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Injecting drug users (IDUs) experience a range of health problems. Access to primary healthcare (PHC) is nevertheless often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. Consequently in some settings IDU-targeted PHC services were introduced to offer low-threshold services. However, few such services have undergone evaluation, and thus limited data are available to inform health service planning. This thesis overviews IDUs’ barriers to healthcare access (Chapter 2), reviews operational models of IDU-targeted PHC services (Chapter 3) and, using a case study approach, evaluates the Redfern Harm Minimisation Clinic (RHMC), a needle and syringe program (NSP)-based PHC in inner-city Sydney, to determine whether this service attracts its intended clientele and documents clients’ reasons for presentation and service utilisation (Chapter 4). The prevention and management of the hepatitis C virus (HCV), is a key goal of the RHMC. Chapter 5 examines the patterns of referral uptake and subsequent antiviral therapy initiation among IDUs referred from RHMC. It is expected that IDUs disclose their drug use and associated risk when they access targeted services to ensure the services delivered are not compromised. Chapter 6 examines the reliability of sensitive information provided by IDUs in targeted PHC services. Cost is a fundamental issue in evaluation. Chapter 7 estimates the cost of implementing RHMC, concluding that greater cost efficiencies could be achieved were RHMC to offer a wider range of services. The results suggest that by providing non-judgemental and cost-free services under a harm reduction framework, targeted PHC services mitigate IDUs’ perceived barriers to PHC, and highlight the potential of these services to facilitate reductions in liver disease burden among IDUs. Adoption of a universal precautionary approach to complement tailored assessment of heal

Objective: Drug users are at elevated risk of HIV and other sexually transmitted infections (STIs). This study examines prevalence of STIs and perceived barriers to safe sex among drug users accessing low-threshold primary healthcare in inner-city Sydney.

Background: Low-threshold primary healthcare (PHC) centres targeting injecting drug users (IDUs) are increasingly being created to offer preventative and opportunistic services. However, no data are available on the characteristics of clients who utilise

Introduction and Aims: Targeted primary health-care services for injecting drug users have been established in several countries to reduce barriers to health care, subsequent poor health outcomes and the considerable costs of emergency treatment. The long

Background: People who inject drugs (PWID) report limited access to healthcare, and may avoid disclosing drug use. Health service utilisation was examined among participants in the Australian Needle and Syringe Program Survey (ANSPS), an annual cross-sect

Background and aim: Excessive alcohol use increases mortality and morbidity among opioid substitution therapy (OST) clients. Regular attendance for OST dosing presents key opportunities for screening and treatment. However, individuals' perception of their alcohol consumption as problematic or otherwise may impact their willingness to change. This study examines patterns of alcohol consumption among OST clients, perceptions of their own use and correlates of excess consumption. Methods: Confidential, structured interviews were conducted with 264 clients of two Sydney OST clinics. Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT); and illicit drug dependence with the Severity of Dependence Scale. Results: Forty-one percent of the participants scored ≥8 on the AUDIT ('AUDIT-positive'), indicating excessive alcohol use. The higher a participant's AUDIT score, the more likely they were to demonstrate insight into the potential problems associated with their drinking (linear trend, p<. 0.01). However, only half of AUDIT-positive participants believed they drank too much and/or had a problem with alcohol. One-third had discussed their drinking with OST staff, and a similar proportion reported a history of alcohol treatment. AUDIT-positive participants were more likely than others to be classified as dependent on an illicit drug in the last six months (AOR=1.76, 95% CI:1.00-3.09), report a history of alcohol treatment (AOR=5.70, 95% CI:2.83-11.48) and believe it is safe to drink 4. + standard drinks in one session (AOR=5.30, 95% CI:2.79-10.06). Conclusions: OST clients with AUDIT scores ≥8 appear to underestimate the risks associated with their alcohol consumption. Regular assessments of alcohol use and targeted brief alcohol interventions may improve health outcomes among OST clients.

