Using nominal group technique with people who are incarcerated in Canadian federal prisons to identify barriers and solutions to improving Prison Needle Exchange Program uptake.

BACKGROUND: Prison needle exchange programs (PNEPs) are a critical component for harm reduction in prisons. Little is known about the PNEP access barriers for people who are incarcerated, but the low uptake in the Canadian program highlights these constraints. We aimed to identify the barriers and potential solutions for increasing PNEP coverage in the nine Canadian federal prisons where they operate. METHODS: Eighteen focus groups were conducted in nine prisons using nominal group technique (NGT) with two stakeholders: peer advocates and people who use or identified as potential users of the PNEP. NGT uses a round-robin technique followed by generating a list of barriers to PNEP enrolment within their prison. Participants then allocated votes to rank the highest priority barriers, followed by an identical process to generate solutions to address the top three barriers. Interview transcripts describing participant narratives during this process were de-identified and coded to generated themes. Barriers and solutions receiving >10 % of votes within respective participant groups, alongside associated narratives, are discussed more fully. RESULTS: Fear of repercussions due to drug use, lack of confidentiality, and fear of being targeted and sanctioned by correctional authorities were perceived by both stakeholder groups as the top barriers inhibiting PNEP enrolment. Stigma (peer advocates) and the application process for the program (PNEP users) were also ranked as a priority. Proposed solutions included education and external oversight of PNEP (i.e., not via correctional officers) by both groups. Peer advocates regarded improving participant confidentiality and a supervised/safe injection site as potential enablers for program participation, while PNEP users identified wrap-around services as likely to improve access. CONCLUSION: Barriers to increasing PNEP coverage in Canadian federal prisons proposed by participants highlight the importance of trust and perceived repercussions surrounding program participation. These barriers and proposed solutions highlight a need for changes in implementation to PNEP delivery if the potential health benefits of PNEPs are to be realised.

Effectively engaging faith-based leaders on syringe services programs: U.S. pastors' knowledge, perceptions, and questions.

OBJECTIVE: To identify faith-based leaders' (FBLs') knowledge, perceptions, and questions about syringe services programs (SSPs). METHODS: We conducted a one-time, national online survey of 461 Christian FBLs August-September 2022. RESULTS: 56% of FBLs agreed they support having SSPs in their communities; only 7% strongly disagreed. We identified 15 main questions FBLs have about SSPs. We found statistically significant differences based on FBL Protestant affiliations. Mainline FBLs are more knowledgeable about SSPs, likely to believe a larger number of SSP services would benefit their community, supportive of SSPs, interested in data related to SSPs, and likely to look to local public health officials to shape their opinions on SSPs compared with non-mainline FBLs. CONCLUSIONS: SSP advocates can address questions that FBLs have about SSPs before beginning outreach. By understanding common Protestant denominational affiliations, advocates can focus initial engagement efforts on FBLs in their communities who are more likely to support SSPs. Our findings suggest that local public health officials can influence FBLs' opinions about SSPs.

Study protocol for an efficacy trial of the "PrEP for Health" intervention to increase HIV PrEP use among people who inject drugs.

