Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland.

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Association of Illicit Fentanyl Use with Injection Risk Practices Among People who Inject Drugs.

We investigated the association between fentanyl injection frequency and sharing of injection equipment among people who inject drugs. We surveyed 249 people who inject drugs in Toronto in 2019. We estimated predicted probabilities of associations between fentanyl injection frequency and injection risk practices. In prior 6 months, 117 (47.0%) of participants injected fentanyl daily, 49 (19.7%) less than daily, and 78 (31.3%) did not inject fentanyl. Participants who injected fentanyl daily shared syringes more often than those not injecting fentanyl (25.0% vs. 4.9%; χ2 = 11.54, p = 0.0007). Participants who injected fentanyl daily (42.4% vs. 11.3%; χ2 = 18.05, p < 0.0001) and less than daily (37.2% vs. 11.3%; χ2 = 5.88 p = 0.02) shared cookers more often than those not injecting fentanyl. Participants who injected fentanyl daily (30.2% vs. 9.7%; χ2 = 9.05, p = 0.003) and less than daily (30.3% vs. 9.7%; χ2 = 4.11, p = 0.04) shared filters more often than those not injecting fentanyl. No differences in probabilities of sharing equipment were detected between participants who injected fentanyl daily and less than daily. People using fentanyl reported injection practices that increased risk for infectious disease transmission.

Network Correlates of Using a Syringe After an Injection Partner Among Women Who Inject Drugs in Philadelphia Pennsylvania.

This analysis aims to identify relationship-level correlates of receptive syringe sharing among women who inject drugs in Philadelphia. Sixty-four women who injected daily were recruited from Prevention Point Philadelphia's syringe exchange program (9/2/20 - 11/23/20). Interviewer-administered surveys collected (1) individual-level demographics and risk behaviors and (2) relationship-level information about each past-6-month injection partner and injecting practices between the two. We built two separate log-binomial regression models which accounted for clustering of network members within participants to identify relationship-level correlates of using a syringe after a partner. Women reported injecting with a syringe previously used by 21.14% of partners. Women were more likely to use a syringe after sex partners (Adjusted Prevalence Ratio [APR]model_1=2.77) and those who provided injection assistance (APRmodel_1=1.92) or emotional support (APRmodel_2=6.19). Future harm reduction efforts could train women to negotiate safer injection practices with sex partners and those who provide injection assistance and/or emotional support.

RESUMEN: Este análisis tiene como objetivo identificar los correlatos a nivel de relación del compartimiento de jeringas receptivas en las mujeres que se inyectan drogas en Filadelfia. Sesenta y cuatro mujeres que se inyectaron diariamente fueron reclutadas en el programa de intercambio de jeringas de Prevention Point Philadelphia (9/2/20 − 11/23/20). Las encuestas fueron administradas por un entrevistador y recabaron (1) características demográficas y comportamientos de riesgo a nivel del individuo y (2) información sobre la relación con cada pareja de inyección durante los últimos 6 meses, incluidas las prácticas de inyección entre los dos. Construimos dos modelos de regresión logarítmico-binomial separados que representaban la agrupación de miembros de la red dentro de los participantes para identificar correlatos a nivel de relación del uso de una jeringa después de una pareja. Las mujeres utilizaron una jeringa que había sido utilizada previamente por 21.14% de las parejas de inyección enumeradas. Las mujeres eran más probables en usar una jeringa después de las parejas sexuales (Razón de prevalencia ajustada [RPA]model_1 = 2.77) y de quienes las ayudaron a inyectarse (RPAmodel_1 = 1.92) o les brindaron apoyo emocional (RPAmodel_2 = 6.19). Los esfuerzos futuros de reducción del daño podrían capacitar a las mujeres para negociar prácticas de inyección más seguras con sus parejas sexuales y quienes brindan asistencia para la inyección y/o apoyo emocional.

Food Insecurity and Transmission Risks Among People with HIV Who Use Substances.

