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BackgroundThe social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual's first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID.MethodsParticipants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019-2020 about assisting with another person's first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics.ResultsAt baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1-4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4-4.6]), syringe sharing (2.2 [1.2-3.9]), and injecting ≥3 times per day (2.0 [1.2-3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person's lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury.ConclusionPWID with a history of assisting with another person's first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.

BackgroundDrug use is a growing concern in Ghana. People who inject drugs (PWID) are highly vulnerable to HIV and other infectious diseases. Ghana's National Strategic Plan for HIV/AIDS 2016-2020 identifies PWID as a key population, but efforts to address the needs of PWID have lagged behind those targeting sex workers and men who have sex with men. Lack of information about PWID is a critical barrier to implementing effective HIV prevention and treatment. We aimed to learn more about the vulnerability of the PWID population in order to inform much-needed harm reduction interventions.MethodsFrom April to July 2018, we conducted a mixed methods study in Kumasi, Ghana, to identify all major drug using locations, count the numbers of PWID to obtain rough population size estimations, and administer anonymous surveys to 221 PWID regarding drug use and sexual behavior. We also tested for HIV, HCV, and HBV from syringes used by survey participants.ResultsKey informants identified five major drug using locations and estimated the total PWID population size to be between 600 and 2000. Enumerators counted between 35 and 61 individuals present at each of the five bases. Sharing syringes and reusing discarded syringes are common practices. Over half of survey participants (59%) reported past-month syringe sharing (34% used a used syringe and 52% gave away a used syringe). Individuals with higher injection frequency (≥ 21 times weekly) and who injected with four or more people had higher odds of syringe sharing. Of the survey participants reporting sex in the last month (23%), most reported having one partner, but only 12% used condoms. Nearly all women (11/13) reported exchanging sex for drugs and 6/13 reported exchanging sex for money in the last six months. Fifteen percent of participants (all men) reported paying for sex using drugs or money. Of the used syringes, prevalence estimates were 3% (HIV), 2% (HCV), and 9% (HBV).ConclusionsOur findings confirm the urgent need to implement harm reduction interventions targeting PWID and to build a strong and enabling legal and policy environment in Ghana to support these efforts.

Background and aimsSyringe-sharing among people who inject drugs, which can occur during incarceration and post-release, has been linked with increased risk of blood-borne infections. We aimed to investigate the cumulative effect of repeated incarceration and the post-release period on receptive syringe-sharing.DesignOngoing community-based cohort, recruited through targeted sampling between 2011 and 2012 with 6-month follow-ups.SettingTijuana, Mexico.ParticipantsSample of 185 participants (median age 35 years; 67% female) with no history of incarceration at study entry, followed to 2017.MeasurementsCumulative incarceration and post-release period were constructed from incarceration events reported in the past 6 months for each study visit. Receptive syringe-sharing in the past 6 months was assessed as a binary variable. We used logistic regression with generalized estimating equations to examine the association between cumulative incarceration events and the post-release period with receptive syringe-sharing over time. Missing data were handled through multiple imputation.FindingsAt baseline, 65% of participants engaged in receptive syringe-sharing in the prior 6 months. At follow-up, 150 (81%) participants experienced a total of 358 incarceration events [median = 2, interquartile range (IQR) = 1-3]. The risk of receptive syringe-sharing increased with the number of repeated incarcerations. Compared with never incarcerated, those with one incarceration had 1.28 [95% confidence interval (CI) = 0.97-1.68] higher adjusted odds of syringe-sharing; two to three incarcerations, 1.42 (95% CI = 1.02-1.99) and more than three incarcerations, 2.10 (95% CI = 1.15-3.85). Participants released within the past 6 months had 1.53 (95% CI = 1.14-2.05) higher odds of sharing syringes compared with those never incarcerated. This post-release risk continued up to 1.5 years post-incarceration (adjusted odds ratio = 1.41, 95% CI = 1.04-1.91), but then waned.ConclusionsA longitudinal community cohort study among people who inject drugs suggested that the effects of incarceration on increased injecting risk, measured through syringe-sharing, are cumulative and persist during the post-release period.

The opioid epidemic is one of the greatest public health problems that the USA faces. Opioid overdose death rates have increased steadily for more than a decade and doubled in 2013-17, as the highly potent synthetic opioid fentanyl entered the drug supply. Demographics of new HIV diagnoses among people who inject drugs are also changing, with more new HIV diagnoses occurring among White people, young people (aged 13-34 years), and people who reside outside large central metropolitan areas. Racial differences also exist in syringe sharing, which decreased among Black people and Hispanic people but remained unchanged among White people in 2005-15. Recent HIV outbreaks have occurred in rural areas of the USA, as well as among marginalised people in urban areas with robust HIV prevention and treatment services (eg, Seattle, WA). Multiple evidence-based interventions can effectively treat opioid use disorder and prevent HIV acquisition. However, considerable barriers exist precluding delivery of these solutions to many people who inject drugs. If the USA is serious about HIV prevention among this group, stigma must be eliminated, discriminatory policies must change, and comprehensive health care must be accessible to all. Finally, root causes of the opioid epidemic such as hopelessness need to be identified and addressed.

IntroductionThe HIV epidemic in Tijuana, Mexico is concentrated in key populations, including people who inject drugs (PWID). However, HIV interventions among PWID are minimal, and federal funding was provided for compulsory abstinence programmes associated with HIV and overdose. Alternatively, opioid agonist therapy reduces overdose, reincarceration, HIV, while improving antiretroviral therapy (ART) outcomes. We assessed potential impact and synergies of scaled-up integrated ART and opioid agonist therapy, compared to scale-up of each separately, and potential harms of compulsory abstinence programmes on HIV and fatal overdose among PWID in Tijuana.MethodsWe developed a dynamic model of HIV transmission and overdose among PWID in Tijuana. We simulated scale-up of opioid agonist therapy from zero to 40% coverage among PWID. We evaluated synergistic benefits of an integrated harm reduction and ART scale-up strategy (40% opioid agonist therapy coverage and 10-fold ART recruitment), compared to scale-up of each intervention alone or no scale-up of low coverage ART and no harm reduction). We additionally simulated compulsory abstinence programmes (associated with 14% higher risk of receptive syringe sharing and 76% higher odds of overdose) among PWID.ResultsWithout intervention, HIV incidence among PWID could increase from 0.72 per 100 person-years (PY) in 2020 to 0.92 per 100 PY in 2030. Over ten years, opioid agonist therapy scale-up could avert 31% (95% uncertainty interval (UI): 18%, 46%) and 22% (95% UI: 10%, 28%) new HIV infections and fatal overdoses, respectively, with the majority of HIV impact from the direct effect on HIV transmission due to low ART coverage. Integrating opioid agonist therapy and ART scale-up provided synergistic benefits, with opioid agonist therapy effects on ART recruitment/retention averting 9% more new infections compared to ART scale-up alone. The intervention strategy could avert 48% (95% UI: 26%, 68%) of new HIV infections and one-fifth of fatal overdoses over ten years. Conversely, compulsory abstinence programmes could increase HIV and overdoses.ConclusionsIntegrating ART with opioid agonist therapy could provide synergistic benefits and prevent HIV and overdoses among PWID in Tijuana, whereas compulsory abstinence programmes could cause harm. Policymakers should consider the benefits of integrating harm reduction and HIV services for PWID.