BACKGROUND: HIV incidence has recently increased among people who inject drugs (PWID) across the United States, with outbreaks occurring in states with long-standing syringe service programs (SSPs) including Massachusetts (MA). Antiretroviral pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy recommended for PWID, but uptake in this marginalized population is extraordinarily low. METHODS: We describe the design and procedures for a National Institute on Drug Abuse (NIDA)-funded (R01) randomized controlled trial (RCT) testing the efficacy of "PrEP for Health," a multicomponent behavioral intervention to increase PrEP uptake, adherence, and persistence among HIV-negative PWID attending SSPs in two areas of the U.S. Northeast that are heavily affected by injection-related HIV transmission. Participants are equally randomized to receive the "PrEP for Health" intervention (involving individually tailored HIV and PrEP education, motivational interviewing, problem-solving skills and planning, and ongoing navigation support) or an enhanced standard of care (eSOC) control condition involving a brief educational video on the utility of PrEP for HIV prevention. Co-primary outcomes are PrEP uptake (using medical/pharmacy records) and adherence (using tenofovir quantification in hair samples); a secondary outcome is PrEP persistence (using medical/pharmacy records) over 12 months. Major assessments occur at baseline, 1-, 3-, 6-, and 12-month follow-up visits. Planned analyses will examine intervention efficacy, specific hypothesized conceptual mediators of the intervention effect (e.g., self-perceived HIV risk; PrEP knowledge, interest in use, motivation, and behavioral skills) and epidemiologically linked moderators (e.g., age; gender; condomless vaginal or anal sex). DISCUSSION: Findings from our extensive preliminary research with the study population revealed that a multicomponent, theory-based intervention targeting PrEP knowledge, motivation, self-efficacy, behavioral skills, and structural barriers to PrEP access is urgently needed for PWID who are at risk of HIV acquisition. We also learned that SSPs represent a highly acceptable service setting for delivering such interventions. In this study, we are evaluating the efficacy of the "PrEP for Health" intervention. If efficacious, findings from our implementation evaluation could help guide its dissemination to diverse SSPs and possibly other community-based settings accessed by this population. TRIAL REGISTRATION: ClinicalTrials.gov number NCT04430257, registered June 12, 2020.

Supporting syringe services programs in the initiation and scale-up of vaccine administration: findings from in-depth interviews.

BACKGROUND: Vaccine-hesitant persons who inject drugs are at increased risk for several vaccine-preventable diseases. However, vaccination rates among this population remain low. While syringe services programs (SSPs) are places where persons who inject drugs feel comfortable accessing services, few offer vaccination services. This study describes facilitators and barriers to vaccination at SSPs. METHODS: We used convenience sampling to conduct semi-structured, qualitative in-depth interviews with 21 SSPs in the USA from June to August 2021. Interview questions asked SSPs about their perceptions, priorities, barriers, facilitators, and the effects of partnerships and policies on vaccine administration. We used deductive thematic analysis to identify the main themes. RESULTS: Eight (n = 8) SSPs offered vaccinations, and thirteen (n = 13) did not offer vaccinations. Most SSPs believed offering vaccination services was important, although addressing SSP participants' immediate needs often took precedence. Staffing, physical space, and logistical issues were the most common barriers to vaccine administration reported by SSPs, followed by SSP participant-related barriers. Facilitators of vaccine administration included access to a tracking system, partnering with agencies or other organizations providing vaccines, and having a licensed vaccination provider on-site. Partnerships provided SSPs opportunities to expand capacity but could also restrict how SSPs operate. Recommended policy changes to facilitate vaccine administration included subsidizing the cost of vaccinations and addressing restrictions around who could administer vaccinations. CONCLUSIONS: Increasing the availability of vaccination services at SSPs requires addressing the varying capacity needs of SSPs, such as tracking systems, licensed vaccinators, and free or low-cost vaccination supplies. While these needs can be met through partnerships and supportive policies, both must consider and reflect cultural competence around the lived experiences of persons who inject drugs.

Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness.

BACKGROUND: During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program. METHODS: We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol. RESULTS: Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day). CONCLUSIONS: COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events.

Characteristics of and Experience Among People Who Use Take-Home Naloxone in Skåne County, Sweden.

