Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023.

BACKGROUND: Most national programmes of opioid agonist therapy (OAT) in Eastern Europe and Central Asia are at a critical juncture for building their sustainability due to decreasing support from the Global Fund and other international HIV funders. Therefore, it is timely to identify the status, trends, opportunities and risk factors of OAT preparedness in the face of donor transition. METHODS: The study assessed the OAT sustainability progress in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine. The study used a comparative country case study design with qualitative methods and two data points in 2020 and 2022-2023. In total, 363 sources were reviewed and used, 83 interviews with key informants and 13 focus groups were conducted with clients, using a joint methodology and a defined Framework with three dimensions: 'Policy & Governance'; 'Finance & Resources'; and, 'Services'. RESULTS: All four countries have made improvements to increase OAT sustainability, though it varied. In 2022, Ukraine had a substantial degree of sustainability, followed by Belarus and Moldova with a moderate degree, while Tajikistan's sustainability was at moderate-to-high risk. No country achieved a high degree of OAT sustainability in any of the three dimensions measured. However, a high degree of sustainability was reported for at least one indicator in Belarus, Moldova and Ukraine: 'Medicines'; 'Financial resources'; 'Evidence and information systems'; 'Service Accessibility'; or, 'Service integration & quality'. On average, the greatest improvement between 2020 and 2022 was seen for 'Availability & coverage'; 'Financial resources'; 'Service quality & integration'; and, 'Service accessibility'. The highest risks across the countries, notably in Belarus and Tajikistan, were recorded for the indicator, 'Availability and coverage'. Of concern is that the least progress, or even a decline, was found in 'Human resources'. CONCLUSIONS: OAT sustainability in the 4 analysed countries remains at risk, despite progress in all countries. Managing HIV donor transition can have positive effects in addressing financial sustainability, especially inspired by Ukraine's continued progress despite economic contraction and Russia's invasion. More attention is needed to non-financial aspects of OAT sustainability in donor transition planning. The directions that could have multifaceted positive influence for OAT long-term resilience and scale up for impact on drug problems include decentralisation outside of health settings and broader drug treatment financial and management transformation, together with drug policy reforms. Thus far, viable solutions for sustainability of OAT in conflict areas appear unlikely. Building OAT resilience should remain high on the agenda of national stakeholders, technical partners and donors.

Changes in Australians' attitudes towards supervised injecting facilities.

INTRODUCTION: Supervised injecting facilities (SIF) have been shown to reduce negative outcomes experienced by people who inject drugs. They are often subject to intense public and media scrutiny. This article aimed to explore population attitudes to SIFs and how these changed over time in Australia. METHODS: Data were drawn from the National Drug Strategy Household Survey, a national sample collecting data on illicit drug use and attitudes towards drug policy among Australians (2001-2019). Ordinal logistic regression assessed sociodemographic characteristics associated with different attitudes to SIFs and binary logistic regression assessed trends over time and by jurisdiction. RESULTS: In 2019, 54% of respondents (95% CI 52.9, 55.1) supported SIFs, 27.5% (95% CI 26.6, 28.4) opposed and 18.4% (95% CI 17.7, 19.2) were ambivalent. Support for SIFs correlated with having a university degree (OR 1.75; 95% CI 1.58, 1.94), non-heterosexual identity (OR 1.81, 95% CI 1.51, 2.17) and recent illicit drug use (OR = 1.74, 95% CI 1.55, 1.94). Male respondents or those living in socioeconomically disadvantaged areas had lower odds of supporting SIFs (OR 0.92, 95% CI 0.85, 1.00; OR 0.64-0.80, respectively). Between 2001 and 2019, support for SIFs increased modestly by 3.3%, those who 'don't know' by 7.4%, whereas opposition decreased by 11.7%. Between 2001 and 2019, support for SIFs increased in NSW and Queensland, whereas opposition decreased in all jurisdictions. DISCUSSION AND CONCLUSIONS: Opposition to SIFs declined over the past 20 years, but a substantial proportion of respondents are ambivalent or 'don't know enough to say'. Plain language information about SIFs and their potential benefits, targeted to those who are ambivalent/'don't know' may further increase public support.

Naloxone cascade of care among people who regularly inject drugs in Australia, 2020-2022.