Cross-border infectious disease transmission is a concern related to drug tourism from the U.S. to Mexico. We assessed this risk among people who inject drugs (PWID) in Tijuana, Mexico. We measured the prevalence and identified correlates of injecting with PWID visiting from the U.S. among PWID in Tijuana using univariable and multivariable logistic regression. Of 727 participants, 18.5% injected during the past 6 months in Mexico with U.S. PWID described mostly as friends (63%) or acquaintances (26%). Injecting with U.S. PWID was independently associated with higher education [adjusted odds ratio (aOR) = 1.13/year], deportation from the U.S. (aOR = 1.70), younger age at first injection (aOR = 0.96/year), more lifetime overdoses (aOR = 1.08), and, in the past 6 months, backloading (aOR = 4.00), syringe confiscation by the police (aOR = 3.02) and paying for sex (aOR = 2.98; all p-values

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

BackgroundHCV incidence is increasing in the US, notably among younger people who inject drugs (PWID). In a cohort of young adult (age

BackgroundEfforts to prevent injection drug use (IDU) are increasingly focused on the role that people who inject drugs (PWID) play in the assistance with injection initiation. We studied the association between recent (ie, past 6 months) injection-related HIV risk behaviors and injection initiation assistance into IDU among PWID in the US-Mexico border region.SettingPreventing Injecting by Modifying Existing Responses (PRIMER) is a multicohort study assessing social and structural factors related to injection initiation assistance. This analysis included data collected since 2014 from 2 participating cohorts in San Diego and Tijuana.MethodsParticipants were 18 years and older and reported IDU within the month before study enrollment. Logistic regression analyses were conducted to assess the association between recent injection-related HIV risk behaviors (eg, distributive/receptive syringe sharing, dividing drugs in a syringe, and paraphernalia sharing) and recent injection initiation assistance.ResultsAmong 892 participants, 41 (4.6%) reported recently providing injection initiation assistance. In multivariable analysis adjusting for potential confounders, reporting a higher number of injection-related risk behaviors was associated with an increased odds of recently assisting others with injection initiation (adjusted odds ratio per risk behavior: 1.3; 95% confidence interval: 1.0 to 1.6, P = 0.04).ConclusionsPWID who recently engaged in one or more injection-related HIV risk behavior were more likely to assist others in injection initiation. These results stress the syndemic of injection initiation and risk behaviors, which indicates that prevention of injection-related HIV risk behaviors might also reduce the incidence of injection initiation.

BackgroundA large body of research has investigated the rise of injection drug use and HIV transmission in Tijuana and Ciudad Juarez (CJ). However, little is known about the dynamics of injecting in Hermosillo. This study compares drug-related behaviors and risk environment for HIV of people who inject drugs (PWID) across Tijuana, CJ, and Hermosillo to identify factors that could explain differences in HIV prevalence.MethodsData from Tijuana belong to a prospective study (El Cuete IV). Data from Hermosillo and Ciudad Juarez belong to a cross-sectional study. Both studies collected data in places where PWID spend time. All participants completed quantitative behavioral and serological testing for HIV. Datasets were merged using only comparable variables. Descriptive statistics tests were used to compare sociodemographic and behavioral characteristics of people who inject drugs PWID sampled in each city. A logistic regression model was built to identify factors independently associated with the likelihood of reporting receptive syringe sharing in the past 6 months.ResultsA total of 1494 PWID provided data between March 2011 and May 2012. HIV prevalence differed significantly between participants in Tijuana (4.2%), CJ (7.7%), and Hermosillo (5.2%; p

BackgroundTo date, research applying the Sexual Relationship Power Scale (SRPS) has been limited to sexual risk behaviors.ObjectiveWe measured levels of sexual relationship power and examined associations between sexual relationship power and injecting and sexual behaviors that place women at increased risk for blood borne infections.MethodsUsing data from a cross-sectional study of young women who inject drugs (WWID) in San Francisco, USA, logistic regression analysis identified independent associations between SRPS and subscale scores (relationship control [RC] and decision making dominance [DMD]) and injecting and sexual behaviors.ResultsOf the 68 young WWID, 24 (34%) reported receptive syringe sharing, 38 (56%) reused/shared a cooker to prepare drugs, and 25 (37%) injected someone else's drug residue during the three-months prior to enrollment. Most (60, 88%) reported condomless sex with main sex-partner, 8 (12%) reported transactional sex, and 36 (53%) had two or more recent sex partners. The median SRPS score was 2.98 (IQR: 2.65, 3.18), 3.23 (IQR: 3.23, 3.57) for RC and 2.40 (IQR: 2.20, 2.60) for DMD. No significant associations were detected between SRPS or DMD and injecting or sexual risk behaviors. After adjusting for gender and years injecting, for every one-point increase in RC, women had a 6.70 lower odds of recent condomless sex (95%CI: 0.92, 50.00, p = 0.06), and a 3.90 lower odds of recent transactional sex (95%CI: 1.22, 12.50, p = 0.02).ConclusionOur study findings suggest that some components of sexual relationship power may play a role in sexual risk, but not in injecting risk.

We examined the association of dyadic-level factors with syringe sharing among people who inject drugs (PWID) in Kerman, Iran. In a cross-sectional study, we collected data on 329 drug-injecting dyads by individual face-to-face interviews. An injecting dyad was defined as 2 PWID who knew each other and injected drugs together during the last 6 months. If they reported at least 1 occasion of syringe sharing, the dyad was considered high-risk. Dyadic-level factors associated with syringe sharing were assessed using cross-classified multilevel logistic regression. The rate of syringe sharing was significantly higher for dyads who were more intimate (adjusted odds ratio [AOR] 4.5, CI 95%, 2.3-8.6), who had instrumental support (AOR 2.1, 95% CI 1.1-4.5), and who pooled money for drugs (AOR 4.1, 95% CI 2.0-8.3). The rate was lower in same-sex dyads (AOR 0.4, 95% CI 0.2-0.9) and in dyads who shared health information (AOR 0.5, 95% CI 0.2-0.9). Findings highlight close-peer influences on syringe-sharing behavior.