Background: Opioid overdose related injury or death can be prevented by bystander naloxone administration. For naloxone to be present when and where overdoses occur, opioid prevention education and naloxone distribution (OPEND) must be established on a broad level. This is the 30-month follow-up of the first multi-site naloxone project in Sweden, implemented at 31 sites in the County of Skåne 2018. Aim: To address participant characteristics and factors associated with returning for naloxone refill and with having used naloxone for overdose reversal. An additional aim was to describe self-reported reasons for naloxone refill and overdose experiences. Methods: Data were collected during June 2018-December 2020 through questionnaires at baseline and upon naloxone refill of the initial and subsequent naloxone kit. Descriptive statistics was used to address participant characteristics, those returning for naloxone refill and reporting overdose reversal. Chi-2 test was used for variable comparison between groups. Factors associated with overdose reversals were examined by logistic regression analysis. Reasons for naloxone refill, overdose situation and management were presented descriptively. Results: Among 1,079 study participants, 22% (n = 235) returned for naloxone refill, of which 60% (n = 140) reported a total of 229 overdose reversals. Reversals were more likely to be reported by participants trained at needle exchange programs (NEPs) [adjusted odds ratio (AOR) = 5.18, 95% Confidence interval (CI) = 3.38-7.95)], with previous experience of own (AOR = 1.63, 95% CI = 1.03-2.58) or witnessed (AOR = 2.12, 95% CI = 1.05-4.29) overdose, or who had used sedatives during the last 30 days before initial training (AOR = 1.56, 95% CI = 1.04-2.33). A majority of overdoses reportedly occurred in private settings (62%), where the victim was a friend (35%) or acquaintance (31%) of the rescuer. Conclusion: Participants with own risk factors associated with overdose (e.g., injection use, concomitant use of benzodiazepines and previous experience of own overdose) were more likely to report administering naloxone for overdose reversal. Overdose management knowledge was high. The findings indicate that implementation of multi-site OPEND reaches individuals at particularly high risk of own overdose in settings with limited previous harm reduction strategies and favors a further scaling up of naloxone programs in similar settings.

Cuidados de enfermería y promoción de la salud en las salas de consumo higiénico / Assistência de enfermagem e promoção da saúde em salas de consumo higiênico / Nursing and health promotion care in drug consumption rooms

Objetivo: Conocer los cuidados de enfermería en las salas de consumo higiénico(SCH) y las propuestas para una intervención más efectiva. Metodología: Estudioetnográfico mediante la observación participante en cinco SCH y entrevistassemiestructuradas a ocho enfermeras. Además, se recopilaron los protocolos de actuaciónde enfermería. Se realizó análisis de contenido de los datos. Resultados: En las SCH esposible el consumo higiénico y seguro bajo supervisión especializada. Sin embargo, lasenfermeras identifican dificultades para la promoción de la salud relacionadas con lainyección higiénica, la prevención de sobredosis y del contagio de infecciones de transmisión sanguínea. También destacan las limitaciones en el diseño de las SCH y labaja cobertura horaria de estos dispositivos. Además, señalan como deficitario elseguimiento de usuarios de drogas de alto riesgo y sin vivienda. Conclusiones: Esnecesario mejorar los mensajes preventivos y complementar la atención de enfermeríacon talleres de inyección higiénica. Se recomienda ampliar las dimensiones de las SCH,poner en marcha más espacios para el consumo por vía pulmonar y ofrecer mayorcobertura horaria. Se propone la creación de albergues para mejorar la calidad de vida delos usuarios de drogas en situación de sinhogarismo.(AU)

Objective: To know the nursing cares drug consumption rooms (DCRs) and theproposals for a more effective intervention. Methodology: Ethnographic study throughparticipant observation in five DCRs and semi-structured interviews with eightnurses. We also compiled nursing intervention protocols. Data content analysis wasperformed. Results: In the DCRs, hygienic and safe consumption under specializedsupervision is possible. However, nurses identify difficulties for health promotionrelated to hygienic injection, prevention of overdose and transmission of blood-borne infections. Nurses highlight the limitations in the design of the DCRs, especiallyin relation to the time frame of coverage of these facilities. In addition, theyacknowledge deficits in the monitoring of high-risk and homeless drug users.Conclusions: It is necessary to improve preventive messages and complement nursingcare with hygienic injection workshops. It is recommended to expand thedimensions of the DCRs, establish more spaces for pulmonary use and to spreadthe time coverage of its offer. The creation of shelters to improve the quality of life ofhomeless drug users is proposed.(AU)