BACKGROUND: Examining take-home naloxone (THN) uptake using a 'cascade of care' framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs. METHODS: People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression. RESULTS: Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91-3.42) and ≥daily injecting (1.32; 1.01-1.73) were associated with awareness. OAT (1.79; 1.38-2.33), past-year opioid overdose (1.68; 1.18-2.42) and older age (1.02; 1.00-1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31-0.58) and acquisition (0.59; 0.44-0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24-0.88). CONCLUSION: Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids.

Candida dubliniensis meningitis in an immunocompetent patient: A case report and review of the literature.

Objective: We present the fifth case of candida dubliniensis meningitis in a young immunocompetent host and suggest extracorporeal membrane oxygenation (ECMO) as a potential risk factor for colonization. Methods: A 22-year-old immunocompetent female presented with a diagnosis of bacterial meningitis. Two years prior, she received ECMO for Covid-19 pneumonia complicated by viral myocarditis & Takutsobo cardiomyopathy. Following discharge, she reported headaches of increasing intensity, all refractory to treatments. Brain magnetic resonance imaging (MRI) was inconclusive. Two weeks prior to her presentation, she was admitted for worsening headaches with cranial nerve VI palsy. Lumbar puncture (LP) revealed white blood cell count (WBC) of 166 cells/µL with neutrophilic predominance and her symptoms progressed, despite 5 days of treatment with broad spectrum antibiotics. All cultures returned negative. Results: At her current presentation, repeat LP revealed 835 WBC/mm3, 225 mg/dL protein, and 4 mg/100 mL glucose. Brain MRI revealed nodular enhancement in the brainstem and communicating hydrocephalus. MRI of the lumbar spine revealed meningeal enhancement. Cerebrospinal fluid (CSF) cultures came back positive for C.dubliniensis. Treatment began with Amphotericin B and Flucytosine. Discussion: When clinical suspicion for fungal meningitis is high, repeate LP and CSF analysis is indicated to establish a definitive diagnosis and begin treatment. Additional studies are needed to confirm risk factors, like ECMO, for the colonization of C.dubliniensis, which likely predisposes individuals to invasive candidiasis.

"I Heard of PrEP-I Didn't Think I Needed it." Understanding the Formation of HIV Risk Perception Among People Who Inject Drugs.

Uptake of pre-exposure prophylaxis medication (PrEP) to prevent HIV among people who inject drugs (PWID) remains extremely low in the United States. West Virginia's rising HIV incidence and highest drug overdose rate in the nation makes it an important locus for opioid use and HIV risk interaction. In this pilot study we pioneered the use of Cultural Theory among PWID to understand HIV-related risk perception arising from four contrasting modes of social organization. Carried out during an HIV outbreak, we explored PrEP uptake qualitatively as a window onto risk perception. Of the 26 interviewees, 18 were HIV- and despite the medication's free availability from the health center where recruitment took place, none had taken PrEP, half considering they were not at risk. Intimate couples who showed characteristics of 'enclaves' considered the boundary around themselves protective against HIV, creating a safe space or 'invisible risk group'. Higher HIV risk was perceived among those who were housed compared to those living homeless. Beliefs about the causation of the local HIV outbreak and the validity of scientific research corresponded with characteristics of the contrasting modes of social organization and the approach is promising for informing public health interventions among PWID.

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney.

INTRODUCTION: People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population. METHODS: Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement. RESULTS: Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone). DISCUSSION AND CONCLUSIONS: Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

Characterising People who inject drugs, and association with HIV infection: A Situation Analysis in Kampala city, Uganda.

