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Abstract: Although considerable research has been conducted to identify the behavioural characteristics that predispose individuals to inject drugs or become infected with HIV via injection drug use, much less research has been conducted on structural and policy determinants, cultural norms, stigma, and ecological factors which may affect drug use risk behaviour, users’ networks and HIV rates associated with drug use across geographic areas. For programme planners, whether official or grassroots, an understanding of place-based characteristics can help better identify risk environments to injection drug use-related HIV, and determine how to facilitate actions regarding public policy and harm reduction to aid in the reduction of risk. As such, we consider in this commentary the importance of geographic place and the socio-spatial and political processes related to place that may help determine where IDU-related HIV risk environments occur. [Copyright &y& Elsevier]

Abstract: Syringe exchange programs (SEPs) aim to reduce the harm associated with injection drug use (IDU). Although they have been accepted as critical components of HIV prevention in many parts of the world, they are often unwelcome and difficult to set up and maintain, even in communities hardest hit by IDU-related HIV transmission. This research examines socio-cultural and political processes that shape community and institutional resistance toward establishing and maintaining SEPs. These processes are configured and reinforced through the socio-spatial stigmatizing of IDUs, and legal and public policy against SEPs. Overarching themes the paper considers are: (1) institutional and/or political opposition based on (a) political and law enforcement issues associated with state drug paraphernalia laws and local syringe laws; (b) harassment of drug users and resistance to services for drug users by local politicians and police; and (c) state and local government (in)action or opposition; and (2) the stigmatization of drug users and location of SEPs in local neighborhoods and business districts. Rather than be explained by “not in my back yard” localism, this pattern seems best conceptualized as an “inequitable exclusion alliance” (IEA) that institutionalizes national and local stigmatizing of drug users and other vulnerable populations. [Copyright &y& Elsevier]

Abstract: Drawing upon the broader health, social, and political geography literature, this paper outlines a framework for considering place-based processes through which syringe exchange availability may be understood. It is argued that the geographic distribution of syringe exchange programs (SEPs) in the United States is linked to the social and political conditions of particular localities through three place characteristics: (1) structural constraints; (2) social and spatial distancing of injection drug users; and (3) localized action. Although SEPs remain controversial and face ongoing obstacles from the government, law enforcement and local communities, they continue to operate through the efforts of grassroots organizations and local activists. Action on this issue occurs locally, and the characteristics of place-based factors affect whether particular areas adopt SEPs. [Copyright &y& Elsevier]

Purpose We estimated female and male incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess whether declines in IARs varied by sex after combination antiretroviral therapy (cART) dissemination. Methods We compared IARs and 95% confidence intervals for female and male PWID in 95 of the most populous MSAs. To stabilize estimates, we aggregated data across three-year periods, selecting a period immediately preceding cART (1993–1995) and the most recent after the introduction of cART for which data were available (2005–2007). We assessed disparities by comparing IAR 95% confidence intervals for overlap, female-to-male risk ratios, and disparity change scores. Results IARs declined an average of 58% for female PWID and 67% for male PWID between the pre-cART and cART periods. Among female PWID, IARs were significantly lower in the later period relative to the pre-cART period in 48% of MSAs. Among male PWID, IARs were significantly lower over time in 86% of MSAs. Conclusions IARs among female PWID in large U.S. MSAs have declined more slowly than among male PWID. This suggests a need for increased targeting of prevention and treatment programs and for research on MSA level conditions that may drive differences in declining AIDS rates among female and male PWID. [ABSTRACT FROM AUTHOR]

Abstract: Drug-related law enforcement activities may undermine the protective effects of syringe exchange programs (SEPs) on local injectors'' risk of injection-related infections. We explored the spatial overlap of drug-related arrest rates and access to SEPs over time (1995–2006) in New York City health districts, and used multilevel models to investigate the relationship of these two district-level exposures to the odds of injecting with an unsterile syringe. Districts with better SEP access had higher arrest rates, and arrest rates undermined SEPs'' protective relationship with unsterile injecting. Drug-related enforcement strategies targeting drug users should be de-emphasized in areas surrounding SEPs. [Copyright &y& Elsevier]