Objetivo: Conhecer os cuidados de enfermagem nas salas de consumohigiênico (SCH) e as propostas para uma intervenção mais efetiva.Metodologia: Estudo etnográfico realizado a partir da observação participante emcinco SCH e de entrevistas semiestruturadas com oito enfermeiras. Além disso, foramrevisados os protocolos de atuação de enfermagem. Realizou-se análise de conteúdodos dados. Resultados: Nas SCH é possível o consumo higiênico e seguro sob supervisão especializada. No entanto,as enfermeiras identificam dificuldades na promoção da saúde relacionadas com a injeçãohigiênica, a prevenção de overdose e do contágio de infecções de transmissão sanguínea.Também destacam as limitações no desenho das SCH e a baixa cobertura horária destesdispositivos. Além disso, assinalam como deficitário o seguimento de usuários de drogasde alto risco e sem moradia.Conclusões: É necessário melhorar as mensagens preventivase complementar o cuidado de enfermagem com oficinas de injeção higiênica.Recomenda-se ampliar as dimensões das SCH, criar mais espaços para o consumo porvia pulmonar e oferecer maior cobertura horária. Propõe-se a criação de abrigos paramelhorar a qualidade de vida dos usuários de drogas em situação de rua.(AU)

Cuando las personas que consumen drogas inyectadas tienen la palabra: Análisis cualitativo de contenidotemático sobre la percepción de uso de una aplicación móvil para los programas de intercambio de jeringas / When people who inject drugs speak: Qualitative thematic analysis of the perception of a mobile app for needle exchange programs

España es el país de Europa Occidental con más prevalencia del Virusde la Inmunodeficiencia Humana entre personas que se inyectan drogas. La presencia de Virus de la Hepatitis-C supera el cincuenta porciento en esta población. Al mismo tiempo, la Organización Mundialde la Salud considera que la cobertura media de material de inyecciónpor usuario y año es baja. Con más de treinta años de experiencia enel despliegue de los servicios y programas de reducción de daños, lasventajas que posibilita la eSalud y la mSalud como la accesibilidad yasequibilidad, pueden incorporarse también a la reducción de daños.El objetivo de este estudio fue analizar la percepción que las personasque consumen drogas inyectadas tienen sobre una aplicación móvilpara mejorar el acceso a material de inyección. Partiendo de un enfoque cualitativo se recogió información a través de cinco grupos focalesen los que participaron 51 personas consumidoras de drogas inyectadas en activo. Se llevó a cabo un análisis de contenido temático cuyos principales resultados indicaron que la aplicación tuvo una buenaaceptación y se consideró sencilla y útil. Los participantes refirieronque la aplicación contribuía a mejorar el acceso a material de inyección, a reducir el estigma de los drogodependientes, y a optimizar laplanificación del usuario para adquirir la jeringa en el proceso ritualdel consumo. Como puntos a mejorar, destacaron reducir el excesode información preventiva y simplificar la ruta de descarga de la webapp. En conclusión, la aplicación se posiciona como una herramienta útil para complementar la intervención ordinaria de los programasde intercambio de jeringas. (AU)

Spain is the Western European country with the highest prevalenceof Human Immunodeficiency Virus among people who inject drugs.The Hepatitis-C Virus affects over fifty per cent of this population. Atthe same time, the World Health Organization considers that the average coverage of injection material for drug user per year is low. Harmreduction programs and services have been deployed for over thirtyyears, and these could now incorporate the advantages of eHealth andmHealth to improve harm reduction. The aim of this qualitative anddescriptive study is to analyze how people who inject drugs perceive anapplication for mobile devices. Fifty-one such drug users participatedactively in five focus groups. The main results of the thematic content analysis indicated that the application was welcomed as easy anduseful. Participants reported that the application contributed to improving access to injection material, reducing the stigma of drug-dependence and optimizing the organization of the ritual of injection.Excessive preventive information and problems downloading the webapp were identified as aspects for improvement. In conclusion, theapplication was seen as a useful eHealth tool that complements thenormal intervention of needle exchange programs. (AU)

Developing and Testing the Populi Needle Exchange Point Finder: An App to Reduce Harm Associated With Intravenous Drug Consumption Among Homeless and Non-homeless Drug Users.