Background: Uganda has implemented targeted interventions to address the rising burden of injection drug use, yet barriers persist in reaching persons who inject drugs (PWID). This study describes the characteristics of people who inject drugs, physical and mental health states, and associated risk behaviors, to inform the designing of programs that are tailored to client's needs and preferences. Methods: A cross-sectional survey was conducted between August and December 2023 at selected hotspots in Kampala, interviewing 499 PWID aged ≥18 years. Data was collected using a semi-structured questionnaire administered by peer educators and Uganda Harm Reduction Network (UHRN) counselors. Measurements included socio-demographics, injecting drug use and sexual risk behaviors, and medical history. HIV serostatus was dtermined by self-report and testing for participants who had no recent history of testing and consented to be tested. Binary logistic regression was used to establish the relationship between HIV infection and risky drug- and sexual behaviors of PWID. Results: Participants were predominantly Ugandan (95.2%), male (73.2%), unmarried (55.9%), unemployed (81.8%), with higher levels of education and varying ages. Mental disorders were prevalent, with 48.7% reporting at least one underlying condition, including depression (30.8%) and anxiety (9.6%). Physical health issues were also noted, with reported cases of fever (32.9%), cough (32.5%), malaria (22%) and sexually transmitted infections (STIs) (15%).Regarding drug use patterns, the majority (82.6%) were introduced to drugs by close acquaintances, with 70.9% categorized as people who inject drugs. HIV prevalence among injecting drug users was 3.7%, with higher rates among females (8.4%) and non-Ugandans (16.7%). Being female and experiencing difficulty accessing sterile injection materials were associated with HIV-positive status, highlighting the complex interplay between socio-demographic factors, risk behaviors, and HIV infection among individuals with injecting drug use Disorder in Uganda. Conclusion: Our study provides a comprehensive insight into the socio-demographic, mental, physical health, and HIV risk behavoir of PWID in Kampala, Uganda. The findings indicate significant vulnerabilities to injecting drug use, mental disorders, and high-risk behaviors that predispose this population to HIV infection. Despite a low HIV prevalence compared to previous estimates, the interplay between drug use, risky injecting practices, and sexual behaviors suggests an urgent need for targeted interventions to address these intertwined challenges.

Patterns of drug use among people who inject drugs: A global systematic review and meta-analysis.

BACKGROUND: A better understanding of global patterns of drug use among people who inject drugs can inform interventions to reduce harms related to different use profiles. This review aimed to comprehensively present the geographical variation in drug consumption patterns among this population. METHODS: Systematic searches of peer reviewed (PsycINFO, Medline, Embase) and grey literature published from 2008-2022 were conducted. Data on recent (past year) and lifetime drug use among people who inject drugs were included. Data were extracted on use of heroin, amphetamines, cocaine, benzodiazepines, cannabis, alcohol, and tobacco; where possible, estimates were disaggregated by route of administration (injecting, non-injecting, smoking). National estimates were generated and, where possible, regional, and global estimates were derived through meta-analysis. RESULTS: Of 40,427 studies screened, 394 were included from 81 countries. Globally, an estimated 78.1 % (95 %CI:70.2-84.2) and 71.8 % (65.7-77.2) of people who inject drugs had recently used (via any route) and injected heroin, while an estimated 52.8 % (47.0-59.0) and 19.8 % (13.8-26.5) had recently used and injected amphetamines, respectively. Over 90 % reported recent tobacco use (93.5 % [90.8-95.3]) and recent alcohol use was 59.1 % (52.6-65.6). In Australasia recent heroin use was lowest (49.4 % [46.8-52.1]) while recent amphetamine injecting (64.0 % [60.8-67.1]) and recent use of cannabis (72.3 % [69.9-74.6]) were higher than in all other regions. Recent heroin use (86.1 % [78.3-91.4]) and non-injecting amphetamine use (43.3 % [38.4-48.3]) were highest in East and Southeast Asia. Recent amphetamine use (75.8 % [72.7-78.8]) and injecting heroin use (84.8 % (81.4-87.8) were highest in North America while non-injecting heroin use was highest in Western Europe (45.0 % [41.3-48.7]). CONCLUSION: There is considerable variation in types of drugs and routes of administration used among people who inject drugs. This variation needs to be considered in national and global treatment and harm reduction interventions to target the specific behaviours and harms associated with these regional profiles of use.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use.

OBJECTIVE: Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. METHODS: A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. RESULTS: Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computed tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. CONCLUSION: This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Vaccination coverage among people who inject drugs: A systematic review.

