Integration of a contraception clinic into an opioid treatment setting to improve contraception knowledge, accessibility and uptake: a pilot study.

OBJECTIVE: To assess the feasibility and acceptability of integrating a contraception clinic within an opioid agonist treatment (OAT) service to improve access to contraception, especially long-acting reversible methods of contraception (LARC), for women receiving OAT, who have increased risk of unplanned pregnancies and adverse pregnancy outcomes. METHODS: A contraception clinic was established at a Sydney OAT service. Forty-eight female OAT clients were surveyed regarding their contraception knowledge and needs. Interested and eligible women were referred to the contraception clinic. RESULTS: Women were aged a median of 39 years (range 24-54 years). Most women (83%) agreed it was acceptable for their OAT clinician to discuss contraception with them. Eight women reported current LARC use and 21 reported they would consider using LARC. Twenty-three women were eligible for contraception (sexually active, aged <50 years, not using contraception, wishing to avoid pregnancy). Six months post-survey two women had presented to the clinic and two reported an unintended pregnancy. CONCLUSION: Uptake of an on-site contraception service within OAT clinic was low, despite participants' expressed willingness to use the service. Access is therefore not the only driver of low contraception uptake for this group. Implications for public health: Other issues besides access to contraception warrant investigation to improve contraception uptake for women receiving OAT.

Health and social interventions in the context of support and control: The experiences of marginalised people who use drugs in Australia.

People who use illicit drugs frequently become targets for welfare intervention, often positioned both as complicit in the reproduction of intergenerational poverty and marginalisation, and as sources of hope for interrupting such patterns. This article draws on empirical research exploring the experiences of highly marginalised people with histories of illicit drug-use to investigate how they negotiate service encounters in the context of the participants' previous experiences with welfare interventions. In doing so, the article seeks to texture the conception of the support and control nexus, drawing out the systemic and service level factors of welfare services which inhibit people who use drugs from benefitting from available support. We conducted 12 in-depth interviews with participants subject to interventions by health, social or legal services between July and September 2018. All interviews were audio-recorded, transcribed verbatim and coded in NVivo. Transcripts were analysed using a grounded theory approach where data were subject to an iterative process of constant comparisons to identify emergent themes and theoretical concepts. The findings suggest that the blending of welfare services and systems of control has unintended and often negative consequences for highly marginalised people. In effect, the drug treatment programme's aims of assisting people to reduce harm and increase stability are significantly undermined by control mechanisms such as mandatory reporting policies. A better understanding of the ways in which welfare service processes alienate marginalised people from seeking support, as well as from benefitting from the support available, might provide a way to address these concerns.

Alcohol policy in Iran: Policy content analysis.

BACKGROUND: Muslim majority countries (MMCs) typically have limited alcohol policy development due to Islamic prohibition of alcohol consumption. In response to recent increases in alcohol consumption and related harms, MMCs have introduced civil alcohol policies, ranging from total prohibition to European-style regulations. Using Iran as a case study, we describe how alcohol prohibition is translated into policy in the face of influences from globalisation. METHODS: We collected information from publicly available literature and policy documents, because of the sensitivity of the topic of alcohol in Iran. The search was conducted in English and Persian. We verified information through consultations with policy actors. We also reviewed newspapers over periods just before the 1979 Islamic revolution, and before and after the 2011 alcohol policy (2008-2010; 2014-2016) was introduced. We analysed policy content based on WHO policy recommendations and used the Walt & Gilson health framework to identify policy content, context, actors and process. RESULTS: Despite its broad approach of civil prohibition with concessions for the non-Muslim population, Iran has developed approaches to reduce the harmful impacts of alcohol and adopted nine of ten policy interventions recommended by WHO. Pricing policy was the only intervention not used. We identified contextual challenges, such as resources, stigma and cultural offence that influence policy development. CONCLUSION: MMCs face challenges in creating civil alcohol policies. Iran has taken steps, including a national alcohol strategy, to reduce alcohol-related harms. The socio-cultural, governance and historical context have shaped Iran's adaptation of policy interventions recommended by WHO.