The spread of viral infections remains a serious public health problem. People who inject drugs represent one of the highest-risk groups. eHealth and mHealth have been shown to be effective in improving individuals' management of their own health and their access to health care and to contribute to reducing the costs associated with certain medical interventions. People who inject drugs, including homeless people, tend to have access to technology. Young homeless people in particular are likely to use smartphones and social networking sites in ways that are similar to the general population. Despite this widespread use of technology, there are no apps designed specifically to reduce harm in people who inject drugs. The objective of this study is to analyze the development and usability testing process for an application for mobile devices, designed to complement the Needle Exchange Program. This app-the first of its kind-was developed by a public health agency, specialized professionals and people who inject drugs. We analyzed the differences in how health providers and drug users experienced the usability of the app. The participants were 61 members of multidisciplinary professional group and 16 people who inject drugs. We used a cross-sectional quantitative, observational design. First, we created and administered a questionnaire to collect the sociodemographic characteristics that could mediate the use of technology. Next participants tried the app and filled out a second questionnaire in which they rated their experience on a Likert scale from 1 to 7 in the following dimensions: overall attractiveness of the app, ease/difficulty of use, the extent to which they believed the app could improve access to injection materials, the extent to which they thought it would improve PWID's participation in the needle exchange program, overall utility, the degree to which they thought PWID would use the app, and the need for the app. To analyze the answers, we used contingency tables and compared means using a Student's t test. Finally, we conducted six audio-recorded focus groups about how the participants experienced the usability of the app. The objective of this part of the study was to classify and quantify the contributions of individuals and the group according to three predefined categories: potential benefits and positive aspects, potential obstacles or difficulties in carrying out the project, and concrete suggestions for improving the interface. There were not significant differences between the sociodemographic variables and the variables related to use of the app between professionals and PWID. Both professionals and PWID rated the app as intuitive and useful, especially the geolocation function for NEPs. Both groups also thought that the interface contained too much information and that this excess could be confusing for users. Both groups also had similar opinions about the app and its uses. An important difference between the two groups is that PWID reported that they would use the app, while professionals reported that they didn't think PWID would use it. All participants proposed improvements on the prototype, suggestions that will be applied in the creation of the definitive interface. Including professionals and patients in this sort of usability test enables researchers and developers to detect the needs of potential app users.

[Managing pleasures and harms: An ethnographic study of drug consumption in public spaces, homes and drug consumption rooms]. / La gestión de placeres y daños: Estudio etnográfico sobre el consumo de drogas en vía pública, viviendas y salas de consumo higiénico.

Drug consumption rooms (DCR) aim to facilitate consumption in hygienic and safe conditions. However, users also consume drugs in public spaces and homes generating incremental risk for health. To strengthen our understanding of consumption practices, we conducted an ethnographic study in different consumption locations in Barcelona, including DCRs, public spaces, and homes. Focusing on consumption practices and narratives, we conducted participant observation and interviewed 16 DCR users. Our findings show that different consumption spaces allow users to experiment different types of pleasures. In addition, consumption in each type of location is associated with various types of harms, which are managed by users by self-regulating their practices. These aspects, therefore, must be taken into account to design harm reduction action aligned with users' practices.