BACKGROUND: People who inject drugs may be at excess risk of acquiring vaccine-preventable diseases and negative associated health outcomes, but experience barriers to vaccination. We aimed to determine vaccination coverage among people who inject drugs globally. METHODOLOGY: We conducted systematic searches of the peer-reviewed and grey literature, date limited from January 2008 to August 2023, focusing on diseases for which people who inject drugs are at elevated risk for and for which an adult vaccination dose is recommended (COVID-19, hepatitis A, hepatitis B, human papillomavirus, influenza, pneumococcal disease, tetanus). To summarise available data, we conducted a narrative synthesis. RESULTS: We included 78 studies/reports comprising 117 estimates of vaccination coverage across 36 countries. Most estimates were obtained from high income countries (80%, n=94). We located estimates for hepatitis B vaccination in 33 countries, which included 18 countries with data on serological evidence of vaccine-derived hepatitis B immunity (range: 6-53%) and 22 countries with self-report data for vaccine uptake (<1-96%). Data for other vaccines were scarcer: reported hepatitis A vaccination coverage ranged 3-89% (five countries), COVID-19 ranged 4-84% (five countries), while we located estimates from fewer than five countries for influenza, tetanus, pneumococcal disease, and human papillomavirus. CONCLUSION: Estimates were sparse but where available indicative of suboptimal vaccination coverage among people who inject drugs. Improving the consistency, timeliness, and geographic coverage of vaccine uptake data among this population is essential to inform efforts to increase uptake.

The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States.

BACKGROUND: Co-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality. METHOD: We recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant. RESULTS: A clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand. CONCLUSION: Transformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs' market dominance at this location and possible interventions.

Liver stiffness and associated risk factors among people with a history of injecting drugs: a prospective cohort study.

BACKGROUND: Persons with opioid use disorders (OUD) and persons with substance use disorders (SUD) who inject substances have a reduced life expectancy of up to 25 years compared with the general population. Chronic liver diseases are a substantial cause of this. Screening strategies based on liver stiffness measurements (LSM) may facilitate early detection, timely intervention, and treatment of liver disease. This study aims to investigate the extent of chronic liver disease measured with transient elastography and the association between LSM and various risk factors, including substance use patterns, hepatitis C virus (HCV) infection, alcohol use, body mass index, age, type 2 diabetes mellitus, and high-density lipoprotein (HDL) cholesterol among people with OUD or with SUD who inject substances. METHODS: Data was collected from May 2017 to March 2022 in a cohort of 676 persons from Western Norway. The cohort was recruited from two populations: Persons receiving opioid agonist therapy (OAT) (81% of the sample) or persons with SUD injecting substances but not receiving OAT. All participants were assessed at least once with transient elastography. A linear mixed model was performed to assess the impact of risk factors such as HCV infection, alcohol use, lifestyle-associated factors, and substance use on liver stiffness at baseline and over time. Baseline was defined as the time of the first liver stiffness measurement. The results are presented as coefficients (in kilopascal (kPa)) with 95% confidence intervals (CI). RESULTS: At baseline, 12% (n = 83) of the study sample had LSM suggestive of advanced chronic liver disease (LSM ≥ 10 kPa). Advanced age (1.0 kPa per 10 years increments, 95% CI: 0.68;1.3), at least weekly alcohol use (1.3, 0.47;2.1), HCV infection (1.2, 0.55;1.9), low HDL cholesterol level (1.4, 0.64;2.2), and higher body mass index (0.25 per increasing unit, 0.17;0.32) were all significantly associated with higher LSM at baseline. Compared with persistent chronic HCV infection, a resolved HCV infection predicted a yearly reduction of LSM (-0.73, -1.3;-0.21) from baseline to the following liver stiffness measurement. CONCLUSIONS: More than one-tenth of the participants in this study had LSM suggestive of advanced chronic liver disease. It underscores the need for addressing HCV infection and reducing lifestyle-related liver risk factors, such as metabolic health factors and alcohol consumption, to prevent the advancement of liver fibrosis or cirrhosis in this particular population.

Has the HCV cascade of care changed among people who inject drugs in England since the introduction of direct-acting antivirals?