"Beyond Safer Injecting"-Health and Social Needs and Acceptance of Support among Clients of a Supervised Injecting Facility.

Health and social issues in aging populations of people who inject drugs (PWID) tend to aggregate, despite risky injecting practices decreasing with age. Identifying needs and avenues of support is becoming increasingly important. We described the health and social situation among clients of a long-running supervised injecting facility (SIF) in Sydney, Australia. An interviewer-administered survey (n = 182) assessed current housing status, employment, physical and mental health, incarceration history, drug use, engagement in drug treatment, health service utilization, and willingness to accept support. Results were compared to the information provided at initial visit. Up to half of the participants transitioned between lower- and higher-risk health and social indicators over time. Willingness to accept support was greatest amongst those with higher self-perceived need. Support for mental health was a low priority, despite the high self-reporting of mental health issues. SIF clients are open to support for health and social issues, despite ongoing active drug use. Lower-threshold services such as SIFs are well-positioned to recognize and respond to deteriorating health and social issues for PWID. Facilitating care and treatment remains a challenge when the services to which people are being referred are higher-threshold with a more rigid approach.

A managed alcohol program in Sydney, Australia: Acceptability, cost-savings and non-beverage alcohol use.

INTRODUCTION AND AIMS: Managed alcohol programs (MAPs) are a novel harm reduction intervention for people who experience long-term homelessness and severe long-term alcohol dependence. MAPs provide regulated amounts of alcohol onsite under supervision. Preliminary international evidence suggests that MAPs are associated with improvements such as reduced non-beverage alcohol consumption and decreases in some alcohol-related harms. There are currently no MAPs in Australia. We aimed to assess the feasibility of a MAP in inner-Sydney. DESIGN AND METHODS: A survey among eligible homeless alcohol-dependent residents of an inner-Sydney short-stay alcohol withdrawal service occurred in 2014 to assess acceptability. Administrative data were analysed to ascertain estimates of cost-savings for a MAP based in Sydney. RESULTS: Fifty-one eligible participants were surveyed. More than one-quarter (28%) reported consumption of non-beverage alcohol. A residential model received greatest support (76%); the majority (75%) of participants indicated a willingness to pay at least 25% of their income to utilise a MAP. Hospital and crisis accommodation cost-savings were conservatively estimated at AUD$926 483.40 and AUD$347 574.00, respectively per year for a 15-person residential MAP. DISCUSSION AND CONCLUSIONS: Our findings demonstrate the acceptability of a MAP in Sydney among a target population sample, with the implementation of a residential MAP likely to produce significant cost-savings. A trial of a Sydney MAP evaluating the impact on health and social outcomes, including a comprehensive economic evaluation, is strongly recommended.

Extent of alcohol prohibition in civil policy in Muslim majority countries: the impact of globalization.

BACKGROUND AND AIMS: Many policies have been introduced to reduce alcohol harm in different countries. However, Muslim majority countries (MMCs), where the major religion (Islam) prohibits alcohol consumption, have less well-developed civil alcohol policies. Overall, MMCs have low prevalence of alcohol consumption, although recently most MMCs have been undergoing transition, which has sometimes increased pressure for alcohol availability and impacted on social practices, alcohol policies and broader public health. Globalization, the influence of the global alcohol industry, recent governmental transition or political instability and the presence of immigrants from non-Muslim countries can all affect civil alcohol policy. In this context, consumption overall has increased compared with two decades ago. This paper presents an overview of current civil alcohol policy, with regard to the presence or absence of alcohol prohibition, and provides an insight into the legal availability of alcohol in MMCs and the challenges facing policymakers. METHODS: English, Arabic and Persian language sources were examined, using PubMed, government websites for each country and the World Health Organization (WHO). Some of the challenges MMCs may face in developing alcohol policies are explored, including the need to interact with the global economy and the potential influence of the alcohol industry. CONCLUSION: Muslim majority countries have adopted a range of civil alcohol policies in recent decades. There is a pressing need for better data and to support Muslim majority countries in alcohol policy development. Lessons from Muslim majority countries can help to inform other parts of the world.

Development of immunity following financial incentives for hepatitis B vaccination among people who inject drugs: A randomized controlled trial.