Food insecurity (FI) impacts people with HIV (PWH) and those who use substances (i.e. drugs and alcohol). We evaluated the longitudinal association between FI and HIV transmission risks (unprotected sexual contacts and shared needles/syringes). Among 351 PWH who use substances in Russia, 51.6% reported FI and 37.0% past month injection drug use. The mean number of unprotected sexual contacts in the past 90 days was 13.4 (SD 30.1); 9.7% reported sharing needles/syringes in the past month. We did not find a significant association between mild/moderate FI (adjusted IRR = 0.87, 95% CI 0.47, 1.61) or severe FI (aIRR = 0.84, 95% CI 0.46, 1.54; global p = 0.85) and unprotected sexual contacts. We observed a significant association between severe FI and sharing needles/syringes in the past month (adjusted OR = 3.27, 95% CI 1.45, 7.39; p = 0.004), but not between mild/moderate FI and sharing needles/syringes in the past month (aOR = 1.40,95% CI 0.58, 3.38; p = 0.45). These findings suggest that severe FI could be a potential target for interventions to lower HIV transmission.

RESUMEN: La inseguridad alimentaria (IF) afecta a las personas que viven con VIH (PVV y a personas con abuso desustancias (.ej. drogas y alcohol). Evaluamos la asociación longitudinal entre la IF y los riesgos de transmisión del VIH (relaciones sexuales sin protección y agujas/jeringas compartidas). Entre 351 PVVcon abuso de sustancias en Rusia, el 51,6% reportó FI y el 37,0% consumió drogas intravenosas en el último mes. El promedio de contactos sexuales sin protección en los últimos 90 días fue de 13,4 (DE 30,1); el 9,7% informó haber compartido agujas/jeringas en el último mes. No encontramos una asociación significativa entre IF leve/moderada (IRR ajustada = 0,87, IC 95% = 0,47, 1,61) o IF grave (IRRa = 0,84, IC 95% = 0,46, 1,54; p global = 0,85) y relaciones sexuales sin protección. Observamos una asociación significativa entre IF grave y compartir agujas/jeringas en el último mes (OR ajustado = 3,27, IC 95% = 1,45, 7,39; p = 0,004), pero no entre IF leve/moderada y compartir agujas/jeringas en el último mes (ORa = 1,40, IC 95% = 0,58, 3,38; p = 0,45). Estos hallazgos sugieren que la IF grave podría ser un enfoque para intervenciones que buscan reducir la transmisión del VIH.

Injection partnership characteristics and HCV status associations with syringe and equipment sharing among people who inject drugs.

BACKGROUND: Sharing of syringes is the leading transmission pathway for hepatitis C (HCV) infections. The extent to which HCV can spread among people who inject drugs (PWID) is largely dependent on syringe-sharing network factors. Our study aims to better understand partnership characteristics and syringe and equipment sharing with those partners, including measures of relationship closeness, sexual activity, and social support, as well as self and partner HCV status to better inform interventions for young urban and suburban PWID. METHODS: Data are from baseline interviews of a longitudinal network-based study of young (aged 18-30) PWID (egos) and their injection network members (alters) in metropolitan Chicago (n = 276). All participants completed a computer-assisted interviewer-administered questionnaire and an egocentric network survey on injection, sexual, and support networks. RESULTS: Correlates of syringe and ancillary equipment sharing were found to be similar. Sharing was more likely to occur in mixed-gender dyads. Participants were more likely to share syringes and equipment with injection partners who lived in the same household, who they saw every day, who they trusted, who they had an intimate relationship with that included condomless sex, and who provided personal support. PWID who had tested HCV negative within the past year were less likely to share syringes with an HCV positive partner compared to those who did not know their status. CONCLUSION: PWID regulate their syringe and other injection equipment sharing to some extent by sharing preferentially with injection partners with whom they have a close personal or intimate relationship, and whose HCV status they are more likely to know. Our findings underscore the need for risk interventions and HCV treatment strategies to consider the social context of syringe and equipment sharing within partnerships.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic.

BACKGROUND: Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises. OBJECTIVE: This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19. METHODS: From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing. RESULTS: One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing. CONCLUSIONS: Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

Differential risks of syringe service program participants in Central Ohio: a latent class analysis.

