [ABSTRACT FROM AUTHOR]

Objective To determine risk factors and estimate their population-level contribution to hepatitis C virus (HCV) burden. Methods Established and potentially modifiable risk factors were estimated using partial population attributable risk ( PARp) in a cohort of new injecting drug users (IDUs) in Sydney, Australia. Results A total of 204 hepatitis C seronegative IDUs were recruited through street-based outreach, methadone clinics and needle and syringe programmes (NSPs) and followed-up at 3–6-monthly intervals. A total of 61 HCV seroconversions were observed during the follow-up [overall incidence rate of 45.8 per 100 person-years (95% confidence interval: 35.6–58.8)]. Overall, five potentially modifiable risk factors (sharing needles/syringes, sharing other injecting equipment, assisted injecting, frequency of injection and not being in drug treatment) accounted for approximately 50% of HCV cases observed. Conclusion While sharing needles/syringes or other injecting equipment were associated most strongly with increased risk of HCV infection, the PARp associated with these behaviours was relatively modest (12%) because they are relatively low-prevalence behaviours. Our analyses suggest that more HCV infection could be avoided by changing more common, but less strongly associated behaviours such as assisted injecting or daily injecting. Results suggest that to have a very substantial effect on HCV, a range of risk factors need modifying. The most efficient use of scarce resources in reducing HCV infections will require complex balancing between the PAR for a given risk factor(s), the efficacy of interventions to actually modify the risk factor, and the cost of these interventions. [ABSTRACT FROM AUTHOR]

Objective To trace the growth of syringe exchange programs (SEPs) in the United States since 1994–95 and assess the current state of SEPs. Methods Annual surveys of US SEPs known to North American Syringe Exchange Network (NASEN). Surveys mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. Results The numbers of programs known to NASEN have increased from 68 in 1994–95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment, human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counseling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of SEPs in 2007. Conclusions While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing SEPs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of SEPs in the United States. [ABSTRACT FROM AUTHOR]

Aims (i) To compare indirect estimation methods to obtain mean injecting drug use (IDU) prevalence for a confined geographic location; and (ii) to use these estimates to calculate IDU and injection coverage of a medically supervised injecting facility. Design Multiple indirect prevalence estimation methods. Setting Kings Cross, Sydney, Australia. Participants IDUs residing in Kings Cross area postcodes recorded in surveillance data of the Sydney Medically Supervised Injecting Centre (MSIC) between November 2001 and October 2002. Measurements Two closed and one open capture–recapture (CRC) models (Poisson regression, truncated Poisson and Jolly–Seber, respectively) were fitted to the observed data. Multiplier estimates were derived from opioid overdose mortality data and a cross-sectional survey of needle and syringe programme attendees. MSIC client injection frequency and the number of needles and syringes distributed in the study area were used to estimate injection prevalence and injection coverage. Findings From three convergent estimates, the mean estimated size of the IDU population aged 15–54 years was 1103 (range 877–1288), yielding a population prevalence of 3.6% (2.9–4.3%). Mean IDU coverage was 70.7% (range 59.1–86.7%) and the mean adjusted injection coverage was 8.8% (range 7.3–10.8%). Approximately 11.3% of the total IDU population were estimated to be new entrants to the population per month. Conclusions Credible local area IDU prevalence estimates using MSIC surveillance data were obtained. MSIC appears to achieve high coverage of the local IDU population, although only an estimated one in 10 injections occurs at MSIC. Future prevalence estimation efforts should incorporate open models to capture the dynamic nature of IDU populations. [ABSTRACT FROM AUTHOR]