Abstract: The concept of the “risk environment” – defined as the “space … [where] factors exogenous to the individual interact to increase the chances of HIV transmission” – draws together the disciplines of public health and geography. Researchers have increasingly turned to geographic methods to quantify dimensions of the risk environment that are both structural and spatial (e.g., local poverty rates). The scientific power of the intersection between public health and geography, however, has yet to be fully mined. In particular, research on the risk environment has rarely applied geographic methods to create neighbourhood-based measures of syringe exchange programmes (SEPs) or of drug-related law enforcement activities, despite the fact that these interventions are widely conceptualized as structural and spatial in nature and are two of the most well-established dimensions of the risk environment. To strengthen research on the risk environment, this paper presents a way of using geographic methods to create neighbourhood-based measures of (1) access to SEP sites and (2) exposure to drug-related arrests, and then applies these methods to one setting (New York City [NYC]). NYC-based results identified substantial cross-neighbourhood variation in SEP site access and in exposure to drug-related arrest rates (even within the subset of neighbourhoods nominally experiencing the same drug-related police strategy). These geographic measures – grounded as they are in conceptualizations of SEPs and drug-related law enforcement strategies – can help develop new arenas of inquiry regarding the impact of these two dimensions of the risk environment on injectors’ health, including exploring whether and how neighbourhood-level access to SEP sites and exposure to drug-related arrests shape a range of outcomes among local injectors. [Copyright &y& Elsevier]

Background: Substantial racial/ethnic disparities exist in HIV infection among people who inject drugs (PWID) in many countries. To strengthen efforts to understand the causes of disparities in HIV-related outcomes and eliminate them, we expand the "Risk Environment Model" to encompass the construct "racialized risk environments," and investigate whether PWID risk environments in the United States are racialized. Specifically, we investigate whether black and Latino PWID are more likely than white PWID to live in places that create vulnerability to adverse HIV-related outcomes.Methods: As part of the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance, 9170 PWID were sampled from 19 metropolitan statistical areas (MSAs) in 2009. Self-reported data were used to ascertain PWID race/ethnicity. Using Census data and other administrative sources, we characterized features of PWID risk environments at four geographic scales (i.e., ZIP codes, counties, MSAs, and states). Means for each feature of the risk environment were computed for each racial/ethnic group of PWID, and were compared across racial/ethnic groups.Results: Almost universally across measures, black PWID were more likely than white PWID to live in environments associated with vulnerability to adverse HIV-related outcomes. Compared to white PWID, black PWID lived in ZIP codes with higher poverty rates and worse spatial access to substance abuse treatment and in counties with higher violent crime rates. Black PWID were less likely to live in states with laws facilitating sterile syringe access (e.g., laws permitting over-the-counter syringe sales). Latino/white differences in risk environments emerged at the MSA level (e.g., Latino PWID lived in MSAs with higher drug-related arrest rates).Conclusion: PWID risk environments in the US are racialized. Future research should explore the implications of this racialization for racial/ethnic disparities in HIV-related outcomes, using appropriate methods. [ABSTRACT FROM AUTHOR]