BACKGROUND: Significant heterogeneity exists among people who use drugs (PWUD). We identify distinct profiles of syringe service program (SSP) clients to (a) evaluate differential risk factors across subgroups and (b) inform harm reduction programming. METHODS: Latent class analysis (LCA) was applied to identify subgroups of participants (N = 3418) in a SSP in Columbus, Ohio, from 2019 to 2021. Demographics (age, sex, race/ethnicity, sexual orientation, housing status) and drug use characteristics (substance[s] used, syringe gauge, needle length, using alone, mixing drugs, sharing supplies, reducing use, self-reported perceptions on the impact of use, and treatment/support resources) were used as indicators to define latent classes. A five-class LCA model was developed, and logistic regression was then employed to compare risk factors at program initiation and at follow-up visits between latent classes. RESULTS: Five latent classes were identified: (1) heterosexual males using opioids/stimulants with housing instability and limited resources for treatment/support (16.1%), (2) heterosexual individuals using opioids with stable housing and resources for treatment/support (33.1%), (3) individuals using methamphetamine (12.4%), (4) young white individuals using opioids/methamphetamine (20.5%), and (5) females using opioids/cocaine (17.9%). Class 2 served as the reference group for logistic regression models, and at the time of entry, class 1 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs, with persistently higher odds of sharing supplies and mixing drugs at follow-up. Class 3 was more likely to report history of overdose, sharing supplies, and mixing drugs, but outcomes at follow-up were comparable. Class 4 was the least likely to report history of overdose, HCV, and mixing drugs, but the most likely to report HIV. Class 5 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs at entry, and higher reports of accessing substance use treatment and testing positive for HCV persisted at follow-up. CONCLUSIONS: Considerable heterogeneity exists among PWUD, leading to differential risk factors that may persist throughout engagement in harm reduction services. LCA can identify distinct profiles of PWUD accessing services to tailor interventions that address risks, improve outcomes, and mitigate disparities.

Hormonothérapie injectable et réduction des risques : pratiques, difficultés, santé des personnes trans en France.

INTRODUCTION: Hormone therapy (HT) adherence practices among trans people are poorly studied. For a large proportion of these people, HT is administered parenterally. The unavailability of certain treatments in France, combined with poor institutional care, keeps injectors away from the health care system and encourages potentially risky injection practices. Following a significant increase in the number of trans people in its active list, the association Safe, coordinator of the remote harm reduction system in France, conducted a cross-sectional descriptive study from December 2020 to February 2021 using an anonymous self-administered online questionnaire. PURPOSE OF RESEARCH: The objective is to better understand the profile of trans people who inject their HT and their injection practices. RESULTS: We observed that a significant proportion of trans injectors do not benefit from professional support, either to obtain treatment or to carry out the injection. This situation can lead to certain misuses of medical supplies, such as needle sharing or reuse, which present significant health risks. This is especially true for injectors whose treatment is not legally available and who obtain it through parallel markets. This study also underlines the importance of self-support associations to accompany transition. CONCLUSIONS: We therefore propose that a harm reduction policy adapted to the practices of trans people be implemented in order to better support this population and avoid the emergence of major health problems such as HIV infection.

Assessment of effectiveness of targeted intervention program under national AIDS control program among injecting drug users across India.

Background: High HIV prevalence among injecting drug users (IDUs) remains a cause of concern and are considered key drivers of concentrated epidemic in India. The present paper aims to assess the effectiveness of the targeted intervention (TI) program on the risk behaviors among IDUs across regions of India. Materials and Methods: This paper used the data from the integrated biological and behavioral surveillance 2014-2015 among the IDUs in India. Descriptive statistics and propensity score matching analysis was carried out to understand the effectiveness of the TI program on the new needle/syringe used and needle/syringe shared in the last injecting episode by accounting for the covariates. Results: The matched samples estimate, i.e., average treatment effect on treated of new needles/syringe used and shared in the last injecting episode by those who received needles/syringes from peer educator or outreach workers (PE/ORWs) and those who did not receive was 2.8% (confidence interval [CI]: 0.05-5.6) increase in the use of new needles/syringes and 6.5% (CI: -9.7--3.3) decrease in the needles/syringes shared in last injecting episode indicating that IDUs who received new needles/syringes from PE/ORWs are more likely to use new needle/syringe and less likely to share needle/syringes to those who did not receive needles/syringes. The results vary across the different regions of India. Conclusion: TI program proves to be an effective initiative in the behavior change among IDUs as substantiated by use of new needles/syringes and decreased sharing of needles/syringes. TI program coverage varies from region to region and may further be expanded to accelerate the program services to prevent HIV/AIDS.

Identification of Genetically Related HCV Infections Among Self-Described Injecting Partnerships.