People who inject drugs (PWID) in Tijuana, Mexico, use heroin and/or methamphetamine. While polydrug use is associated with HIV risk behavior, less is known about the stability of polydrug use patterns over time and how polydrug use is related to perceived treatment need. Within a cohort of PWID in Tijuana (N = 735) we sought to (1) characterize subgroups of polydrug and polyroute use from baseline to six months; (2) determine the probabilities of transitioning between subgroups; and (3) examine whether self-reported need for help for drug use modified these transition probabilities. Latent transition analysis (LTA) identified four latent statuses: heroin-only injection (38% at both baseline and follow-up); co-injection of heroin with methamphetamine (3% baseline, 15% follow-up); injection of heroin and methamphetamine (37% baseline, 32% follow-up); and polydrug and polyroute users who injected heroin and both smoked and injected methamphetamine (22% baseline, 14% follow-up). Heroin-only injectors had the highest probability of remaining in the same latent status at follow-up. The majority reported great or urgent need for treatment (51%) and these PWID had greater odds of transitioning to a higher-risk status at follow-up, emphasizing the need for evidence-based drug treatment options for PWID.

Introduction and aimsPatterns of polydrug use among people who inject drugs (PWID) may be differentially associated with overdose and unique human immunodeficiency virus (HIV) risk factors. Subgroups of PWID in Tijuana, Mexico, were identified based on substances used, route of administration, frequency of use and co-injection indicators.Design and methodsParticipants were PWID residing in Tijuana age ≥18 years sampled from 2011 to 2012 who reported injecting an illicit substance in the past month (n = 735). Latent class analysis identified discrete classes of polydrug use characterised by 11 indicators of past 6 months substance use. Multinomial logistic regression examined class membership association with HIV risk behaviours, overdose and other covariates using an automated three-step procedure in mplus to account for classification error.ResultsParticipants were classified into five subgroups. Two polydrug and polyroute classes were defined by use of multiple substances through several routes of administration and were primarily distinguished from each other by cocaine use (class 1: 5%) or no cocaine use (class 2: 29%). The other classes consisted primarily of injectors: cocaine, methamphetamine and heroin injection (class 3: 4%); methamphetamine and heroin injection (class 4: 10%); and heroin injection (class 5: 52%). Compared with the heroin-only injection class, memberships in the two polydrug and polyroute use classes were independently associated with both HIV injection and sexual risk behaviours.Discussion and conclusionsSubstance use patterns among PWID in Tijuana are highly heterogeneous, and polydrug and polyroute users are a high-risk subgroup who may require more tailored prevention and treatment interventions. [Meacham MC, Roesch SC, Strathdee SA, Lindsay S, Gonzalez-Zuniga P, Gaines TL. Latent classes of polydrug and polyroute use and associations with human immunodeficiency virus risk behaviours and overdose among people who inject drugs in Tijuana, Baja California, Mexico. Drug Alcohol Rev 2018;37:128-136].

BackgroundPeople who inject drugs with sexual partners or close friends have high rates of syringe/ancillary equipment sharing and HIV and hepatitis C virus (HCV) infection. Although evidence suggests that interpersonal factors underlie these higher risk profiles, there is no quantitative measure of how interpersonal factors operate within injecting relationships. We aimed to develop and validate a quantitative scale to assess levels of injecting drug-related interpersonal factors associated with risky injecting behaviours within injecting partnerships.MethodsWe conducted qualitative interviews with 45 people who inject drugs (PWID) who reported having injecting partners to inform item development, and tested these items in a quantitative study of 140 PWID from San Francisco, USA, to assess internal reliability (Cronbach's alpha) and validity (convergent, and discriminant validity).ResultsWith results from the qualitative interview data, we developed the Interpersonal Dynamics in Injecting Partnerships (IDIP) scale with 54 final items for 5 subscales of injecting-related interpersonal factors. Exploratory factor analysis revealed 5 factors ("trust", "power", "risk perception", "intimacy", and "cooperation") with eigenvalues of 14.32, 6.18, 3.55, 2.46, and 2.14, explaining 57% of the variance, and indicating good internal reliability (alpha: 0.92-0.68). Strong convergent validity was observed in bivariate logistic regression models where higher levels of trust, intimacy, and cooperation within partnerships were positively associated with partners sharing needles and injecting equipment, whereas higher levels of power and risk perception were negatively associated with partners sharing needles and injecting equipment.ConclusionsThese findings offer strong evidence that the IDIP scale provides a psychometrically sound measure of injecting drug-related interpersonal dynamics. This measurement tool has the potential to facilitate additional investigations into the individual and collective impact of trust, intimacy, power, cooperation, and risk perception on injection drug using behaviours and engagement in HIV and HCV testing and treatment among PWID in a variety of settings.

BackgroundInjection drug use remains a primary driver of HIV and HCV-related harms globally. However, there is a gap in efforts to prevent individuals from transitioning into injecting. People who inject drugs (PWID) play a key role in the transition of others into injecting, and while behavioral interventions have been developed to address this phenomenon, socio-structural approaches remain unexplored. To that end, we hypothesize that certain interventions designed to reduce injecting-related risk behaviors may also reduce the risk that PWID expose and introduce others into injecting. Identifying the preventive potential of existing interventions will inform broader efforts to prevent injecting and related harms.MethodsThe Preventing Injecting by Modifying Existing Responses (PRIMER) study is a multi-country mixed methods study with an aim to investigate whether specific interventions (e.g., opioid substitution therapy, supervised injection facilities, stable housing, incarceration environments) and related factors (e.g., public injecting and gender) influence the likelihood that PWID initiate others into injecting. This study will (1) investigate the PWID participation in injection initiation; (2) identify factors influencing the risk that PWID expose others to or facilitate injection initiation; (3) describe drug scene roles that increase the risk of PWID facilitating injection initiation; and (4) evaluate the impact of structural, social, or biomedical interventions on the risk that PWID facilitate injection initiation. It does so by pooling observational data from cohort studies of PWID in six cities: Vancouver, Canada; San Diego, USA; Tijuana, Mexico; Paris, Marseille, and Bordeaux, France.ResultsTeam members are conducting a prospective, multi-site study of PWID (n = 3050) in North America and France that includes quantitative and qualitative data collection through four separate cohort studies of PWID (San Diego, STAHR II; Tijuana, El Cuete IV; Vancouver, V-DUS; Bordeaux, Marseille, Paris and Strasbourg, COSINUS).ConclusionsPRIMER is the largest study of injection initiation to date and the first to investigate structural approaches to preventing injection drug use initiation. Findings have the potential to inform the development and scale up of new and existing interventions to prevent transitions into injecting.Trial registrationPreventing Injecting by Modifying Existing Responses (PRIMER), NIDA DP2-DA040256-01 .