Introduction and Aims.: Opioid substitution therapy (OST) ideally constitutes a window of opportunity for the provision of essential primary health care (PHC) for OST clients. In the absence of such opportunities, however, OST clients access PHC from existing outlets, either general services or those targeted to specific groups. This study examined OST clients' current main source and preferred future outlets of PHC services and correlates of preferences. Design and Methods.: Anonymous interviews conducted with n=257 clients of two public OST clinics in Sydney's inner-west. Results.: Overall, 61% (n=158) of participants reported currently accessing PHC primarily from general outlets (general practitioners or medical centres: 51%, hospital/emergence departments: 10%) and the remainder (39%, n=99) from outlets that target specific groups (e.g. Aboriginal Medical Services, OST prescriber/clinics, drug user-targeted PHCs). Twenty-two percent reported discomfort disclosing drug use to their current PHC providers. However, the majority were satisfied with the care they received and reported a preference to remain with their current PHC providers for a range of reasons, most commonly familiarity with and trust in staff (56%) and not feeling judged about their drug use (49%). Nevertheless, 28% reported that they would access PHC through their OST clinic if it were available. Discussion and Conclusions.: PHC outlets that target specific groups appear to have an ongoing and important role in providing accessible health care to OST clients.

Background: Injecting drug users (IDUs) are at increased risk of health problems ranging from injecting-related injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed. However, there is insufficient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature of study designs. Nevertheless, an integrative literature review of IDU-targeted PHC may provide useful insights into the range of operational models and strategies to enhance the accessibility and acceptability of these services to the target population. Methods: Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced from relevant journal publications, grey literature and policy documents. Results: Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall healthcare utilisation and health status of this population with consequent savings to the health system due to a reduction in visits to emergency departments and tertiary hospitals. Conclusions: Although such findings are promising, there remains a dearth of rigorous evaluations of these targeted PHC, with the public health impact of such outlets yet to be systematically documented.

Research with injecting drug users (IDUs) suggests greater willingness to report sensitive and stigmatised behaviour via audio computer-assisted self-interviewing (ACASI) methods than during face-to-face interviews (FFIs); however, previous studies were limited in verifying this within the same individuals at the same time point. This study examines the relative willingness of IDUs to report sensitive information via ACASI and during a face-to-face clinical assessment administered in health services for IDUs. During recruitment for a randomised controlled trial undertaken at two IDU-targeted health services, assessments were undertaken as per clinical protocols, followed by referral of eligible clients to the trial, in which baseline self-report data were collected via ACASI. Five questions about sensitive injecting and sexual risk behaviours were administered to participants during both clinical interviews and baseline research data collection. Percentage agreement determined the magnitude of concordance/discordance in responses across interview methods, while tests appropriate to data format assessed the statistical significance of this variation. Results for all five variables suggest that, relative to ACASI, FFI elicited responses that may be perceived as more socially desirable. Discordance was statistically significant for four of the five variables examined. Participants who reported a history of sex work were more likely to provide discordant responses to at least one socially sensitive item. In health services for IDUs, information collection via ACASI may elicit more reliable and valid responses than FFI. Adoption of a universal precautionary approach to complement individually tailored assessment of and advice regarding health risk behaviours for IDUs may address this issue.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients. This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic. Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Despite a plethora of health-related problems, access to primary healthcare is often limited for drug users (DUs). Many seek care at emergency departments and tertiary hospitals because of late presentation of illness. The costs to both DUs and the health system are such that harm reduction based healthcare centres (HRHCs) have been established in various settings and utilising a variety of models. These provide a range of medical and sometimes social services, in one, integrated, low-threshold facility, including (or closely linked with) programs such as needle syringe provision. In some countries these HRHCs are becoming an alternative healthcare system for DUs. However, the need to provide such services on a broad, public health scale, in a sustainable, cost-effective manner, raises the question as to whether such programmes should be mainstreamed. This commentary provides insights on advantages and disadvantages to mainstreaming HRHCs, and approaches and barriers to achieving this. Two approaches suggest themselves: (i) providing harm reduction services through the regular healthcare system, or (ii) more closely integrating HRHCs with mainstream services. Funding and stigma are major barriers to mainstreaming. Diverse national policies towards DUs, healthcare systems and contexts, necessitate different approaches. Because of the various barriers to mainstreaming, any steps towards mainstreaming should be taken whilst maintaining the option of continuing the current targeted harm reduction services.