BACKGROUND: The current opioid epidemic across the United States has fueled a surge in the rate of new hepatitis C virus (HCV) infections among young persons who inject drugs (PWIDs). Paramount to interrupting transmission is targeting these high-risk populations and understanding the underlying network structures facilitating transmission within these communities. METHODS: Deep sequencing data were obtained for 52 participants from 32 injecting partnerships enrolled in the U-Find-Out (UFO) Partner Study, which is a prospective study of self-described injecting dyad partnerships from a large community-based study of HCV infection in young adult PWIDs from San Francisco. Phylogenetically linked transmission events were identified using traditional genetic-distance measures and viral deep sequence phylogenies reconstructed to determine the statistical support of inferences and the direction of transmission within partnerships. RESULTS: Using deep sequencing data, we found that 12 of 32 partnerships were genetically similar and clustered. Three additional phylogenetic clusters were found describing novel putative transmission links outside of the injecting relationship. Transmission direction was inferred correctly for 5 partnerships with the incorrect transmission direction inferred in more than 50% of cases. Notably, we observed that phylogenetic linkage was most often associated with a lower number of network partners and involvement in a sexual relationship. CONCLUSIONS: Deep sequencing of HCV among self-described injecting partnerships demonstrates that the majority of transmission events originate from outside of the injecting partnership. Furthermore, these findings caution that phylogenetic methods may be unable to routinely infer the direction of transmission among PWIDs especially when transmission events occur in rapid succession within high-risk networks.

The opioid crisis and HIV in the USA: deadly synergies.

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.

The association of gender with receptive and distributive needle sharing among individuals who inject drugs.

BACKGROUND: Injection drug use and needle sharing remains a public health concern due to the associated risk of HIV, HCV and skin and soft tissue infections. Studies have shown gendered differences in the risk environment of injection drug use, but data are currently limited to smaller urban cohorts. METHODS: To assess the relationship between gender and needle sharing, we analyzed publicly available data from the 2010-2019 National Survey on Drug Use and Health (NSDUH) datasets. Chi-square tests were conducted for descriptive analyses and multivariable logistic regression models were built adjusting for survey year, age, HIV status, and needle source. RESULTS: Among the entire sample, 19.8% reported receptive needle sharing, 18.8% reported distributive sharing of their last needle, and 37.0% reported reuse of their own needle during last injection. In comparison with men, women had 34% increased odds (OR 1.34, 95% CI 1.11-1.55) of receptive needle sharing and 67% increased odds (OR 1.67, 95% CI 1.41-1.98) of distributive needle sharing. Reuse of one's own needle did not differ by gender. CONCLUSIONS: In this nationally representative sample, we found that women are more likely in comparison with men to share needles both through receptive and distributive means. Expansion of interventions, including syringe service programs, to increase access to sterile injection equipment is of great importance.

The Changing Epidemiology of Hepatitis C Virus Infection in the United States During the Years 2010 to 2018.

Hepatitis C virus (HCV) infection remains an important cause of morbidity and mortality throughout the world, leading to serious health problems among those who are chronically infected. Since 1992, the Centers for Disease Control and Prevention has been collecting data on the incidence of HCV infection in the United States. In 2018, more than 50 000 individuals were estimated to have acute HCV infection.The most recently reported data on the prevalence of infection indicate that approximately 2.4 million people are living with hepatitis C in the United States. Transmission of HCV occurs predominantly through sharing contaminated equipment for injecting drugs.Two major events have had a significant impact on the incidence and prevalence of hepatitis C in the past few decades: the US opioid crisis and the discovery of curative treatments for HCV infection. To better understand the impact of these events, we examine reported trends in the incidence and prevalence of infection.

Partner Notification Services for Patients with Established and New HIV Infection Leads to Diagnosis and Linkage of HIV-Positive Partners.

Offering people living with HIV the opportunity to refer partners for HIV testing is an efficient way of identifying new HIV diagnoses. This report describes the outcomes of physician-led partner services at an urban academic center. Patients with HIV VL > 1000 copies/mL in both inpatient and outpatient settings were offered partner notification services (PNS). Of referred partners, 8.7% had a new diagnosis of HIV. New HIV+ partners were as likely to be referred by patients with existing HIV diagnoses as new diagnoses (p = 0.61), and as likely to be referred by patients interviewed while hospitalized as those in the clinic (p = 0.61).

Hazardous Alcohol Use, Impulsivity, and HIV-Risk Behavior Among HIV-Positive Russian Patients With a History of Injection Drug Use.