BACKGROUND: People who inject drugs (PWID) are at risk of hepatitis B virus (HBV) but have low rates of vaccination completion. The provision of modest financial incentives increases vaccination schedule completion, but their association with serological protection has yet to be determined. OBJECTIVE: To investigate factors associated with vaccine-induced immunity among a sample of PWID randomly allocated to receive AUD$30 cash following receipt of doses two and three ('incentive condition') or standard care ('control condition') using an accelerated 3-dose (0,7,21 days) HBV vaccination schedule. STUDY DESIGN: A randomised controlled trial among PWID attending two inner-city health services and a field site in Sydney, Australia, assessing vaccine-induced immunity measured by hepatitis B surface antibodies (HBsAb ≥ 10 mIU/ml) at 12 weeks. The cost of the financial incentives and the provision of the vaccine program are also reported. RESULTS: Just over three-quarters of participants - 107/139 (77%)--completed the vaccination schedule and 79/139 (57%) were HBsAb ≥ 10 mIU/ml at 12 weeks. Vaccine series completion was the only variable significantly associated with vaccine-induced immunity in univariate analysis (62% vs 41%, p<0.035) but was not significant in multivariate analysis. There was no statistically discernible association between group allocation and series completion (62% vs 53%). The mean costs were AUD$150.5, (95% confidence interval [CI]: 142.7-158.3) and AUD$76.9 (95% CI: 72.6-81.3) for the intervention and control groups respectively. CONCLUSION: Despite increasing HBV vaccination completion, provision of financial incentives was not associated with enhanced serological protection. Further research into factors which affect response rates and the optimal vaccination regimen and incentive schemes for this population are needed.

The effect of social functioning and living arrangement on treatment intent, specialist assessment and treatment uptake for hepatitis C virus infection among people with a history of injecting drug use: The ETHOS study.

BACKGROUND: The objective was to assess social functioning and its association with treatment intent, specialist assessment and treatment uptake for hepatitis C virus (HCV) infection among people with a history of injecting drug use. METHODS: ETHOS is a prospective observational cohort evaluating the provision of HCV assessment and treatment among people with chronic HCV and a history of injecting drug use, recruited from nine community health centres and opioid substitution treatment clinics (NSW, Australia). Social functioning was assessed using a short form of the Opioid Treatment Index social functioning scale. Those classified in the highest quartile (score >6) were considered having lower social functioning. Analyses were performed using logistic regression. RESULTS: Among 415 participants (mean age 41 years, 71% male), 24% were considered having lower social functioning, 70% had early HCV treatment intent (intention to be treated in the next 12 months), 53% were assessed by a specialist and 27% initiated treatment. Lower social functioning was independently associated with unemployment, unstable housing, recent injecting drug use and moderate to extremely severe symptoms of depression, anxiety and stress. Lower social functioning was independently associated with reduced early HCV treatment intent (aOR 0.51, 95% CI 0.30-0.84) and lower specialist assessment (aOR 0.48, 95% CI 0.29-0.79), but not HCV treatment uptake (aOR 0.76, 95% CI 0.40-1.43). Living with someone was independently associated with HCV treatment uptake (with someone and children: aOR 2.28, 95% CI 1.01-5.14; with someone and no children: aOR 2.36, 95% CI 1.30-4.31), but not early HCV treatment intent or specialist assessment. CONCLUSIONS: This study highlights the need for the development and implementation of strategies targeting people who inject drugs with lower social functioning to enhance HCV treatment intent and specialist assessment. Further, strategies to enhance social support may play a role in increasing HCV treatment uptake.

Overview of substance use and treatment from Australia.