BACKGROUND: In England, over 80 % of those with hepatitis C virus (HCV) infection have injected drugs. We quantified the HCV cascade of care (CoC) among people who inject drugs (PWID) in England and determined whether this improved after direct-acting antivirals (DAAs) were introduced. METHODS: We analysed data from nine rounds of national annual cross-sectional surveys of PWID recruited from drug services (2011-2019; N = 12,320). Study rounds were grouped as: 'Pre-DAAs' (2011-2014), 'Prioritised DAAs' (2015-2016) and 'Unrestricted DAAs' (2017-2019). Participants were anonymously tested for HCV antibodies and RNA and completed a short survey. We assessed the proportion of PWID recently (current/previous year) tested for HCV. For participants ever HCV treatment eligible (past chronic infection with history of treatment or current chronic infection), we assessed the CoC as: HCV testing (ever), received a positive test result, seen a specialist nurse/doctor, and ever treated. We used logistic regression to determine if individuals progressed through the CoC differently depending on time-period, whether time-period was associated with recent testing (all participants) and lifetime HCV treatment (ever eligible participants), and predictors of HCV testing and treatment in the Unrestricted DAAs period. RESULTS: The proportion of ever HCV treatment eligible PWID reporting lifetime HCV treatment increased from 12.5 % in the Pre-DAAs period to 25.6 % in the Unrestricted DAAs period (aOR:2.40, 95 %CI:1.95-2.96). There were also increases in seeing a specialist nurse/doctor. The largest loss in the CoC was at treatment for all time periods. During the Unrestricted DAAs period, recent (past year) homelessness (vs never, aOR:0.66, 95 %CI:0.45-0.97), duration of injecting (≤3 years vs >3 years; aOR:0.26, 95 %CI:0.12-0.60), never (vs current, aOR:0.31, 95 %CI:0.13-0.75) or previously being prescribed OAT (vs current, aOR:0.67, 95 %CI:0.47-0.95), and never using a NSP (vs past year, aOR:0.27, 95 %CI:0.08-0.89) were negatively associated with lifetime HCV treatment. The proportion of PWID reporting recent HCV testing was higher during Unrestricted DAAs (56 %) compared to Pre-DAAs (48 %; aOR:1.28, 95 %CI:1.06-1.54). CONCLUSION: COC stages from seeing a specialist onwards improved after DAAs became widely available. Further improvements in HCV testing are needed to eliminate HCV in England.

Experiences of stigma and subsequent reduced access to health care among women who inject drugs.

INTRODUCTION: Research into stigma and injecting drug use has typically involved predominantly male participants, with limited research about the unique experience of women who inject drugs. METHODS: This study used survey methods to assess reduced access to health care due to stigma among a sample of women who inject drugs. Women (n = 232) completed a survey as part of a broader national study of people who inject drugs. RESULTS: Only 46 (19.9%) women reported that they had not experienced any injecting drug use-related stigma in the past year and most commonly noted 'sometimes' experiencing injecting-related stigma (36.8%) with more than 75% of women reporting that health workers had treated them negatively because of their injecting drug use. Most women undertook strategies to prevent experiencing stigma, such as not disclosing drug use to a health worker (81.3%), not attending follow-up appointments (76.7%) and delaying accessing health care (76.8%). Women with lower levels of personal wellbeing, who had experienced poorer treatment by health workers, had engaged in greater past month injecting, were employed and identified as lesbian, gay, bisexual, transgender or queer (LGBTQ) reported more reduced access to health care. DISCUSSION AND CONCLUSIONS: Stigma has concerning health care implications for women who inject drugs and this research highlights the importance of understanding the impact of stigma in impeding health care access. Public health interventions should focus on addressing the systemic factors that reduce health care access for women who inject and take account of the impact of stigma in diminishing the quality and accessibility of health care for this group.

Measuring sustainability of opioid agonist therapy programs in the context of transition from global fund support.