Background Intervention impact on reductions in hepatitis C virus (HCV) incidence among injecting drug users (IDUs) are modest. There is a need to explore how drug injectors' interpret HCV risk. Aims To review English-language qualitative empirical studies of HCV risk among IDUs. Methods Qualitative synthesis using a meta-ethnographic approach. Searching of eight electronic databases and reference lists identified manually papers in peer-reviewed journals since 2000. Only studies investigating IDU perspectives on HCV risk were included. Themes across studies were identified systematically and compared, leading to a synthesis of second- and third-order constructs. Findings We included 31 papers, representing 24 studies among over 1000 IDUs. Seven themes were generated: risk ubiquity; relative viral risk; knowledge uncertainty; hygiene and the body; trust and intimacy; risk environment; and the individualization of risk responsibility. Evidence supports a perception of HCV as a risk accepted rather than avoided. HCV was perceived largely as socially accommodated and expected, and in relative terms to human immunodeficiency virus (HIV) as the ‘master status’ of viral dangers. Symbolic knowledge systems, rather than biomedical risk calculus, and especially narratives of hygiene and trust, played a primary role in shaping interpretations of HCV risk. Critical factors in the risk environment included policing, homelessness and gendered risk. Conclusions Appealing to risk calculus alone is insufficient. Interventions should build upon the salience of hygiene and trust narratives in HCV risk rationality, and foster community changes towards the perceived preventability of HCV. Structural interventions in harm reduction should target policing, homelessness and gendered risk. [ABSTRACT FROM AUTHOR]

Background We report on an exploratory qualitative study investigating drug injectors' narratives of vein damage and groin (femoral vein) injection associated with the injection of crack–heroin speedball. Methods We undertook 44 in-depth qualitative interviews among injectors of crack–heroin speedball in Bristol and London, England, in 2006. Findings The data suggest an emerging culture of crack-based speedball injection. Injectors' narratives link speedball injection with shifts towards groin injection articulated as an acceptable risk, and not merely as a last resort in the face of increased vein deterioration associated with speedball. Accounts of vein damage linked to speedball emphasize ‘missed hits’ related to the local anaesthetic action of crack, the excess use of citric in the preparation of speedball injections and ‘flushing’ when making a hit. We find that groin injection persists despite an awareness of health risks and medical complications. Conclusions We emphasize an urgent need for reviewing harm reduction in relation to vein care in the context of shifts to crack-based speedball injection, and the use of the femoral vein, among UK injectors. There is an additional need for interventions to promote safer groin and speedball injecting as well as to prevent transitions toward groin and crack injection. [ABSTRACT FROM AUTHOR]

Objectives To investigate the impact of harm-reduction programmes on HIV and hepatitis C virus (HCV) incidence among ever-injecting drug users (DU) from the Amsterdam Cohort Studies (ACS). Methods The association between use of harm reduction and seroconversion for human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) was evaluated using Poisson regression. A total of 714 DU were at risk for HIV and/or HCV during follow-up. Harm reduction was measured by combining its two most important components—methadone dose and needle exchange programme (NEP) use—and looking at five categories of participation, ranging from no participation (no methadone in the past 6 months, injecting drug use in the past 6 months and no use of NEP) to full participation (≥ 60 mg methadone/day and no current injecting or ≥ 60 mg methadone/day and current injecting but all needles exchanged). Results Methadone dose or NEP use alone were not associated significantly with HIV or HCV seroconversion. However, with combination of these variables and after correction for possibly confounding variables, we found that full participation in a harm reduction programme (HRP) was associated with a lower risk of HIV and HCV infection in ever-injecting drug users (DU), compared to no participation [incidence rate ratio 0.43 (95% CI 0.21–0.87) and 0.36 (95% CI 0.13–1.03), respectively]. Conclusions In conclusion, we found that full participation in HRP was associated with a lower incidence of HCV and HIV infection in ever-injecting DU, indicating that combined prevention measures—but not the use of NEP or methadone alone—might contribute to the reduction of the spread of these infections. [ABSTRACT FROM AUTHOR]