Abstract: City-specific studies have suggested the quality of the local environment and economic circumstances are associated with greater risk of injection drug use (IDU). No studies have assessed the relation among the quality of the local environment, economic circumstances, and IDU over time across US metropolitan areas. Annual numbers of IDUs in the 88 largest US metropolitan statistical areas (MSAs) were estimated by extrapolating, adjusting, and allocating existing estimates using various data sources. Generalized estimating equations were used to assess the relation among the quality of the local environment, metropolitan political economy, and IDU prevalence using lagged models taking into account potential confounders. MSAs with a worse local environment (measured as a one standard deviation difference) had a greater risk of IDU (relative risk [RR]=1.03, 95% confidence interval [CI]: 1.01, 1.06); similarly, a one-percentage point worsening of the political economy for an MSA was associated with greater risk of IDU (RR=1.04–1.10). Final models stratified by region indicated heterogeneity of effect by region whereby the quality of the local environment was associated with IDU strongest in the South (RR=1.12, CI: 1.05, 1.12) followed by the West (RR=1.04, CI: 1.01, 1.07) and Midwest (RR=1.03, CI: 1.00, 1.06), and the metropolitan political economy was associated with IDU in the West (RR=1.03–1.09) and Northeast (RR=1.04–1.12). Our results underscore the importance of sociopolitical factors as determinants of IDU in MSAs. Structural solutions targeted at improving environmental conditions and economic circumstances should be considered as drug use interventions. [Copyright &y& Elsevier]

Background: The 2008 Recession was a global event that led to funding cuts for programs and services in the United States; though this recession officially ended in 2009, its aftershocks continued through 2012. We evaluated the relationship between the severity of the Great Recession's aftermath and spatial access to combined prevention services (i.e. HIV testing, syringe service programs, substance use disorder treatment program) for people who inject drugs (PWID) living in 19 metropolitan statistical areas (MSAs) in the United States.Methods: The unit of analysis was the ZIP code; we sampled ZIP codes in these 19 MSAs where ≥1 PWID lived in 2009 and 2012, according to the CDC's National HIV Behavioral Surveillance. We used administrative data to describe the combined prevention environment (i.e., spatial access to HIV testing) for each ZIP code, and measured the severity of the recession's aftermath in each ZIP code, and in the counties and MSAs where these ZIP codes were located. Multilevel modeling estimated associations between changes in the aftermath of the Great Recession and ZIP code-level changes in spatial access to combined prevention services from 2009 to 2012.Results: 675 ZIP codes located in 36 counties and 19 MSAs were included in this analysis. From 2009 to 2012, 21% of ZIP code areas lost access to combined prevention services and 14% gained access. ZIP codes with higher poverty rates relative to their respective MSAs were less likely to lose access (aOR: 0.91; 95% CI: 0.88, 0.95) and more likely to gain access (aOR: 1.05; 95% CI: 1.01, 1.09); there is some evidence to suggest the former association was attenuated for ZIP codes with higher percentages of non-Hispanic white residents.Conclusion: Combined prevention services for PWID living in these 675 ZIP codes demonstrated resilience in the aftermath of the Great Recession. Future research should explore whether community-based and federal HIV prevention initiatives contributed to this resilience, particularly in areas with higher concentrations of people of color. [ABSTRACT FROM AUTHOR]

Purpose: Investigate whether characteristics of geographic areas are associated with condomless sex and injection-related risk behavior among racial/ethnic groups of people who inject drugs (PWID) in the United States.Methods: PWID were recruited from 19 metropolitan statistical areas for 2009 National HIV Behavioral Surveillance. Administrative data described ZIP codes, counties, and metropolitan statistical areas where PWID lived. Multilevel models, stratified by racial/ethnic groups, were used to assess relationships of place-based characteristics to condomless sex and injection-related risk behavior (sharing injection equipment).Results: Among black PWID, living in the South (vs. Northeast) was associated with injection-related risk behavior (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.21-4.17; P = .011), and living in counties with higher percentages of unaffordable rental housing was associated with condomless sex (AOR = 1.02, 95% CI = 1.00-1.04; P = .046). Among white PWID, living in ZIP codes with greater access to drug treatment was negatively associated with condomless sex (AOR = 0.93, 95% CI = 0.88-1.00; P = .038).Conclusions: Policies that increase access to affordable housing and drug treatment may make environments more conducive to safe sexual behaviors among black and white PWID. Future research designed to longitudinally explore the association between residence in the south and injection-related risk behavior might identify specific place-based features that sustain patterns of injection-related risk behavior. [ABSTRACT FROM AUTHOR]