BACKGROUND: Programmatic and financial sustainability of health responses dependent on donor funding has risen as a major concern. In the HIV field in particular, it generated a number of instruments and assessments on sustainability and processes related to donor transition planning. The authors aimed to develop an instrument specific to opioid agonist therapy (OAT) programs as they were addressed only marginally by the HIV-specific assessments. METHODS: The development of the OAT sustainability instrument used desk review of existing HIV sustainability concepts and tools, an International Advisory Board, and piloting to validate the instrument. RESULTS: The new OAT sustainability instrument is comprised of the three parts: the conceptual framework, methodological guidelines and a practical implementation tool for assessing the degree of OAT sustainability at the country level. It measures sustainability in the three broad areas for sustainability measuring-Policy & Governance; Finance & Resources; and Services. The selection of indicators and their composites for the three sustainability areas extensively used the United Nations and World Health Organization's guidance on health system building blocks, on care and HIV and viral hepatitis prevention among people using opioids and for opioid dependence, and the definition of access to health framed by the United Nations Convent on Economic, Social and Cultural Rights. The instrument's methodological guidelines require the engagement of a national consultant to conduct desk review, key informant interviews and focus groups for measuring discrete milestones and adding qualitative information for interpretation of the data, progress and opportunities. The guidelines advise engaging a country-specific multi-stakeholder advisory group for planning, validation and follow-up of the assessment. The pilot of the instrument in 3 countries in 2020 validated it and required minor adjustments in the instrument. By mid-2023, the instrument has been successfully applied in 5 countries. CONCLUSIONS: The developed instrument enables a comprehensive review of the resilience of OAT programs and their ability to scale up and to inform a roadmap for improved sustainability. While developed in the context of Eastern Europe and Central Asia, it has been reviewed by a global advisory panel and could be easily adapted outside this regional context.

Epidemiology of acute infections in people who inject drugs in Australia.

ISSUES: People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described. APPROACH: We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health. KEY FINDINGS: The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care. IMPLICATIONS: Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health-care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors. CONCLUSION: Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health-care systems. Flexible health-care models, such as low-threshold wound clinics, would help directly target, and address early interventions, for these infections.

Excellent hepatitis C virus cure rates despite increasing complexity of people who use drugs: Integrated-Test-stage Treat study final outcomes.

Achieving hepatitic C virus (HCV) elimination requires linking people who use drugs (PWUD) into care. We report final direct-acting antivirals (DAAs)-based outcomes from the Integrated-Test-stage -Treat (ITTREAT) study. Project ITTREAT (2013-2021), based at an addiction centre, was a 'one-stop' service with innovative linkage to care strategies. Primary outcome was sustained virological response (SVR12) (intention to treat ITT) including whether individuals were recruited in first (period 1) versus last four (period 2 included the COVID-19 pandemic) years of the study. Number recruited were n = 765, mean age 40.9 ± 10.1 years, 78% males, history of current/past injecting drug use (IDU) and alcohol use being 77% and 90%, respectively. Prevalence of a positive HCV PCR was 84% with 19% having cirrhosis. Comparing those recruited in period 2 versus period 1, there was increasing prevalence of IDU, 90% versus 72% (p < .001); homelessness, 67% versus 50% (p < .001); psychiatric diagnosis, 84% versus 50% (p < .001); overdose history 71% versus 31% (p < .001), receiving opioid agonist treatment (OAT) 75% versus 52% (p < .001) and comorbidity 44% versus 25% (p < .001). Of those treated with DAAs (n = 272), ITT SVR rates were 86% (95% CI: 81%-90%), being similar in period 2 versus period 1. Predictors of non-SVR were receiving OAT (OR 0.33, 95% CI: 0.12-0.87, p = .025) and ≥80% adherence (OR 0.01, 95% CI: 0.003-0.041, p < .001). Reinfection rates period 2 versus period 1 (per 100 person-years) were 1.84 versus 1.70, respectively. In the treated cohort, mortality was 15%, being mostly drug-related. Despite increasing complexity of PWUD, high SVR12 rates are achievable with use of OAT and good adherence.

Parents who inject drugs: Demographics, care arrangements and correlates for child placement in out-of-home care.

INTRODUCTION: Children in families affected by substance use disorders are at high risk of being placed in out-of-home care (OOHC). We aimed to describe the characteristics of parents who inject drugs and identify correlates associated with child placement in OOHC. METHODS: We used baseline data from a community-based cohort of parents who inject drugs (SuperMIX) from Melbourne, Australia. Participants were recruited via convenience, respondent-driven and snowball sampling from April 2008 to November 2020, with follow-up until March 2021. To explore correlates associated with child placement to OOHC, we used multivariable logistic regression and assessed for potential interactions between gender and a range of relevant covariates. RESULTS: Of the 1067 participants, 611 (57%) reported being parents. Fifty-six percent of parents reported child protection involvement. Almost half (49%) had children in OOHC. Nearly half of the parents lived in unstable accommodation (44%) and many of them experienced moderate-severe levels of anxiety (48%) and depression (53%). Female or non-binary gender, identifying as Aboriginal or Torres Strait Islander, experiencing assault and having more children were associated with child removal to OOHC. Of the 563 participants who reported their own childhood care status, 135 (24%) reported they had been removed to OOHC. DISCUSSION AND CONCLUSIONS: We identified high rates of child placement in OOHC among parents who inject drugs. There is a need for targeted health and social services, that are gender and culturally responsive, in addition to systems-level interventions addressing social inequities, such as housing, to support parents to care for their children.