Aims To characterize heroin and cocaine users in New York City who have changed from injection to non-injection drug administration and to identify factors associated with long-term non-injection use. Design Two cross-sectional studies of heroin and cocaine users in New York City. Settings and participants New admissions were recruited at drug abuse treatment programs (2000–04) and respondent-driven sampling was used to recruit drug users from the community (2004). Both injecting and non-injecting drug users participated in each study. ‘Former injectors’ were defined operationally as people who had used heroin and/or cocaine in the 6 months prior to the interview and who had injected illicit drugs in the past, but whose most recent injection was more than 6 months before the study interview. ‘Current’ injectors were defined as people who had injected heroin and/or cocaine in the 6 months prior to the interview. Measurements A structured interview on drug use history was administered, and a serum sample was collected and tested for the human immunodeficiency virus (HIV). Findings A total of 104 former injectors was recruited for the drug abuse treatment program study, and 229 current injectors were recruited for the community recruitment study; 160 former injectors and 1731 current injectors were recruited from the drug abuse treatment study. Compared with the current injectors, former injectors were older and more likely to be African American. The former injectors reported long intervals since their most recent injection, a mean of 8 years in the drug abuse treatment program study and a mean of 12 years in the community recruitment study. The most common reasons for stopping injection drug use included concerns about health, social stigmatization and self-image, and preference for intranasal use as a route of drug administration. The results were highly consistent across the two studies. Conclusions The transition from injection to non-injection use appears to be relatively stable behavior change for many former injectors, who report a decade or more without injecting. Developing a greater understanding of the transition from injection to stable non-injection drug use may provide insights into the natural histories of drug use and addiction. [ABSTRACT FROM AUTHOR]

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term ‘harm reduction’ is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term ‘harm reduction’ and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of ‘harm reduction’ and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A ‘model package’ for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses. [ABSTRACT FROM AUTHOR]

Aims To determine the incidence of hepatitis C virus (HCV) infection and identify risk factors for seroconversion. Design Prospective cohort study. Participants were recruited through direct approaches, street-based outreach, methadone and sexual health clinics and needle and syringe programmes. Setting Urban, regional and rural settings in New South Wales, Australia. Participants Injecting drug users (IDUs) ( n = 584) were screened and tested for exposure to HCV. Between 1999 and 2002 antibody HCV negative IDUs ( n = 368) were enrolled and followed-up every 3–6 months until seroconversion or study completion. Measurements Interviewer-administered baseline and follow-up questionnaires consisted of 131 items and included demographics, drug use and risk behaviour. Approximately 10 cc of whole blood was drawn at each visit. Specimens were stored at −70C and serology performed using one or two third-generation enzyme-linked immunosorbent assays and polymerase chain reaction testing. Findings Sixty-eight seroconversions were observed and incidence was 30.8 per 100 person-years, with incidence in IDUs injecting < 1 year, 133 per 100 person-years. Independent predictors of seroconversion were female gender, duration of injecting, injecting cocaine, shared use of filters and recruitment strategy. Conclusions Women, new initiates and IDUs recruited via outreach appear to be at increased risk of infection. Results confirm the significance of cocaine injection as a risk factor and provide the first evidence outside North America of the link between shared use of drug preparation equipment and incident HCV infection. Prevention efforts should attempt to raise awareness of the risks associated with drug sharing and, in particular, the role of potentially contaminated syringes in HCV infection. [ABSTRACT FROM AUTHOR]

Background One key structural dimension in the distribution of drug-related harm associated with injecting drug use is the injecting environment. Epidemiological evidence associates elevated blood-borne viral risk with injecting in ‘public’ and ‘semipublic’ environments. Yet the quality of evidence on public injecting and related viral risk is variable, and is lacking in many countries such as the United Kingdom. Aim This commentary considers the micro-injecting environment as a critical dimension of risk, exploring the need for ‘safer injecting environment interventions’. Methods We draw upon published research evidence and qualitative case examples. Results We note the limits in epidemiological evidence on public injecting and emphasize the need for ethnographic research to determine the ‘social relations’ of how drug users and risk practices interact with injecting environments. We identify three main forms of ‘safer environment intervention’: purpose-built drug consumption rooms; interventions within existing spatial relations; and spatial programming and urban design. While drug consumption rooms find evidence-based support, they are not a panacea. We emphasize the potential of interventions embedded within existing spatial and social relations. These include low-cost pragmatic interventions enhancing facilities and safety at public and semipublic injecting sites and, primarily, peer-based interventions, including peer-supervised injecting sites. We caution against spatial programming and urban design interventions which can cause the displacement of socially marginalized populations and the redistribution of harm. Conclusions Public health interventions in the addictions field have in the past focused upon individual behavioural change at the cost of social interventions and environmental change. We wish to focus greater attention on reducing risks related to public injecting and encourage greater debate on ‘safer environment interventions’ in harm reduction. [ABSTRACT FROM AUTHOR]

