"No-one just does drugs during business hours!": evaluation of a 24/7 primary needle and syringe program in St Kilda, Australia.

BACKGROUND: Primary needle and syringe programs (NSPs) have been integral for the prevention of blood-borne virus (BBV) transmission among people who inject drugs. Despite this, many people who inject drugs face barriers accessing these services, particularly after-hours when most services are closed. To our knowledge, the St Kilda NSP, in Melbourne, Victoria, is the only primary NSP providing 24/7 dedicated stand-alone face-to-face services for people who inject drugs in Australia. We conducted an evaluation of the St Kilda NSP to assess its role and effectiveness in meeting client needs. METHODS: Mixed research methods were used to conduct the evaluation. We analysed four quantitative data sets including the Victorian Needle and Syringe Program Information System data; NSP 'snapshot' survey data; and St Kilda NSP records of after-hours contacts and naloxone training events. Qualitative interviews were conducted with 20 purposively selected NSP clients, which were focused on individual needs, expectations and experiences accessing the service. Interviews were audio recorded and transcribed, and data were analysed thematically. A convergent research design was used to merge the five data sets. RESULTS: St Kilda NSP had 39,898 service contacts in 2018; 72% of contacts occurred outside business hours. Similarly, of 1,185,000 sterile needles and syringes dispatched, 71% were distributed outside business hours. Participants described valuing the after-hours service because drug use patterns did not always align with standard NSP opening hours and after-hours access afforded anonymity when collecting injecting equipment. Narratives highlighted several additional benefits of the 24/7 service, including: access to safer sex equipment; material support; naloxone training; referrals to specialist services; face-to-face emotional and social support from a non-judging worker; and for women involved in sex work in particular, being able to seek refuge when feeling unsafe on the streets. CONCLUSIONS: Our study provides evidence of the social and health benefits (beyond that of preventing BBV transmission) that can be gained through the provision of 24/7 primary NSP services. Findings support the need for the establishment of after-hours primary NSPs in other areas of Australia where active street-based drug markets operate outside business hours and concentrated numbers of people who inject drugs live and spend time.

Distribution of rapid HCV antibody self-test kits via needle/syringe dispensing machines: Implementation and evaluation of the Vend-C pilot study in Melbourne, Australia.

Recent guidance from the World Health Organization strongly recommended hepatitis C virus (HCV) self-testing. We implemented the Vend-C pilot study to explore the effectiveness and feasibility of distributing rapid HCV antibody self-test kits to people who inject drugs via needle/syringe dispensing machines (SDMs). Over a 51-day study period between August and September 2022, we distributed HCV antibody self-test kits via two SDMs. During the study period, 63 self-test kits were dispensed, averaging 1.2 self-test kits per day. Our access methods for evaluation questionnaires failed to attract participants (n = 4). We implemented the Vend-C pilot study in direct response to recent WHO recommendations. While self-test kits were effectively distributed from the two SDMs, our evaluation methodology failed. Consequently, we cannot determine the success of linkage to care. Even so, with HCV treatment numbers dropping in Australia, innovative engagement solutions are needed, and considering the number of self-test kits provided in our pilot, the model could have an important future place in HCV elimination efforts.

Analysis of four syringe dispensing machine point-of-access data 2017-2020 in Melbourne, Australia: machine utilisation and client demographics.

BACKGROUND: Australian needle and syringe distribution occurs via a mix of modalities, including syringe dispensing machines (SDMs). SDMs are electronic vending machines providing (often) 24-h access to needles/syringes and may attract greater numbers of people who are younger, female, and/or have limited connection to health care services compared to individuals accessing fixed-site needle and syringe programs (NSPs). However, validating the demographic characteristics of SDM clients has proven difficult in previous research. METHODS: In this paper, we analyse SDM order and client demographic data from four SDMs located in South-East Melbourne, Australia, and compare this against the managing fixed-site NSP between May 2017 and December 2020. SDM data were collected via a novel 0-9 numeric keypad input tool. Via the tool, SDM clients were requested to input their categorised age, gender and postcode. Given the novelty of the tool, we evaluate the feasibility of the data collection method. We analysed data according to: (1) total SDM orders made, (2) estimated 'unique SDM presentations' and (3) describing the demographics of unique SDM clients. Importantly, we noted substantial invalid demographic data, and consequently, severely restricted data for analysis. RESULTS: There were 180,989 SDM orders made across the four SDMs to an estimated 90,488 unique SDM presentations. There was little variation in unique presentations across days of the week, but 69% occurred out of NSP operating hours. Across the study period, the SDMs distributed 66% of the number of syringes distributed by the fixed-site NSP. Due to invalid demographic data, our restriction method provided only 10,914 (6% of all data) unique presentations for analysis. There were some demographic differences between SDM and NSP client, but these should be treated with caution. CONCLUSIONS: The data collection tool provides a novel means of comparing SDM and fixed-site presentations, demonstrating the substantial expansion of service via the SDMs. However, the validity of the demographic data was highly questionable and requires significant data coding, meaning it is not feasible for community NSPs. While we recommend the inclusion of automatically collected SDM order data, the use of a 0-9 numeric keypad to collect demographic data-while an innovation-requires alteration to support NSP data.