Las salas de consumo higiénico (SCH) son espacios para consumir drogas en condiciones higiénicas y seguras. Sin embargo, los usuarios alternan sus prácticas de consumo en vía pública y viviendas, entornos que conllevan mayores riesgos a la salud. Para comprender mejor este problema, se realizó un estudio etnográfico en diferentes espacios de consumo de Barcelona, incluyendo SCH, vía pública y viviendas. Centrándonos en los discursos y prácticas de consumo, se recogieron datos mediante la observación participante y entrevistas semiestructuradas a 16 usuarios de las SCH. Los resultados muestran que, en los diferentes espacios de consumo, los usuarios experimentan varios tipos de placer. Además, estos espacios están asociados a diversos daños, los cuales son gestionados por los usuarios autorregulando sus prácticas. Estos aspectos, por lo tanto, deben tenerse en cuenta para diseñar acciones de reducción de daños adaptadas a las necesidades de los usuarios.

Syringe Service Program Utilization, Barriers, and Preferences for Design in Rural Appalachia: Differences between Men and Women Who Inject Drugs.

Background People who inject drugs (PWID) in rural areas of the United States have had limited access to syringe service programs (SSP). Rural SSP have recently surged, but accompanying research is lacking about PWID utilization, barriers, and preferences for SSP design and how those preferences vary by gender. Methods: Interviewer-administered surveys elicited information about utilization, barriers, and preferences for SSP design from 234 PWID recruited using respondent-driven sampling in Appalachian, Kentucky. Gender differences among reported barriers to utilizing SSP and preferences for program design were explored using Mantel-Haenszel chi-square tests. Results: Overall, 49% of PWID had ever utilized an SSP. The most common reasons for not utilizing an SSP were lack of awareness (23%), fear of being seen or disclosing drug use (19%), and lack of need (19%). The most preferred SSP design was located within a health department (74%) and operating during afternoon hours (66%). Men were more likely than women to prefer SSP in health departments (80% vs. 65%, p = 0.01), while more women than men preferred staffing by health department personnel (62% vs. 46%, p = 0.02). Women were less likely to favor evening hours (55% vs. 70%, p = 0.02). Fewer women wanted SSP nurses (78% vs. 90%, p = 0.01), social workers (11% vs. 24%, p = 0.01), or people who use drugs (20% vs 34%, p = 0.02) to staff SSP. Conclusions: Despite recent scale-up, SSP in Appalachia remain under-utilized. PWID were open to a range of options for SSP design and staffing, though there were variations by gender. Implementation research that identifies best strategies for tailored SSP scale-up in rural settings should be considered.

Impact of 24-hour schedule of a drug consumption room on service use and number of non-fatal overdoses. A quasiexperimental study in Barcelona.

BACKGROUND: The opening hours of drug consumption rooms could constitute a barrier to access among people who use drugs (PWUD). CAS Baluard is an outpatient substance use care center in Barcelona, which provides a drug consumption room in Barcelona among other services. The objectives of our study were to compare the client profile, the facility use, the drugs used, and the number of non-fatal overdose episodes between (1) a 15-hour opening period of a drug consumption room versus a 24-hour opening period; and (2) between daytime and nighttime during the 24-hour period. METHODS: Data from CAS Baluard was obtained from March-June (15-hour opening period) and July-October (24-hour opening period), 2018. The sociodemographic characteristics of clients were gathered in both periods and in the daytime and nighttime client groups in the 24-hour period. Finally, associations were estimated between facility use and period and between facility use and opening hours. RESULTS: There were 1,089 clients in the 15-hour period and 1,262 in the 24-hour period. There were no sociodemographic differences in the clients between periods. During nighttime, there was a higher proportion of women (17%) and homeless people (47%) than during daytime (12% and 30%, respectively). Injected cocaine use was more frequent during nighttime (34%) than during daytime (25%) and injected heroin use was less frequent during nighttime (17%) than during daytime (24%). There was a non-significant increase in non-fatal overdose risk during nighttime (PR 3.9 95%CI 0.98-15.64). However, when we analyzed heroin use alone, the increase in non-fatal overdose risk was significant (PR 4.69 95%CI 1.17-18.75). CONCLUSION: During nighttime, attendance at the facility was higher among women, homeless people, and people who used stimulants. Our results point to a possible increase in overdose risk during nighttime, when most drug consumption rooms are closed.

