Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility.

There have been concerns that safer injecting facilities may promote initiation into injection drug use. We examined length of injecting career and circumstances surrounding initiation into injection drug use among 1065 users of North America's first safer injecting facility and found that the median years of injection drug use were 15.9 years, and that only 1 individual reported performing a first injection at the safer injecting facility. These findings indicate that the safer injecting facility's benefits have not been offset by a rise in initiation into injection drug use.

Summary of findings from the evaluation of a pilot medically supervised safer injecting facility.

In many cities, infectious disease and overdose epidemics are occurring among illicit injection drug users (IDUs). To reduce these concerns, Vancouver opened a supervised safer injecting facility in September 2003. Within the facility, people inject pre-obtained illicit drugs under the supervision of medical staff. The program was granted a legal exemption by the Canadian government on the condition that a 3-year scientific evaluation of its impacts be conducted. In this review, we summarize the findings from evaluations in those 3 years, including characteristics of IDUs at the facility, public injection drug use and publicly discarded syringes, HIV risk behaviour, use of addiction treatment services and other community resources, and drug-related crime rates. Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts. These findings should be useful to other cities considering supervised injecting facilities and to governments considering regulating their use.

Cannabis vaping and public health--some comments on relevance and implications.

Cannabis-vaping entails relevant but probably varied effects for public health: it may reduce certain cannabis use-related health risks, but entice cannabis-naive individuals into use due to "cleaner" imagery. Improved evidence is needed to guide informed and differentiated policies for cannabis-vaping, which emphasizes the urgent need for public health-based cannabis regulation.

Impact of supervised injection facilities on community HIV levels: a public health perspective.

The health and social consequences of intravenous drug use pose major challenges to cities across North America. Preventable drug-related harms including accidental overdose, serious bacterial infections, injuries of violence and more recently, the emergence of HIV and hepatitis C, have major impacts on community health. Among the various interventions designed to reduce the harms associated with injection drug use, the establishment of a supervised injection facility is perhaps the most controversial. This review will focus on the potential impact of supervised injection facilities on HIV transmission in conjunction with current HIV prevention initiatives. This will include a review of the health and social consequences associated with illicit drugs use, the limitations of drug enforcement, and the potential impact of supervised injection facilities on reducing the harms associated with injection drug use.

Mortality in a large community-based cohort of inner-city residents in Vancouver, Canada.

BACKGROUND: The Downtown Eastside is a robust and densely populated neighbourhood in Vancouver, Canada, that is characterized by low-income housing and drug use and a high prevalence of HIV infection. We evaluated mortality and excess mortality among the broader community of individuals living in this neighbourhood. METHODS: The Community Health and Safety Evaluation is a community-based study of inner-city residents in the Downtown Eastside who were recruited in 2003 and 2004. Participants' data were linked with data in provincial virology and mortality databases retrospectively and prospectively for the period 1991-2009. Mortality and standardized mortality ratios (SMRs) were calculated for the period 2003-2009 to compare death rates in the study population with rates in the population of Vancouver. RESULTS: Among 2913 participants, 374 deaths occurred, for an all-cause mortality of 223 per 10 000 person-years (95% confidence interval [CI] 201-247 per 10 000 person-years). Compared with the population of Vancouver, significant excess mortality was observed in the study population (SMR 7.1, 95% CI 6.4-7.9). Excess mortality was higher among women (SMR 15.4, 95% CI 12.8-18.5) than among men (SMR 5.8, 95% CI 5.1-6.6). Although crude mortality increased with age, excess mortality was greatest among participants less than 35 years old (SMR 13.2, 95% CI 9.4-18.5) and those 35-39 years old (SMR 13.3, 95% CI 10.3-17.1). Excess risk was also elevated among participants with hepatitis C virus (HCV), HIV and HCV/HIV infection, with SMRs of 5.9 (95% CI 4.9-7.1), 19.2 (95% CI 12.8-28.9) and 23.0 (95% CI 19.3-27.4), respectively. INTERPRETATION: Our study showed high mortality in this inner-city population, particularly when compared with the general population of Vancouver. Excess mortality was highest among women, younger participants and those infected with either HCV or HIV or both.

A review of barriers and facilitators of HIV treatment among injection drug users.

Globally, injection drug use continues to account for a substantial proportion of HIV infections. There have not, however, been any evidence-based reviews of the barriers and facilitators of HIV treatment among injection drug users. For this review, published studies were extracted from nine academic databases, with no language or date specified in the search criteria. Existing evidence demonstrates that, although injection drug users often have worse outcomes from HIV treatment than non-injection drug users, major antiretroviral-associated survival gains still have been observed among this population. Inferior outcomes are explained by a range of barriers to antiretroviral access and adherence, which often stem from the negative influences of illicit drug policies, as well as issues within medical systems, including lack of physician education about substance abuse. Evidence demonstrates that several under-utilized interventions and novel antiretroviral delivery modalities have helped to greatly address these barriers in several settings, and there is sufficient evidence to support immediate scale-up of these programmes. These interventions include coupling antiretroviral therapy with opioid substitution therapies as well as directly administered antiretroviral therapy programmes. Of particular interest for future evaluation is the coupling of HIV treatment programmes within comprehensive services, which also provide low-threshold (harm reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and prevention to injection drug users, however, will require increasing political will among both national policy-makers and international public health agencies.