BACKGROUND AND OBJECTIVES: Previous findings on the association between hazardous drinking and HIV-risk behavior have been equivocal, varying by population and individual difference factors. This study examined associations between hazardous drinking, impulsivity, and HIV-risk behaviors among HIV-positive Russian patients with a history of injection drug use (IDU), not on antiretroviral therapy. METHODS: Negative binomial regression analyses of data from a randomized controlled trial were performed (N = 241). Main independent variables were the Alcohol Use Disorders Identification Test and the Barratt Impulsiveness Scale. Outcomes were number of condomless sexual episodes (CSE; primary), number of sexual partners, and needle-sharing frequency (secondary). RESULTS: Hazardous drinking was positively associated with the frequency of CSE (adjusted incidence rate ratio [aIRR] = 2.16, 95% confidence interval [CI], 1.98-2.36). Moderate (aIRR = 0.51, 95% CI, 0.46-0.56) and high (aIRR = 0.66, 95% CI, 0.60-0.73) impulsivity were associated with fewer CSE compared with low impulsivity. Hazardous drinking (aIRR = 0.64, 95% CI, 0.52-0.79) and impulsivity (aIRR = 0.95, 95% CI, 0.94-0.96) were both associated with fewer sexual partners. Hazardous drinking and impulsivity were each associated with increased needle sharing. The association between hazardous drinking and number of needle-shares was strongest at higher impulsivity levels. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Hazardous drinking may be a risk factor for CSE among HIV-positive Russian patients and may influence needle sharing. Findings contribute to our understanding of the interactive associations between hazardous drinking and impulsivity with sexual risk behaviors and needle sharing among HIV-positive Russian patients with a history of IDU. (Am J Addict 2020;00:00-00).

Assessing the relationship between syringe exchange, pharmacy, and street sources of accessing syringes and injection drug use behavior in a pooled nationally representative sample of people who inject drugs in the United States from 2002 to 2019.

Provision of sterile syringes is an evidence-based strategy of reducing syringe sharing and reusing and yet, access to sterile syringes through pharmacies and syringe exchange programs (SEPs) in the United States remains inadequate. This nationally representative study examined associations between obtaining syringes from pharmacies, SEPs, and sterilizing syringes with bleach and risk of syringe borrowing, lending and reusing syringes in a pooled cross-sectional dataset of 1737 PWID from the 2002-2019 National Survey on Drug Use and Health. Logistic regression was used to produce odds ratios (OR) of the odds of injection drug behaviors after adjusting for obtaining syringes from SEPs, pharmacies, the street, and other sources and potential confounders of race, ethnicity, sex, education, and insurance coverage. Obtaining syringes through SEPs was associated with lower odds of borrowing (OR = .4, CI95% = .2, .9, p = .022) and reusing syringes (OR = .3, CI95% = .2, .6, < .001) compared to obtaining syringes on the street. Obtaining syringes from pharmacies was associated with lower odds of borrowing (OR = .5, CI95% = .3, .9, p = .037) and lending (OR = .5 CI95% = .3, .9, p = .020) syringes. Using bleach to clean syringes was associated with increased odds of borrowing (OR = 2.0, CI95% = 1.3, 3.0, p = .002), lending (OR = 2.0, CI95% = 1.3, 3.0, p = .002) and reusing syringes (OR = 2.4, CI95% = 1.6, 3.6, p < .001). Our findings support provision of syringes through pharmacies and SEPs as a gold-standard strategy of reducing sharing and reuse of syringes in the US.

Injection drug use practices and HIV infection among people who inject drugs in Kigali, Rwanda: a cross-sectional study.