Substances injected at the Sydney supervised injecting facility: A chemical analysis of used injecting equipment and comparison with self-reported drug type.

Providing information about substances injected can reduce the negative impact of illicit drug consumption and support people who inject drugs to make informed decisions. In Australia, information about drugs injected relies largely on periodic self-report surveys. For the first time, the analysis of the residual content of used injecting equipment was conducted in a supervised injecting facility (SIF) located in Sydney, Australia. The aim was to gain a better understanding of the substances injected by clients through: (1) chemical analyses of the content of used syringes; (2) comparison of these results with clients' self-reported drug use; and (3) assessing the usefulness of analysing other injecting equipment to detect substances used. During one week in February 2019, syringes and other injecting equipment were collected at the Sydney SIF. Their residual content was analysed by gas-chromatography/mass-spectrometry. Heroin was the most commonly detected substance (present in 51% of syringes), followed by methamphetamine (22%) and oxycodone (10%). In addition to the main psychoactive substance, cutting agents reported in the literature were also detected in used syringes. The main psychoactive substance identified by laboratory analysis reliably corresponded with users' self-reported drug type. Analytical confirmation of substances injected allows for the provision of better targeted harm reduction messaging based on timely and objective data. The approach used is amenable to clients and feasible in the Australian SIF context. Upscaling and wider implementation could be done through Needle and Syringe Programs, and would support the early detection of harmful substances entering drug markets and better inform harm reduction strategies.

La gestión de placeres y daños: Estudio etnográfico sobre el consumo de drogas en vía pública, viviendas y salas de consumo higiénico / Managing pleasures and harms: An ethnographic study of drug consumption in public spaces, homes and drug consumption rooms

RESUMEN Las salas de consumo higiénico (SCH) son espacios para consumir drogas en condiciones higiénicas y seguras. Sin embargo, los usuarios alternan sus prácticas de consumo en vía pública y viviendas, entornos que conllevan mayores riesgos a la salud. Para comprender mejor este problema, se realizó un estudio etnográfico en diferentes espacios de consumo de Barcelona, incluyendo SCH, vía pública y viviendas. Centrándonos en los discursos y prácticas de consumo, se recogieron datos mediante la observación participante y entrevistas semiestructuradas a 16 usuarios de las SCH. Los resultados muestran que, en los diferentes espacios de consumo, los usuarios experimentan varios tipos de placer. Además, estos espacios están asociados a diversos daños, los cuales son gestionados por los usuarios autorregulando sus prácticas. Estos aspectos, por lo tanto, deben tenerse en cuenta para diseñar acciones de reducción de daños adaptadas a las necesidades de los usuarios.

ABSTRACT Drug consumption rooms (DCR) aim to facilitate consumption in hygienic and safe conditions. However, users also consume drugs in public spaces and homes generating incremental risk for health. To strengthen our understanding of consumption practices, we conducted an ethnographic study in different consumption locations in Barcelona, including DCRs, public spaces, and homes. Focusing on consumption practices and narratives, we conducted participant observation and interviewed 16 DCR users. Our findings show that different consumption spaces allow users to experiment different types of pleasures. In addition, consumption in each type of location is associated with various types of harms, which are managed by users by self-regulating their practices. These aspects, therefore, must be taken into account to design harm reduction action aligned with users' practices.

Dynamic modeling of hepatitis C transmission among people who inject drugs.