ObjectiveAlthough persons who inject drugs (PWID) in the western United States-Mexico border region are known to inject both heroin and methamphetamine, little is known about the prevalence and risks associated with co-injection of this depressant-stimulant combination (also known as "goofball" and "Mexican speedball").MethodBaseline data from parallel cohort studies of PWID conducted concurrently in San Diego, CA, and Tijuana, Mexico, were used to estimate the prevalence and identify correlates of heroin-methamphetamine co-injection. PWID older than 18 years of age who reported injecting illicit drugs in the past month (N = 1,311; 32.7% female) were recruited in San Diego (n = 576) and Tijuana (n = 735) and completed interviewer-administered questionnaires. Bivariate and multivariable logistic regression analyses were used to identify correlates of heroin-meth-amphetamine co-injection.ResultsThe prevalence of co-injection in the past 6 months was 39.9% overall and was higher in Tijuana (55.8%) than in San Diego (19.8%). In multivariable analyses adjusting for study cohort, distributive syringe sharing, purchasing syringes prefilled with drugs, finding it hard to get new syringes, reporting great or urgent need for treatment, and younger age were independently associated with co-injection. Past-6-month overdose was significantly associated with higher odds of co-injection in San Diego than in Tijuana.ConclusionsThese findings indicate that heroin-methamphetamine co-injection is more common in Tijuana than in San Diego, yet this practice was only associated with overdose in San Diego. Heroin-methamphetamine coinjection was also independently associated with HIV-associated injection risk behaviors. Overdose-prevention interventions should address co-injection of depressants and stimulants.

IntroductionPolice officers are at an elevated risk for needle-stick injuries (NSI), which pose a serious and costly occupational health risk for HIV and viral hepatitis. However, research on NSIs among police officers is limited, especially in low- and middle-income countries. Despite the legality of syringe possession in Mexico, half of people who inject drugs (PWID) in Tijuana report extrajudicial syringe-related arrests and confiscation by police, which has been associated with needle-sharing and HIV infection. We assessed the prevalence and correlates of NSIs among Tijuana police officers to inform efforts to improve occupational safety and simultaneously reduce HIV risks among police and PWID.MethodsTijuana's Department of Municipal Public Safety (SSPM) is among Mexico's largest. Our binational, multi-sectoral team analyzed de-identified data from SSPM's 2014 anonymous self-administered occupational health survey. The prevalence of NSI and syringe disposal practices was determined. Logistic regression with robust variance estimation via generalized estimating equations identified factors associated with ever having an occupational NSI.ResultsApproximately one-quarter of the Tijuana police force was given the occupational health survey (N=503). Respondents were predominantly male (86.5%) and ≤35 years old (42.6%). Nearly one in six officers reported ever having a NSI while working at SSPM (15.3%), of whom 14.3% reported a NSI within the past year. Most participants reported encountering needles/syringes while on duty (n=473, 94%); factors independently associated with elevated odds of NSIs included frequently finding syringes that contain drugs (adjusted odds ratio (AOR): 2.98; 95% confidence interval (CI): 1.56-5.67) and breaking used needles (AOR: 2.25; 95% CI: 1.29-3.91), while protective factors included being willing to contact emergency services in case of NSIs (AOR: 0.39; 95% CI: 0.22-0.69), and wearing needle-stick resistant gloves (AOR: 0.43; 95% CI: 0.19-0.91).ConclusionsTijuana police face an elevated and unaddressed occupational NSI burden associated with unsafe syringe-handling practices, exposing them to substantial risk of HIV and other blood-borne infections. These findings spurred the development and tailoring of training to reduce NSI by modifying officer knowledge, attitudes and enforcement practices (e.g. syringe confiscation) - factors that also impact HIV transmission among PWID and other members of the community.

BackgroundArmed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.MethodsConsenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.ResultsOf 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection.ConclusionThere is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

Given that syphilis is associated with HIV infection among people who inject drugs (PWID), we examined syphilis incidence among PWID in Tijuana, Mexico. From 2006 to 2007, 940 PWID (142 women and 798 men) were recruited via respondent-driven sampling and followed for 18 months. At semi-annual visits, participants were tested for syphilis and completed surveys, which collected information on socio-demographics, sexual behaviours, substance use and injection behaviours. Poisson regression was used to estimate syphilis incidence rates (IRs), incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Twenty-one participants acquired syphilis during follow-up (IR = 1.57 per 100 person-years, 95% CI: 1.02-2.41). In a multivariate analysis, syphilis incidence was higher among women (IRR = 3.90, 95% CI: 1.37-11.09), HIV-positive participants (IRR = 4.60, 95% CI: 1.58-13.39) and those who reported ever exchanging sex for drugs, money, or other goods (IRR = 2.74, 95% CI: 0.97-7.76), while syphilis incidence was lower among those living in Tijuana for a longer duration (IRR = 0.95 per year, 95% CI: 0.91-1.00) and those reporting at least daily injection drug use (past 6 months) (IRR = 0.22, 95% CI: 0.09-0.54). Our findings suggest interventions that address the destabilising conditions associated with migration and integrate sexual and drug-related risk reduction strategies may help reduce syphilis incidence among PWID along the Mexico-US border.

BackgroundStudies have shown intimate injection partners engage in higher rates of syringe and injecting equipment sharing. We examined the drug use context and development of injection drug use behaviors within intimate injection partnerships.MethodsIn-depth interviews (n=18) were conducted with both members of nine injecting partnerships in Sydney, Australia. Content analysis identified key domains related to the reasons for injecting with a primary injection partner and development of drug injection patterns.Main findingsMost partnerships (n=5) were also sexual; three were blood-relatives and one a friend dyad. The main drug injected was heroin (66%) with high rates of recent sharing behaviors (88%) reported within dyads. Injecting within a primary injection partnership provided perceived protection against overdose events, helped reduce stress, increased control over when, where, and how drugs were used, and promoted the development of an injecting pattern where responsibilities could be shared. Unique to injecting within primary injection partnerships was the social connection and companionship resulted in a feeling of fulfillment while also blinding one from recognizing risky behavior.ConclusionsFindings illuminated the tension between protection and risks within primary injection partnerships. Primary injection partnerships provide a potential platform to expand risk reduction strategies.