Access and utilization of HIV treatment and services among women sex workers in Vancouver's Downtown Eastside.

Many HIV-infected women are not realizing the benefits of highly active antiretroviral therapy (HAART) despite significant advancements in treatment. Women in Vancouver's Downtown Eastside (DTES) are highly marginalized and struggle with multiple morbidities, unstable housing, addiction, survival sex, and elevated risk of sexual and drug-related harms, including HIV infection. Although recent studies have identified the heightened risk of HIV infection among women engaged in sex work and injection drug use, the uptake of HIV care among this population has received little attention. The objectives of this study are to evaluate the needs of women engaged in survival sex work and to assess utilization and acceptance of HAART. During November 2003, a baseline needs assessment was conducted among 159 women through a low-threshold drop-in centre servicing street-level sex workers in Vancouver. Cross-sectional data were used to describe the sociodemographic characteristics, drug use patterns, HIV/hepatitis C virus (HCV) testing and status, and attitudes towards HAART. High rates of cocaine injection, heroin injection, and smokeable crack cocaine use reflect the vulnerable and chaotic nature of this population. Although preliminary findings suggest an overall high uptake of health and social services, there was limited attention to HIV care with only 9% of the women on HAART. Self-reported barriers to accessing treatment were largely attributed to misinformation and misconceptions about treatment. Given the acceptability of accessing HAART through community interventions and women specific services, this study highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.

Satellite needle distribution among injection drug users: policy and practice in two canadian cities.

Access to clean needles and syringes through needle exchange programs (NEPs) has reduced both high-risk behaviors and the transmission of blood-borne infections among injection drug users (IDUs). However, policies regarding "needle-for-needle" exchange versus unrestricted needle distribution remain controversial. The objective of this study was to compare sources of needles, trends in needle distribution, and the practice of satellite needle distribution (SND) among IDUs in Vancouver and Montreal. SND was defined as receiving a new syringe from another individual through trading, purchasing, borrowing, or being given the syringe outright, or supplying a syringe to another individual through trading, selling, lending, or giving a syringe outright. This was practiced by 46% of IDUs in Vancouver and 50% of IDUs in Montreal. SND was associated with borrowing used injection equipment (adjusted OR [AOR], 2.62; 95% CI: 1.85-3.71), conducting bulk needle exchanges (AOR, 1.85; 95% CI: 1.34-2.54), being married or in a common-law relationship (AOR, 1.85; 95% CI: 1.34-2.54), and regular visits to the NEP (> weekly) (AOR, 1.54; 95% CI: 1.17-2.13). In Vancouver, SND was also associated with borrowing used needles (AOR, 2.07; 95% CI: 1.22-3.52). In these two cities, despite different distribution policies, almost half of the participants reported SND, and this was associated with high risk sharing. The practice of SND appears to be an important mechanism for needle acquisition, especially for those at highest risk for HIV and hepatitis C transmission.

Impact of supply-side policies for control of illicit drugs in the face of the AIDS and overdose epidemics: investigation of a massive heroin seizure.

BACKGROUND: More than 93% of the nearly $500 million spent annually on Canada's drug strategy goes toward efforts to reduce the illicit drug supply. However, little is known about the effectiveness of this strategy. On Sept. 2, 2000, Canadian police seized approximately 100 kg of heroin in one of the nation's largest-ever seizures of this drug. An ongoing prospective cohort study of injection drug users afforded an opportunity to evaluate the impact of this seizure. METHODS: The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users that began in 1996. The present study relied primarily on data acquired from participants who were seen during the 30-day periods immediately before and after the seizure. We compared drug use and behavioural characteristics, heroin and cocaine prices, and participants' reports of whether law enforcement had affected their source of drugs or the types of drugs available on the street, as well as overdoses, in these 2 periods. RESULTS: The 138 participants seen before the seizure were similar to the 123 participants seen after the seizure with respect to age, sex, ethnic background, education, HIV serostatus, neighbourhood residence, instability of housing, employment status, use of methadone maintenance therapy and all other measured potential confounders (all p > 0.10). We found no difference in the extent to which participants in the 2 groups reported daily use of heroin, frequency of nonfatal overdoses, or whether law enforcement had affected their source of drugs or the types of drugs available on the street (all p > 0.10). Although we detected no difference in the price of cocaine, the median reported price of heroin went down after the seizure (p = 0.034), which suggests that other shipments compensated for the seizure. External evaluations of deaths from overdoses and heroin purity indicated that the seizure had no impact, nor was any impact seen when the periods of analysis were extended. INTERPRETATION: The massive heroin seizure appeared to have no measurable public health benefit. Closer scrutiny of enforcement efforts is warranted to ensure that resources are delivered to the most efficient and cost-effective public health programs.