BACKGROUND: In Rwanda, epidemiological data characterizing people who inject drugs (PWID) and their burden of HIV are limited. We examined injection drug use (IDU) history and practices, and HIV infection in a sample of PWID in Kigali. METHODS: From October 2019 to February 2020, 307 PWID aged ≥ 18 were enrolled in a cross-sectional study using convenience sampling in Kigali. Participants completed interviewer-administered questionnaires on IDU history and practices and HIV testing. We used Poisson regression with robust variance estimation to assess IDU practices associated with HIV infection and assessed factors associated with needle sharing in the six months preceding the study. RESULTS: The median age was 28 years (IQR 24-31); 81% (251) were males. Female PWID were more likely to report recent IDU initiation, selling sex for drugs, and to have been injected by a sex partner (p < 0.05). In the prior six months, heroin was the primary drug of choice for 99% (303) of participants, with cocaine and methamphetamine also reported by 10% (31/307) and 4% (12/307), respectively. In total, 91% (280/307) of participants reported ever sharing needles in their lifetime and 43% (133) knew someone who died from a drug-related overdose. HIV prevalence was 9.5% (95% CI 8.7-9.3). Sharing needles at least half of the time in the previous six months was positively associated with HIV infection (adjusted prevalence ratio (aPR) 2.67; 95% CI 1.23-5.78). Overall, 31% (94/307) shared needles and 33% (103/307) reused needles in the prior six months. Female PWID were more likely to share needles compared to males (aPR 1.68; 95% CI 1.09-2.59). Additionally, bisexual PWID (aPR 1.68; 95% CI 1.09-2.59), those who shared needles at the first injection (aPR 2.18; 95% CI 1.59-2.99), reused needles recently (aPR 2.27; 95% CI 1.51-3.43) and shared other drug paraphernalia (aPR 3.56; 95% CI 2.19-5.81) were more likely to report recent needle sharing. CONCLUSION: HIV infection was common in this study. The high prevalence of needle reuse and sharing practices highlights significant risks for onward transmission and acquisition of HIV and viral hepatitis. These data highlight the urgent need for PWID-focused harm reduction services in Rwanda, including syringe services programs, safe injection education, naloxone distribution, and substance use disorder treatment programs and optimizing these services to the varied needs of people who use drugs in Rwanda.

High levels of used syringe use and unsafe sex among people who inject drugs in Kumasi, Ghana: an urgent call for a comprehensive harm reduction approach.

BACKGROUND: Drug 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. METHODS: From 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. RESULTS: Key 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). CONCLUSIONS: Our 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.

Prevalence and Correlates of Syringe Disposal Box Use in a Philadelphia Neighborhood with High Levels of Public Drug Injection.

Background: Philadelphia (Pennsylvania, USA) is facing an unprecedented public health crisis due to fentanyl use. To combat drug-related litter, the Philadelphia Department of Public Health installed 7 public syringe disposal boxes (SDB) in Kensington, the neighborhood most impacted by the opioid crisis and home to a syringe exchange. Methods: We used street- and business-intercepts to recruit residents (N=358) and business owners/staff (N=78) who completed a brief survey with two binary items measuring observing and using SDB. Multivariable logistic regression was used to assess factors independently associated with SDB observance and use. Results: 78% (340/436) observed SDB and 34.1% (116/340) had ever used SDB among those who had seen them. Unstably housed persons had 4.3 times greater odds of observing SDB (Adjusted odds ratio [aOR= 4.29; 95% confidence interval [CI]: 1.56, 11.82) and had 2.5 times greater odds of using SDB (aOR = 2.51; 95% CI: 1.33, 4.74) as did people who use opioids (aOR = 2.61; 95% CI: 1.45, 4.72). Among individuals reporting opioid use who also saw SDB (n=123), those who were unstably housed were more likely to use SDB than those with stable housing (67.8% vs 45.3%, p=.012). Conclusion: These results suggest Kensington residents, especially those who are unstably housed, use SDB once they see them in the neighborhood.

Novel Routes of Potential Hepatitis C Virus Transmission among People Who Inject Drugs: Secondary Blood Exposures Related to Injection Drug Use.

BACKGROUND: The US is in the midst of a national Hepatitis C Virus (HCV) epidemic that appears to be driven by new cases among people who inject drugs (PWID). While HCV transmission among PWID is believed to occur mostly through direct sharing of syringes, some infections may be spread via secondary processes and materials involved in injecting. OBJECTIVES: Here, we present the prevalence of secondary blood exposures on clothing and nearby surfaces after injection episodes and examine the correlations of these exposures to lifetime HCV infection among a targeted sample of 553 PWID in Los Angeles and San Francisco, California in 2016-18. RESULTS: In multivariate logistic regression models, higher odds of blood on clothing in the last 30 days was significantly (p < 0.05) associated with lifetime positive HCV status, opioids as primary drug, injecting with others, sharing cookers, and receptive syringe sharing. Higher adjusted odds of blood on nearby surfaces in the last 30 days was significantly associated with lifetime positive HCV status, sharing cookers, and receptive syringe sharing. Native American race was associated with significantly lower adjusted odds of both outcome variables. Conclusions/Importance: Results indicate the relevance of physical and social micro-environments to the potential for blood exposures secondary to injection episodes. Individuals with chronic HCV seropositivity are potentially more likely to expose others to blood due to decreases in the blood's ability to clot. This highlights the need for increased HCV testing at harm reduction sites and increased supply of first aid and wound-care materials to help stop potential blood exposures after injection episodes.