BackgroundSharing blood-contaminated syringes is the main risk factor for acquiring and transmitting blood-borne infections among persons who inject drugs (PWID). To reduce this risk, in 2005, California enacted legislation allowing local health jurisdictions to legalize non-prescription syringe sales after approving a disease prevention demonstration project (DPDP). With San Francisco approving a DPDP immediately and San Diego never approving one, we compared PWID across cities for their use of pharmacies PWID to obtain syringes.MethodsPWID age 18-30 years old were recruited into separate studies in San Francisco (n=243) and San Diego (n=338) between 2008 and 2011. We used multivariable logistic regression to compare the proportions of PWID who obtained syringes from pharmacies by city while controlling for sociodemographics, injection practices and other risk behaviors.ResultsOverall, most PWID were White (71%), male (63%), and between the ages of 18-25 years (55%). Compared to San Francisco, a smaller proportion of PWID in San Diego had bought syringes from pharmacies in the prior three months (16.9% vs. 49.8%; p

BackgroundHepatitis C virus (HCV) testing and counselling have the potential to impact individual behaviour and transmission dynamics at the population level. Evidence of the impact of an HCV-positive status notification on injection risk reduction is limited. The objective of our study was to (1) assess drug and alcohol use and injection risk behaviours following notification; (2) to compare behaviour change in people who inject drugs (PWID) who received a positive test result and those who remained negative; and (3) to assess the effect of age on risk behaviour.MethodsData from the International Collaboration of Incident HIV and HCV Infection in Injecting Cohorts (InC3 Study) were analysed. Participants who were initially HCV seronegative were followed prospectively with periodic HCV blood testing and post-test disclosure and interview-administered questionnaires assessing drug use and injection behaviours. Multivariable generalised estimating equations were used to assess behavioural changes over time.ResultsNotification of an HCV-positive test was independently associated with a small increase in alcohol use relative to notification of a negative test. No significant differences in postnotification injection drug use, receptive sharing of ancillary injecting equipment and syringe borrowing postnotification were observed between diagnosis groups. Younger PWID receiving a positive HCV test notification demonstrated a significant increase in subsequent alcohol use compared with younger HCV negative.ConclusionsThe proportion of PWID reporting alcohol use increased among those receiving an HCV-positive notification, increased the frequency of alcohol use postnotification, while no reduction in injection drug use behaviours was observed between notification groups. These findings underscore the need to develop novel communication strategies during post-test notification to improve their impact on subsequent alcohol use and risk behaviours.

Injection drug-using men from the US and Mexico who purchase sex in Tijuana, Mexico are at risk for transmitting HIV to their contacts in both countries via syringe sharing. We used social network methods to understand whether place of residence (US vs. Mexico) moderated the effect of emotional closeness on syringe sharing. We interviewed 199 drug-using men who reported paying/trading for sex in Tijuana, Mexico using an epidemiological and social network survey and collected samples for HIV/STI testing. Seventy-two men reported using injection drugs with 272 network contacts. Emotional closeness was strongly associated with syringe sharing in relationship where the partner lives in the US, while the relationship between emotional closeness and syringe sharing was considerably less strong in dyads where the partner lives in Mexico. Efforts to reduce HIV risk behaviors in emotionally close relationships are needed, and could benefit from tailoring to the environmental context of the relationship.

BackgroundInjection drug use is increasingly contributing to the HIV epidemic across sub-Saharan Africa. This paper provides the first descriptive analysis of injection drug use in western Kenya, where HIV prevalence is already highest in the nation at 15.1%.MethodsWe draw on quantitative data from a study of injection drug use in Kisumu, Kenya. We generated descriptive statistics on socio-demographics, sexual characteristics, and drug-related behaviors. Logistic regression models were adjusted for sex to identify correlates of self-reported HIV positive status.ResultsOf 151 participants, mean age was 28.8 years, 84% (n = 127) were male, and overall self-reported HIV prevalence reached 19.4%. Women had greater than four times the odds of being HIV positive relative to men (Odds Ratio [OR] 4.5, CI: 1.7, 11.8, p = .003). Controlling for sex, ever experiencing STI symptoms (Adjusted Odds ratio [AOR] 4.6, 95% CI 1.7, 12.0, p = .002) and sharing needles or syringes due to lack of access (AOR 3.6, 95% CI 1.2, 10.5, p = .02) were significantly associated with HIV positive status. Lower education (AOR 2.3, 95% CI 0.9, 5.6, p=.08), trading sex for drugs (AOR 2.8, 95% CI 0.9, 8.8, p = .08), being injected by a peddler (AOR 2.9, 95% CI 1.0, 8.5, p = .05), and injecting heroin (AOR 2.3, 95% CI 1.0, 5.7, p = .06), were marginally associated with HIV.ConclusionsThis exploratory study identified patterns of unsafe drug injection and concurrent sexual risk in western Kenya, yet few resources are currently available to address addiction or injection-related harm. Expanded research, surveillance, and gender sensitive programming are needed.

BackgroundHigh dead-space syringes (HDSS) are believed to confer an elevated risk of acquiring HIV and other blood-borne infections.ObjectivesWe identified prevalence and correlates of HDSS use among injection drug users (IDU) in Tijuana, Mexico, where syringe purchase and possession is legal without a prescription.MethodsBeginning in 2011, IDU who reported being 18 years or older and injected drugs within the last month were recruited into a prospective study. At baseline and semi-annually, 557 IDU underwent HIV-testing and interviewer-administered surveys. Logistic regression was used to identify correlates of using HDSS.ResultsOf 557 IDU, 40% had ever used HDSS, mostly because no other syringe type was available (72%), or because they were easier to get (20%). Controlling for sex and age at first injection, use of HDSS was associated with cocaine as the first drug injected (Adjusted Odds Ratio [AOR]: 2.68; Confidence Interval 95% [CI]: 1.15-6.22), having been stopped or arrested by police (AOR: 1.84; 95% CI: 1.11-3.07), being deported from the US (AOR: 1.64; 95% CI:1.06-2.53), and believing it is illegal to carry syringes (AOR:1.78; 95% CI: 1.01-3.15).ConclusionUse of HDSS is surprisingly common among IDU in Tijuana. Efforts are needed to expand coverage of low-dead space syringes through existing syringe exchange programs. Education is required to increase awareness of the harms associated with HDSS, and to inform IDU that syringe possession is legal across Mexico.

Unsafe injection practices significantly increase the risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection among injection drug users (IDUs). We examined individual and socio-environmental factors associated with unsafe injection practices in young adult IDUs in San Diego, California. Of 494 IDUs, 46.9 % reported receptive syringe sharing and 68.8 % sharing drug preparation paraphernalia in the last 3 months. Unsafe injection practices were associated with increased odds of having friends who injected drugs with used syringes, injecting with friends or sexual partners, and injecting heroin. Perceived high susceptibility to HIV and perceived barriers to obtaining sterile syringes were associated with increased odds of receptive syringe sharing, but not with sharing injection paraphernalia. Over half the IDUs reported unsafe injection practices. Our results suggest that personal relationships might influence IDUs' perceptions that dictate behavior. Integrated interventions addressing individual and socio-environmental factors are needed to promote safe injection practices in this population.