Objectives To estimate the prevalence of HIV, hepatitis C virus (HCV) and syphilis in injecting drug users (IDUs) in Russia. Methods Unlinked anonymous cross-sectional survey of 1473 IDUs recruited from non-treatment settings in Moscow, Volgograd and Barnaul (Siberia), with oral fluid sample collection for HIV, HCV antibody (anti-HIV, anti-HCV) and syphilis testing. Results Prevalence of antibody to HIV was 14% in Moscow, 3% in Volgograd and 9% in Barnaul. HCV prevalence was 67% in Moscow, 70% in Volgograd and 54% in Barnaul. Prevalence of positive syphilis serology was 8% in Moscow, 20% in Volgograd and 6% in Barnaul. Half of those HIV positive and a third of those HCV positive were unaware of their positive status. Common risk factors associated with HIV and HCV infection across the cities included both direct and indirect sharing of injecting equipment and injection of home-produced drugs. Among environmental risk factors, we found increased odds of anti-HIV associated with being in prison in Moscow, and some association between official registration as a drug user and anti-HIV and anti-HCV. No associations were found between sexual risk behaviours and anti-HIV in any city. Conclusions HIV prevalence among IDUs was markedly higher than city routine surveillance data suggests and at potentially critical levels in terms of HIV prevention in two cities. HCV prevalence was high in all cities. Syphilis prevalence highlights the potential for sexual risk and sexual HIV transmission. Despite large-scale testing programmes, knowledge of positive status was poor. The scaling-up of harm reduction for IDUs in Russia, including sexual risk reduction, is an urgent priority. [ABSTRACT FROM AUTHOR]

This study sought to estimate the prevalence of injecting drug users (IDU) in Togliatti city and to examine the implications of these estimates for HIV prevalence and harm reduction.Routine data sources of IDUs were identified. Covariate capture–recapture techniques were used on the individuals identified on the three data sources and used to estimate the number of IDU‘not observed’ by the data sources, and thereby estimate the prevalence of IDU.Togliatti City, Samara Oblast, Russian Federation.IDUs recorded on three data sources (narcology records, HIV positive test results and police arrest data) during 2001.Poisson regression models were fitted to the observed data, with interactions between data sources fitted to replicate‘dependencies’ between those data sources. To select the best model the goodness of fit was approximated byχ2 distribution and the best-fitting model was selected on the basis of standard information criteria and log likelihood ratio tests.The total estimated population of IDUs is 20 226[95% confidence interval (CI): 16 971–24 749] giving a population prevalence of 5.4% (95% CI: 4.5–6.6%) of the registered population and 2.7% (95% CI: 2.4–3.5%) of the population (including migrants) aged 15–44 years. For every one IDU in contact with a service there were three out of contact.There is a high prevalence of IDU which, in the context of a fast-emerging IDU-associated HIV epidemic, will have serious public health implications. [ABSTRACT FROM AUTHOR]

To develop and evaluate a brief intervention for reducing risk behaviours associated with HCV transmission in injecting drug users (IDU). Randomized controlled trial of an individually tailored brief behavioural intervention (BBI) (experimental) versus a standardized educational intervention (control). Specialist drug treatment facility in Melbourne, Australia. One hundred and forty-five IDU (aged 18 or over, injecting at least weekly in the preceding 6 months) recruited and randomized to the experimental condition ( n = 73) or the control condition ( n = 72). The BBI was based on the Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ)—a standardized blood-borne virus risk assessment instrument comprising injecting risk, sexual risk and other skin penetration risk subscales. The BBV-TRAQ was used to identify individual HCV risk practices and to tailor the 30-minute experimental BBI. Control participants received a standardized HCV educational session, using current educational materials. BBV-TRAQ subscale and total scores and measures of participant satisfaction. One hundred and twenty-four participants (86%) were followed-up at 4 weeks (±7 days). Analyses revealed a significant reduction in HCV risk behaviours for both groups at 1-month follow-up, with participants in the experimental BBI condition reporting higher overall satisfaction with the intervention compared to the control group. Both groups reported significant reductions in risk behaviour, indicating that while BBI methods hold promise for HCV education and prevention, they were not demonstrated to be more effective than the provision of standard educational materials. Future research could evaluate the efficacy of the BBV-TRAQ as a risk behaviour intervention and counselling tool in clinical, NSP and peer education settings. [ABSTRACT FROM AUTHOR]