To reach the WHO goal of hepatitis C elimination, it is essential to identify the number of people unaware of their hepatitis C virus (HCV) infection and to investigate the effect of interventions on the disease transmission dynamics. In many high-income countries, one of the primary routes of HCV transmission is via contaminated needles shared by people who inject drugs (PWIDs). However, substantial underreporting combined with high uncertainty regarding the size of this difficult to reach population, makes it challenging to estimate the core indicators recommended by the WHO. To support progress toward the elimination goal, we present a novel multi-layered dynamic transmission model for HCV transmission within a PWID population. The model explicitly accounts for disease stage (acute and chronic), injection drug use status (active and former PWIDs), status of diagnosis (diagnosed and undiagnosed) and country of disease acquisition (domestic or abroad). First, based on this model, and using routine surveillance data, we estimate the number of undiagnosed PWIDs, the true incidence, the average time until diagnosis, the reproduction numbers and associated uncertainties. Second, we examine the impact of two interventions on disease dynamics: (1) direct-acting antiviral drug treatment, and (2) needle exchange programs. As a proof of concept, we illustrate our results for a specific data set. In addition, we develop a web application to allow our model to be explored interactively and with different parameter values.

Cross-country Comparison of Treatment Policies Facing the Drug Abuse in Five Selected Countries.

BACKGROUND: Drug abuse is one of the main problems of human's life; thus communities have been thinking about the solution of this problem. The present study aimed to compare the general features of drug abuse treatment policies, war on drugs (WOD), and harm reduction (HR), in the selected countries. METHODS: The present study was a comparative and desk research that sought to compare context, stewardship, financing, type of substance abuse treatment services, reasons of paradigm shift, and executive challenges of treatment policies in the selected countries (China, Malaysia, Germany, Netherland, and Iran). The necessary data for comparison of the countries were collected through valid databases, review of documents, and reports of international organizations. FINDINGS: Context conditions were better in the HR countries. In most countries, the central government played a key role in the stewardship, financing, and service providing. In WOD countries, the presence of judicial structure was higher in the treatment of drug abuse. The policy-making approach was ideological in WOD countries, but evidence-based in HR countries. CONCLUSION: It seems that performance of HR countries is better than WOD countries.

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange.

BACKGROUND: Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic. OBJECTIVE: Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP). METHODS: We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire. RESULTS: The median number of barriers reported was 5 (range 0-19). Fear of arrest by police (72% of PWID "agreed" or "strongly agreed") and difficulty with purchasing needles from a pharmacy (64% "agreed" or "strongly agreed") were the most frequently cited barriers. CONCLUSIONS/IMPORTANCE: Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists.

Community-based, point-of-care hepatitis C testing: perspectives and preferences of people who inject drugs.

A barrier to hepatitis C treatment for people who inject drugs (PWID) is needing to attend multiple appointments for diagnosis. Point-of-care hepatitis C tests provide results within 20 to 105 minutes and can be offered opportunistically in nonclinical settings such as needle syringe programmes. In this nested qualitative study, we explored the acceptability of point-of-care testing for PWID. PWID attending participating needle syringe programmes were screened using the OraQuick HCV antibody mouth swab (result in 20 minutes); those with a reactive result then underwent venepuncture for a point-of-care RNA test: the Xpert HCV Viral Load (result in 105 minutes). Convenience sampling was used to select participants for a semi-structured interview. A hybrid thematic analysis was performed, guided by Sekhon's "Theoretical Framework of Acceptability." Nineteen participants were interviewed. Three core themes emerged: "people and place," "method of specimen collection," and "rapidity of result return." It was highly acceptable to be offered testing at the needle syringeprogrammes by nurses and community health workers, who were described as competent and nonjudgemental. Most participants reported that even if a finger-stick point-of-care RNA test were an option in the future, they would prefer venepuncture, as the sample could be used for pre-treatment workup and bundled testing. Waiting 20 minutes to receive the antibody test result was acceptable, whereas the 105 minutes required for the RNA result was unacceptable. Offering point-of-care hepatitis C testing at needle syringe programmes is acceptable to PWID, however tests that avoid venepuncture are not necessarily the most attractive to PWID.

The value of harm reduction for injection drug use: A clinical and public health ethics analysis.

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.