BackgroundPolicymakers and researchers seek answers to how liberalized drug policies affect people who inject drugs (PWID). In response to concerns about the failing "war on drugs," Mexico recently implemented drug policy reforms that partially decriminalized possession of small amounts of drugs for personal use while promoting drug treatment. Recognizing important epidemiologic, policy, and socioeconomic differences between the United States-where possession of any psychoactive drugs without a prescription remains illegal-and Mexico-where possession of small quantities for personal use was partially decriminalized, we sought to assess changes over time in knowledge, attitudes, behaviors, and infectious disease profiles among PWID in the adjacent border cities of San Diego, CA, USA, and Tijuana, Baja California, Mexico.MethodsBased on extensive binational experience and collaboration, from 2012-2014 we initiated two parallel, prospective, mixed methods studies: Proyecto El Cuete IV in Tijuana (n = 785) and the STAHR II Study in San Diego (n = 575). Methods for sampling, recruitment, and data collection were designed to be compatible in both studies. All participants completed quantitative behavioral and geographic assessments and serological testing (HIV in both studies; hepatitis C virus and tuberculosis in STAHR II) at baseline and four semi-annual follow-up visits. Between follow-up assessment visits, subsets of participants completed qualitative interviews to explore contextual factors relating to study aims and other emergent phenomena. Planned analyses include descriptive and inferential statistics for quantitative data, content analysis and other mixed-methods approaches for qualitative data, and phylogenetic analysis of HIV-positive samples to understand cross-border transmission dynamics.ResultsInvestigators and research staff shared preliminary findings across studies to provide feedback on instruments and insights regarding local phenomena. As a result, recruitment and data collection procedures have been implemented successfully, demonstrating the importance of binational collaboration in evaluating the impact of structural-level drug policy reforms on the behaviors, health, and wellbeing of PWID across an international border.ConclusionsOur prospective, mixed methods approach allows each study to be responsive to emerging phenomena within local contexts while regular collaboration promotes sharing insights across studies. The strengths and limitations of this approach may serve as a guide for other evaluations of harm reduction policies internationally.

IntroductionYoung injection drug users (IDU, under age 30) often inject with other IDU, creating an environment for risk of blood-borne disease transmission through sharing of needles and drug preparation equipment. Epidemiologic studies rely on self reported injection behavior data for measures of transmission risk, therefore we sought to quantify the degree of concordance of reported injecting risk behaviors between injecting dyads.MethodsFrom May, 2006 through 2013 we enrolled 72 injecting dyads in San Francisco, California, who were hepatitis C virus (HCV) RNA discordant. Each partnership was followed prospectively for up to six months. Monthly interviews from each partner were date-matched and responses to relationship characteristics and risk behavior questions were compared. Concordance of reporting was estimated with the concordance correlation coefficient for longitudinal data (CCC) and the prevalence adjusted bias adjusted kappa (PABAK).ResultsParticipants had a median age of 26 (IQR: 23, 28) years and median years injecting of 7.0 (IQR: 3.0, 10.6). Thirty-eight percent of the injecting dyads were also sexual partners. Concordance levels were highest for partnership characteristics, such as length of acquaintance, number of days cohabitating, and sexual intercourse in the past month (CCC=0.95; 0.82, and 0.90, respectively). Shared injection risk behaviors such as injecting with the HCV+ partner's previously used syringe and using contaminated injection preparation equipment had slight to fair agreement (CCC=0.22; 0.23; PABAK=0.43, 0.36, respectively).ConclusionsConcordance levels ranged from low to high. Potential sources of measurement error for low agreement items include recall and social-desirability biases and question interpretation.

BackgroundStudies of injection drug-using couples suggest a gendered performance of risk in which men exert greater control over drug use and render their female partners vulnerable to HIV infection and other negative health outcomes. This study assesses gender roles in injection drug use as practiced among female sex workers and their intimate male partners within a risk environment marked by rapid socioeconomic changes.MethodsWe draw on quantitative surveys, semi-structured interviews, and ethnographic fieldwork conducted as part of cohort study of HIV/STI risk among female sex workers and their intimate, non-commercial partners along the Mexico-U.S. border. This study employed descriptive statistics and inductive analyses of transcripts and field notes to examine practices related to drug procurement, syringe sharing, and injection assistance among couples in which both partners reported injecting drugs in the past 6 months.ResultsAmong 156 couples in which both partners injected drugs (n=312), our analyses revealed that women's roles in drug use were active and multidimensional, and both partners' injection risk practices represented embodied forms of cooperation and compassion. Women often earned money to purchase drugs and procured drugs to protect their partners from the police. Sharing drugs and syringes and seeking injection assistance were common among couples due to drug market characteristics (e.g., the use of "black tar" heroin that clogs syringes and damages veins). Both women and men provided and received injection assistance, which was typically framed as caring for the partner in need of help.ConclusionOur mixed methods study suggests that in certain risk environments, women are more active participants in injection-related practices than has often been revealed. This participation is shaped by dynamic relationship and structural factors. Our suggestion to consider gendered injection risk as a nuanced and relational process has direct implications for future research and interventions.

Little is known about the needs or characteristics of transgender individuals in substance abuse treatment settings. Transgender (n=199) and non-transgender (cisgender, n=13,440) individuals were compared on psychosocial factors related to treatment, health risk behaviors, medical and mental health status and utilization, and substance use behaviors within a database that documented individuals entering substance abuse treatment in San Francisco, CA from 2007 to 2009 using logistic and linear regression analyses (run separately by identified gender). Transgender men (assigned birth sex of female) differed from cisgender men across many psychosocial factors, including having more recent employment, less legal system involvement, greater incidence of living with a substance abuser, and greater family conflict, while transgender women (assigned birth sex of male) were less likely to have minor children than cisgender women. Transgender women reported greater needle use, and HIV testing rates were greater among transgender women. Transgender men and women reported higher rates of physical health problems, mental health diagnoses, and psychiatric medications, but there were no differences in service utilization. There were no differences in substance use behaviors except that transgender women were more likely to endorse primary methamphetamine use. Transgender individuals evidence unique strengths and challenges that could inform targeted services in substance abuse treatment.