This paper aims to provide an overview of drug and alcohol issues and their management in Australia. Overall, Australia has good health relative to the United States and other similar nations and generally similar rates of substance use disorders. A whole-of-government strategic approach has been developed for managing drug and alcohol problems, with a National Drug Strategy that has adopted a pragmatic approach to substance use problems through 3 "pillars"--demand, supply, and harm reduction. This approach has been attributed to Australia's remarkably low human immunodeficiency virus (HIV) prevalence among people who inject drugs (<2%). Most community primary health care is provided through Australia's universal health care scheme, which provides a rebate for nearly all medical services according to a scheduled fee. Inpatient and outpatient care, including drug and alcohol services, delivered at public hospitals are currently provided with no patient co-payments. The health of Australia's first peoples, Australian Aboriginals and Torres Strait Islanders, remains challenging primarily due to the transgenerational impacts of dispossession, social and economic disadvantage, and some cultural differences. Although substance use is a key issue for Australian Aboriginals, there are currently insufficient dedicated drug and alcohol services for this group. Notwithstanding this important exception, Australia's health and substance use is favorable relative to other developed nations, offering universal health care and a pragmatic drug and alcohol strategy.

Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study.

BACKGROUND: Access to hepatitis C virus (HCV) treatment remains extremely limited among people who inject drugs (PWID). HCV assessment and treatment was evaluated through an innovative model for the provision of HCV care among PWID with chronic HCV infection. METHODS: Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) was a prospective observational cohort. Recruitment was through 5 opioid substitution treatment (OST) clinics, 2 community health centers, and 1 Aboriginal community controlled health organization in New South Wales, Australia. RESULTS: Among 387 enrolled participants, mean age was 41 years, 71% were male, and 15% were of Aboriginal ethnicity. Specialist assessment was undertaken in 191 (49%) participants, and 84 (22%) commenced interferon-based treatment. In adjusted analysis, HCV specialist assessment was associated with non-Aboriginal ethnicity (adjusted odds ratio [AOR], 4.02; 95% confidence interval [CI], 2.05-7.90), no recent benzodiazepine use (AOR, 2.06; 95% CI, 1.31-3.24), and non-1 HCV genotype (AOR, 2.13; 95% CI, 1.32-3.43). In adjusted analysis, HCV treatment was associated with non-Aboriginal ethnicity (AOR, 4.59; 95% CI, 1.49-14.12), living with the support of family and/or friends (AOR, 2.15; 95% CI, 1.25-3.71), never receiving OST (AOR, 4.40; 95% CI, 2.27-8.54), no recent methamphetamine use (AOR, 2.26; 95% CI, 1.12-4.57), and non-1 HCV genotype (AOR, 3.07; 95% CI, 1.67-5.64). CONCLUSIONS: HCV treatment uptake was relatively high among this highly marginalized population of PWID. Potentially modifiable factors associated with treatment include drug use and social support.

A randomised controlled trial of financial incentives to increase hepatitis B vaccination completion among people who inject drugs in Australia.

OBJECTIVE: This study aimed to investigate the efficacy of modest financial incentives in increasing completion of an accelerated 3-dose hepatitis B virus (HBV) vaccination schedule (0, 7, 21days) among people who inject drugs (PWID). METHODS: Randomised controlled trial. Participants were randomly allocated to receive $30 Australian Dollars cash following receipt of vaccine doses two and three ('incentive condition'), or standard care ('control condition'). Serologically confirmed HBV-susceptible PWID. Two inner-city health services and a field study site in Sydney, Australia. The primary outcome was completion of the vaccination series. Additional assessments included self-reported demographic, drug use and treatment, and risk-taking histories. RESULTS: Compared to the control condition, significantly more participants in the incentive condition received all three vaccine doses, under intention-to-treat analyses (n=139; 87% versus 66%; p=.004); and within the specified window periods under per protocol analyses (n=107 received three vaccine doses; 92% versus 67%; p=.001). Multivariate analysis indicated that the incentive condition and longer injecting histories significantly increased the likelihood of series completion. Aboriginal/Torres Strait Islanders were significantly less likely to complete the series. CONCLUSIONS: Modest financial incentives, per-dose, increased adherence to the accelerated HBV vaccination schedule among PWID. Results have implications for increasing HBV and, potentially, other vaccine-preventable infections, among PWID.

Factors influencing pharmacy services in opioid substitution treatment.