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

ABSTRACT Aims As conceptualized by Robert Park in 1928, the ‘marginal man’ occupies simultaneously an intermediate point between two distinct cultures that embody some level of contradictory normative expectations, behaviors and beliefs. This paper explores the influence of ageing and social change on the creation of marginality among injection drug users over age 50 who have been chronic heroin users since their youth. Design Our data are drawn from in-depth interviews with 40 (28 male and 12 female) not-in-drug-treatment, active injecting drug users between the ages of 18 and 68. Setting Our sample was recruited using street outreach as part of a larger, community-based study conducted from a converted storefront in a high crime, economically depressed neighborhood on the west side of Chicago. Findings As they aged, and under the pressures of social change, the older users whom we studied moved from center positioning in the illicit drug culture of their youth to the margins of a differing drug culture of today where they participate largely unseen by others. Nostalgic for the ‘Old School’ mores of the past, and unable to transcend or assimilate fully into the cultural practices and norms of the ‘New’, they respond to their predicament by embracing ‘poise’ in the face of loneliness, stress and fear of victimization. Conclusions Our respondents’ experiences draw attention to the need to refine the field's theoretical and practical understandings of what it means to be marginal and its consequences for older drug users and people in general. The results also point to what happens when society changes but some of its members do not. [ABSTRACT FROM AUTHOR]

Aims: To describe syringe exchange provision in the United Kingdom. Design: Two-phase cross-sectional survey: phase I, establishing a sampling frame of syringe exchange coordinators (n = 420); phase II, surveying the coordinators seeking data on the number of syringe exchange outlets, visits and syringes distributed during April 1997 (68% response rate). Setting: United Kingdom. Findings: In 1997, nearly all Health Authorities in the United Kingdom (96%) operated some form of syringe exchange service, except Northern Ireland. In April 1997, 1 707 000 syringes were reported as being distributed. Assuming that non-responders coordinated the median number of outlets and distributed the median number of syringes as responders, we estimate that 27 million syringes were distributed annually from over 2000 outlets in the United Kingdom. The number distributed in Scotland was 3-4 times less than in England when measured as a number per adult (15-44), drug user in treatment, or estimated injecting drug user. Conclusions: Overall, there has been a 6.5-fold increase in syringe distribution in England since 1991. The number of syringes distributed in the United Kingdom may be higher than the United States. However, there appears to be unequal distribution of syringes within the United Kingdom, which may be associated with higher levels of HCV among injectors in Scotland compared to England. [ABSTRACT FROM AUTHOR]

In this article the author focuses on the development of harm reduction programmes in the U.S., and the importance of these programmes to injecting drug users (IDUs). The author examines the study conducted by Des Jarlais and colleagues which examined approaches to help IDUs and the future of harm reduction in the U.S. The author recommends making a provision that will permit billing of harm reduction services to health insurance companies though contracting.

The authors discuss the study on the impacts of opiate substitution treatment (OST) in lessening the risk of hepatitis C virus (HCV). They mention that OST averts infections having projections from Great Britain which suggest that OST high coverage levels might have contributed to lessening the chronic HCV prevalence. They say that it appears that there needs to be no argument in scaling-up OST because economic analyses recommend that OST could be cost-saving.

In this article the author discusses the study of M. J. Milloy and colleagues on the mortality rates of drug overdose among First Nation people in a Canadian setting. It notes that there are steps to be prioritized to turn around overdose-related mortality among the indigenous people in Canada. The author says that as there is minimal study on overdose mortality among indigenous people in developed nations, it is safe to assume an even greater dearth for indigenous people in developing nations.