BackgroundSubstance use and HIV are growing problems in the Mexico-U.S. border city of Tijuana, a sex tourism destination situated on a northbound drug trafficking route. In a previous longitudinal study of injection drug users (IDUs), we found that >90% of incident HIV cases occurred within an 'HIV incidence hotspot,' consisting of 2.5-blocks. This study examines behavioral, social, and environmental correlates associated with injecting in this HIV hotspot.MethodsFrom 4/06 to 6/07, IDUs aged ≥18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and interviewer-administered surveys eliciting information on demographics, drug use, sexual behaviors, and socio-environmental influences. Participants were defined as injecting in the hotspot if they most frequently injected within a 3 standard deviational ellipse of the cohort's incident HIV cases. Logistic regression was used to identify individual and structural factors associated with the HIV 'hotspot'.ResultsOf 1031 IDUs, the median age was 36 years; 85% were male; HIV prevalence was 4%. As bivariate analysis indicated different correlates for males and females, models were stratified by sex. Factors independently associated with injecting in the HIV hotspot for male IDUs included homelessness (AOR 1.72; 95%CI 1.14-2.6), greater intra-urban mobility (AOR 3.26; 95%CI 1.67-6.38), deportation (AOR 1.58; 95%CI 1.18-2.12), active syphilis (AOR 3.03; 95%CI 1.63-5.62), needle sharing (AOR 0.57; 95%CI 0.42-0.78), various police interactions, perceived HIV infection risk (AOR 1.52; 95%CI 1.13-2.03), and health insurance status (AOR 0.53; 95%CI 0.33-0.87). For female IDUs, significant factors included sex work (AOR 8.2; 95%CI 2.2-30.59), lifetime syphilis exposure (AOR 2.73; 95%CI 1.08-6.93), injecting inside (AOR 5.26; 95%CI 1.54-17.92), arrests for sterile syringe possession (AOR 4.87; 95%I 1.56-15.15), prior HIV testing (AOR 2.45; 95%CI 1.04-5.81), and health insurance status (AOR 0.12; 95%CI 0.03-0.59).ConclusionWhile drug and sex risks were common among IDUs overall, policing practices, STIs, mobility, and lack of healthcare access were correlated with injecting in this HIV transmission hotspot. Although participants in the hotspot were more aware of HIV risks and less likely to report needle sharing, interventions addressing STIs and structural vulnerabilities may be needed to effectively address HIV risk.

We analyzed data from a large randomized HIV/HCV prevention intervention trial with young injection drug users (IDUs). Using categorical latent variable analysis, we identified distinct classes of sexual behavior for men and women. We conducted a latent transition analysis to test the effect of the intervention on transitions from higher to lower risk classes. Men who were in a high-risk class at baseline who received the intervention were 86 % more likely to be in a low-risk class at follow-up compared to those in the control group (p = 0.025). High-risk intervention participants were significantly more likely to transition to the class characterized by unprotected sex with a main partner only, while low-risk intervention participants were significantly less likely to transition to that class. No intervention effect was detected on the sexual risk behavior of women, or of men who at baseline were having unprotected sex with a main partner only.

Young injection drug users (IDUs), a highly mobile population, engage in high levels of injecting risk behavior, yet little is understood about how such risk behavior may vary by the characteristics of the cities to which they travel, including the existence of a syringe exchange program (SEP), as well as travel partner characteristics. In 2004-2005, we conducted a 6-month prospective study to investigate the risk behavior of 89 young IDUs as they traveled, with detailed information gathered about 350 city visits. In multivariable analyses, travel to larger urban cities with a population of 500,000-1,000,000 was significantly associated with injecting drugs (adjusted odds ratio (AOR) = 3.71; 95 % confidence interval (CI), 1.56-8.82), ancillary equipment sharing (AES; AOR = 7.05; 95 % CI, 2.25-22.06) and receptive needle sharing (RNS; AOR = 5.73; 95 % CI, 1.11-27.95), as compared with visits to smaller cities with populations below 50,000. Region of the country, and the existence of a SEP within the city visited, were not independently associated with injecting drugs, AES, or RNS during city visits. Traveling with more than one injecting partner was associated with injecting drugs during city visits (AOR = 2.77; 95 % CI, 1.46-5.27), when compared with traveling alone. Additionally, both non-daily and daily/almost daily alcohol use during city visits were associated with AES (AOR = 3.37; 95 % CI, 1.42-7.68; AOR = 3.03; 95 % CI, 1.32-6.97, respectively) as compared with no alcohol consumption. Traveling young IDUs are more likely to inject when traveling with other IDUs and to engage in higher risk injection behavior when they are in large cities. Risk behavior occurring in city visits, including equipment sharing and alcohol consumption, suggests further need for focused interventions to reduce risk for viral infection among this population.

BackgroundHeavy alcohol consumption has been associated with risk-taking behaviors in intravenous drug users (IDU). However, limited information exists on the relationship between alcohol use and injecting and sexual risk in young adult IDU (

ObjectiveTo evaluate whether HAART is associated with subsequent sexual and drug-related risk behavior compensation among injection drug users (IDUs).DesignA community-based cohort study of 362 HIV-infected IDUs initiating HAART in Baltimore, Maryland.MethodsHAART use and risk behavior was assessed at 8316 biannual study visits (median 23). Using logistic regression with generalized estimating equations (GEE), we examined the effect of HAART initiation on changes in risk behavior while adjusting for sociodemographics, alcohol use, CD4 cell count, year of initiation and consistency of HAART use.ResultsAt HAART initiation, participants were a median of 44.4 years old, 71.3% men and 95.3% African-American. In multivariable analysis, HAART initiation was associated with a 75% reduction in the likelihood of unprotected sex [adjusted odds ratio (aOR) 0.25; 95% confidence interval (CI), 0.19-0.32] despite no change in overall sexual activity (aOR 0.95; 0.80-1.12). Odds of any injecting decreased by 38% (aOR 0.62; 0.51-0.75) after HAART initiation. Among the subset of persistent injectors, needle-sharing increased nearly two-fold (aOR 1.99; 1.57-2.52). Behavioral changes were sustained for more than 5 years after HAART initiation and did not differ by consistency of HAART use. Reporting specific high-risk behaviors in the year prior to initiation was a robust predictor of engaging in those behaviors subsequent to HAART.ConclusionOverall, substantial declines in sexual risk-taking and active injecting argue against significant behavioral compensation among IDUs following HAART initiation. These data also provide evidence to support identifying persons with risky pre-HAART behavior for targeted behavioral intervention.