INTRODUCTION AND AIM: Heroin dependence is a serious health burden in Australia. Opioid substitution treatment (OST) has been delivered in Australian community pharmacies since 1985. The effectiveness of pharmacy-based OST is evident and the demand is increasing; however, the participation rate of community pharmacies is low, with over 60% non-providers. While previous Australian studies have focused on perspectives of community pharmacists providing the service, the views of non-providers have not yet been explored. This study aimed to further investigate factors influencing pharmacists' participation in provision of OST in the community pharmacy setting in New South Wales, Australia. DESIGN AND METHODS: Semi-structured interviews were conducted with 35 NSW community pharmacists (20 providers, 15 non-providers). Transcripts of interviews were thematically analysed. RESULTS: Factors influencing non-providers were mainly stigma and fear, the nature of an opt-in scheme, professionals' moral responsibilities, lack of awareness and knowledge, disproportionate distribution of clients and lack of financial support for OST clients. Providers were motivated by positive attitudes, functional relationships with OST clients/stakeholders, professional satisfaction and financial rewards. Recommendations to improve participation in OST services were offered by both groups. DISCUSSION AND CONCLUSION: This study explored views from both OST providers and non-providers, revealing a number of previously undocumented barriers that affect the uptake of OST provision in New South Wales community pharmacies. There were also profound ethical issues raised for consideration. These findings may help inform future policies aimed at encouraging pharmacists' provision of OST, to address the unmet needs of the ever-increasing number of heroin-dependent clients in the community.

Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia.

BACKGROUND: Low-threshold primary healthcare (PHC) centres targeting injecting drug users (IDUs) are increasingly being created to offer preventative and opportunistic services. However, no data are available on the characteristics of clients who utilise such services, or the effectiveness of these services in facilitating prevention or treatment. METHOD: A retrospective clinical record audit examined the characteristics, service utilisation patterns and referral uptake of 384 clients presenting to a low-threshold PHC service in Sydney, Australia. RESULTS: Of the 384 clients, 85% were IDUs. Sixty-two percent reported also having access to a general medical practitioner (GP), with this group more likely to report taking benzodiazepines or other psychoactive medication. Despite this relatively high level of GP access, only 50% were fully vaccinated against hepatitis B virus (HBV). Testing for blood-borne viral and sexually transmitted infections were the most common reasons for presentation to the PHC. Most (82%) clients made at least one return visit, with an average of 3.5 presentations per client. All clients were offered HBV vaccination where indicated (n = 145); and more than half (55%) of referrals to external services were attended. Clients accessing this PHC were younger, more likely to be male and born outside Australia than IDUs attending needle syringe programs (NSPs) in Australia's most populous state, New South Wales. CONCLUSION: Results suggest that this low-threshold PHC service was underutilised and its role as a low-threshold healthcare outlet remains limited. Further research is needed to more clearly delineate the health and economic benefits of this model.

The cost of providing primary health-care services from a needle and syringe program: a case study.

INTRODUCTION AND AIMS: Targeted primary health-care services for injecting drug users have been established in several countries to reduce barriers to health care, subsequent poor health outcomes and the considerable costs of emergency treatment. The long-term sustainability of such services depends on the resources required and the coverage provided. This study assesses the additional cost required to operate a nurse-led primary health care in an existing needle syringe program setting, estimates the costs per occasion of service and identifies key factors influencing improved service utilisation. DESIGN AND METHODS: Using standard costing methods and the funder perspective, this study estimates costs using the 'ingredients' approach where the costs of inputs are based on quantities and unit prices (the ingredients). RESULTS: During the 2009-2010 fiscal year, the primary health-care clinic provided 1252 occasions of service to 220 individuals, who each made an average of 3.9 presentations. A total cost of AU$250,626 was incurred, 69% of which was for personnel and 22% for pathology. During the study period the average cost per occasion of service was AU$199.96, which could be as low as AU$93.32 if the clinic reached its full utilisation level. DISCUSSION AND CONCLUSIONS: Although the average number of presentations per client was satisfactory, the clinic was underutilised during the study period. Proactive engagement of clients at the needle syringe program shopfront and an increased range of services offered by the clinic may help to attract more clients.

The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: a narrative synthesis of literature.

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

Harm reduction healthcare: from an alternative to the mainstream platform?

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