Adverse health outcomes among people who inject drugs who engaged in recent sex work: findings from a national survey.

OBJECTIVES: This study explores trends in sex work among people who inject drugs (PWID) by gender and the relationship between sex work and adverse health outcomes including overdose, injection-site, and blood-borne virus (BBV) infections. STUDY DESIGN: The Unlinked Anonymous Monitoring Survey of PWID is an annual cross-sectional survey that monitors BBV prevalence and behaviours, including transactional sex, among PWID recruited through specialist services in England, Wales, and Northern Ireland. METHODS: Trends in sex work among PWID (2011-2021) were described. Data were analysed to assess differences between PWID who engaged in sex work in the past year (sex workers [SWs]) and those who did not (non-SWs) by gender (Pearson Chi2 tests) (2018-2021). Associations between sex work in the past year and adverse health outcomes were investigated using logistic regression. RESULTS: Between 2011 and 2021, sex work among PWID remained stable, with 31% of women and 6.3% of men who inject, reporting having ever engaged in sex work, and 14% of women and 2.2% of men engaging in sex work in the past year. Between 2018 and 2021, SWs had greater odds of reporting symptoms of an injection-site infection (adjusted odds ratio (aOR): 1.68 [95% confidence interval {CI}: 1.31-2.16], P < 0.001) and reporting overdose (aOR: 2.21 [CI: 1.74-2.80], P < 0.001) than non-SWs had in the past year. Among men, SWs had 243% greater odds of having HIV than non-SWs (aOR: 3.43 [CI: 1.03-11.33], P = 0.043). CONCLUSIONS: Our findings highlight disproportionate vulnerability and intersection of overlapping risk factors experienced by PWID SWs and a need for tailored interventions which are inclusive and low-threshold.

Injection drug use and sexually transmitted infections among men who have sex with men: A retrospective cohort study at an HIV/AIDS referral hospital in Tokyo, 2013-2022.

Men who have sex with men (MSM) who use injection drugs (MSM-IDU) are at high risk of sexually transmitted infections (STIs), but the long-term incidence is unclear. We conducted a single-centre retrospective cohort study using the clinical records of non-haemophilia men with human immunodeficiency virus (HIV) who visited the Institute of Medical Science, the University of Tokyo (IMSUT) Hospital, located in Tokyo, Japan, from 2013 to 2022. We analysed 575 patients including 62 heterosexual males and 513 MSM patients, of whom 6.8% (35/513) were injection drug use (IDU). Compared to non-IDU MSM, MSM-IDU had a higher incidence of hepatitis C virus (HCV) (44.8 vs 3.5 /1,000 person-years (PY); incidence rate ratio (IRR) [95% confidence interval (95% CI)], 12.8 [5.5-29.3], p < 0.001) and syphilis (113.8 vs 53.3 /1,000 PY; IRR, 2.1 [1.4-3.1], p < 0.001). The incidence of other symptomatic STIs (amoebiasis, chlamydia, and gonorrhoea infections) was <4/1,000 PY. In multivariable Poisson regression analysis, HCV incidence was associated with MSM (IRR, 1.8 × 106 [9.9 × 105-3.4 × 106], p < 0.001), IDU (IRR, 10.1 [4.0-25.6], p < 0.001), and syphilis infection during the study period (IRR, 25.0 [1.2-518.3]/time/year, p < 0.001). Among men with HIV, the prevalence of IDU in MSM and the long-term incidence of STIs in MSM-IDU were high. IDU and sexual contact are important modes of transmission of HCV among HIV-infected MSM in Tokyo.