BackgroundInjection drug use (IDU) is a primary vector for blood-borne infections. Awareness of Hepatitis C virus (HCV) infection status may affect risky injection behaviors. This study determines the prevalence of risky injection practices and examines associations between awareness of positive HCV status and risky injection behaviors.MethodsWe surveyed individuals seeking treatment for substance use at 12 community treatment programs as part of a national HIV screening trial conducted within the National Drug Abuse Treatment Clinical Trials Network. Participants reported socio-demographic characteristics, substance use, risk behaviors, and HCV status. We used multivariable logistic regression to test associations between participant characteristics and syringe/needle sharing.ResultsThe 1281 participants included 244 (19.0%) individuals who reported injecting drugs in the past 6 months and 37.7% of IDUs reported being HCV positive. During the six months preceding baseline assessment, the majority of IDUs reported obtaining sterile syringes from pharmacies (51.6%) or syringe exchange programs (25.0%), but fewer than half of IDUs always used a sterile syringe (46.9%). More than one-third (38.5%) shared syringe/needles with another injector in the past 6 months. Awareness of positive HCV vs. negative/unknown status was associated with increased recent syringe/needle sharing (aOR 2.37, 95% CI 1.15, 4.88) in multivariable analysis.ConclusionsRisky injection behaviors remain prevalent and awareness of HCV infection was associated with increased risky injection behaviors. New approaches are needed to broadly implement HCV prevention interventions for IDUs seeking addiction treatment.

We examined correlates of ever injecting drugs in Mexico among residents of San Diego, California. From 2007 to 2010, injecting drug users (IDUs) in San Diego underwent an interviewer-administered survey. Logistic regression identified correlates of injection drug use in Mexico. Of 302 IDUs, 38% were Hispanic, 72% male and median age was 37; 27% ever injected in Mexico; 43% reported distributive syringe sharing there. Factors independently associated with ever injecting drugs in Mexico included being younger at first injection, injecting heroin, distributive syringe sharing at least half of the time, and transporting drugs over the last 6 months. One-quarter of IDUs reported ever injecting drugs in Mexico, among whom syringe sharing was common, suggesting possible mixing between IDUs in the Mexico-US border region. Prospective studies should monitor trends in cross-border drug use in light of recent Mexican drug policy reforms partially decriminalizing drug possession.

Injection drug users (IDU) who use methamphetamine (MA) are at an increased risk of HIV infection due to engagement in injection-related risk behavior including syringe sharing. In this cohort study of young IDU aged 18-30, we investigated the relationship between injection MA use and syringe sharing, and whether difficulty accessing sterile syringes mediated this association. Behavioral questionnaires were completed by 384 IDU in Vancouver, Canada between October 2005 and May 2008. Generalized estimating equations were used to estimate direct and indirect effects. The median age of participants was 24 (IQR: 22-27) and 214 (55.7%) were male. Injecting MA was independently associated with syringe sharing. Mediation analyses revealed that difficulty accessing sterile syringes partially mediated the association between injecting MA and syringe sharing. Interventions to reduce syringe sharing among young methamphetamine injectors must address social and structural barriers to accessing HIV prevention programs.

Limited prevalence data for HIV, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) exist for Afghanistan. We studied a cross-sectional sample of adult injection drug users (IDUs) in Kabul, Afghanistan, from June 2005 through June 2006. Study participants completed interviewer-administered questionnaires and underwent testing for HIV, antibody to HCV, and HBsAg. Overall prevalences of HIV, HCV, and HBsAg were 3.0% (95% confidence interval [CI] 1.7%-5.1%), 36.6% (95% CI 32.2%-41.0%), and 6.5% (95% CI 4.2%-8.7%), respectively (N = 464). Among male IDUs (n = 463), risky behavior, including sharing syringes (50.4%), paying women for sex (76.2%), and having sex with men or boys (28.3%), were common. Needle sharing, injecting for > or = 3 years, and receiving injections from nonmedical providers were independently associated with increased risk for HCV infection. The high prevalence of risky behavior indicate that Kabul is at risk for an HIV epidemic. Scale-up of harm-reducing interventions is urgently needed.

Studies among normative samples generally demonstrate a positive impact of marriage on health behaviors and other related attitudes. In this study, we examine the impact of marriage on HIV/AIDS risk behaviors and attitudes among impoverished, highly stressed, homeless couples, many with severe substance abuse problems. A multilevel analysis of 368 high-risk sexually intimate married and unmarried heterosexual couples assessed individual and couple-level effects on social support, substance use problems, HIV/AIDS knowledge, perceived HIV/AIDS risk, needle-sharing, condom use, multiple sex partners, and HIV/AIDS testing. More variance was explained in the protective and risk variables by couple-level latent variable predictors than by individual latent variable predictors, although some gender effects were found (e.g., more alcohol problems among men). The couple-level variable of marriage predicted lower perceived risk, less deviant social support, and fewer sex partners but predicted more needle-sharing.

Homeless individuals are at risk for numerous health problems including Hepatitis C virus (HCV). HCV is primarily caused by sharing of equipment associated with injection drug use (IDU). In the current study, we assessed differences among HCV-negative and HCV-positive homeless men residing in Los Angeles (N = 198; about 50% HCV positive) on a number of risk factors and behaviors. Findings revealed several significant correlates of HCV-positive status. HCV-positivity was significantly and positively associated with a history of substance use (IDU and non-IDU), recent IDU-related behaviors including equipment sharing, other forms of sharing (e.g., toothbrushes, razors), homelessness severity, tattoos, sexually transmitted diseases, a jail/prison history, and greater age. Lifetime alcohol problems were not associated with HCV. Although associations of HCV with current IDU-related behaviors are not surprising, it is alarming that these behaviors were recent. Those who work among homeless populations should be aware not only of the high likelihood of HCV infection in this population but also of the transmission risk due to continued IDU sharing behaviors. Substance abuse treatment should be implemented to hinder the spread of HCV in this vulnerable population. Also, needle exchange and provision of clean ancillary IDU equipment should be encouraged in areas where homeless people are known to congregate.

We studied prevalence and correlates of injection drug use, awareness of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and risky behaviors among drug users serviced by a nongovernmental organization catering to drug users in three Pakistani cities (Quetta, Peshawar, and Rawalpindi). Logistic regression analysis was used to identify correlates of injection drug use. Of 608 drug users, 99.8% were male; median age was 32 years, and 44% were married. Most (79.8%) were Pakistani; 15.3% were Afghani. The majority used heroin (98.7%), mostly by inhalation; 15.2% injected drugs. Only 41% had heard of HIV/AIDS, and 30% had been paid for donating blood. Injection drug use and needle sharing were highest in Quetta. Injecting drug users (IDUs) were nearly twice as likely to have donated blood and to have heard about HIV/AIDS compared to other drug users. Interventions to discourage transitions to injection, increase HIV testing, and safeguard the blood supply in Pakistan are urgently needed.