Barriers to engaging people who use drugs in harm reduction services during the COVID-19 pandemic: A mixed methods study of syringe services program perspectives.

BACKGROUND: Syringe services programs (SSPs) provide critical evidence-based public health services that decrease harms from drug use for people who use drugs (PWUD). Many SSPs have experienced significant and evolving COVID-19-related disruptions. We aimed to characterize the impacts of COVID-19 on SSP operations in the United States approximately one year into the pandemic. METHODS: Participating sites, selected from a national sample of SSPs, completed a semi-structured interview via teleconference and brief survey evaluating the impacts of COVID-19 on program operations. Data collection explored aspects of program financing, service delivery approaches, linkages to care, and perspectives on engaging PWUD in services one year into the pandemic. Interview data were analyzed qualitatively using Rapid Assessment Process. Survey data were analyzed using descriptive statistics and triangulated with qualitative findings. RESULTS: 27 SSPs completed study-related interviews and surveys between February 2021 - April 2021. One year into the pandemic, SSPs reported continuing to adapt approaches to syringe distribution in response to COVID-19, and identified multiple barriers that hindered their ability to engage program participants in services, including 1) isolation and decreased connectivity with participants, 2) resource restrictions that limit responsiveness to participant needs, 3) reduced capacity to provide on-site HIV/HCV testing and treatment linkages, and 4) changing OUD treatment modalities that were a "double-edged sword" for PWUD. Quantitative survey responses aligned with qualitative findings, highlighting increases in the number of syringes distributed, increases in mobile and home delivery services, and reductions in on-site HIV and HCV testing. CONCLUSION: These data illuminate persistent and cascading risks of isolation, reduced access to services, and limited engagement with program participants that resulted from COVID-19 and continue to create barriers to the delivery of critical harm reduction services. Findings emphasize the need to ensure SSPs have the resources and capacity to adapt to changing public health needs, particularly as the COVID-19 pandemic continues to evolve.

Modeling the impact of interventions during an outbreak of HIV infection among people who inject drugs in 2012-2013 in Athens, Greece.

BACKGROUND: A large HIV outbreak in People Who Inject Drugs (PWID) occurred in Athens, Greece in 2011-2013. In response, opioid substitution treatment (OST) and needle and syringe programs (NSP) were scaled-up and a seek-test-treat program was introduced in mid-2012. We aim to assess the impact of these interventions. METHODS: A mathematical model of HIV transmission among PWID was calibrated to data available over time (2009-2013) on HIV prevalence, NSP/antiretroviral treatment (ART) coverage and high-risk injection. A combined interventions scenario, including decrease in high-risk injection through linkage to OST and modification of risk behaviours and access to NSP and ART, was compared to a counterfactual scenario (no improvement at the levels of these interventions), with HIV incidence being the main outcome. RESULTS: HIV incidence increased from <0.1 new cases/100 person-years (in 2009) to 11.0 new cases/100 person-years (in 2012). Under both models, a subsequent decline was projected following early 2012, with incidence at the end of 2013 in the combined interventions scenario being lower by 77% compared to the counterfactual. The projected reduction in incidence under the intervention scenario was in agreement with empirical data. HIV prevalence would have escalated to 20.4% (95% CrI: 16.9%, 23.6%) in 2013 under the counterfactual scenario (vs. 16.8% (95% CrI: 11.2%, 23.0%) under the combined interventions scenario). In total, 31.4% of HIV cases (392) were averted over 2012-2013. CONCLUSION: These results underline the importance of high-coverage harm reduction programs and of community-based interventions to rapidly reach PWID most in need.

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)

Toward a human-centered use of technology: a stakeholder analysis of harm reduction and CBO staff.

BACKGROUND: Technology can enable syringe service programs (SSPs) and other community-based organizations (CBOs) operating under a harm reduction framework to work with an increased number of clients and can also enable organizations to offer services more effectively (e.g., offering HIV testing in ways participants may be more likely to accept). In the current time of COVID-19 social distancing, technology can also help organizations more safely provide services to people with compromised immune systems and to clients who might otherwise not be reached. However, technology projects implemented in harm reduction settings are frequently conceptualized and developed by researchers or technology specialists rather than by SSP staff or clients. METHODS: To more effectively meet the needs of SSPs and other CBOs across the USA, our team conducted qualitative interviews with 16 individuals who have extensive backgrounds working in the field of harm reduction. Interviews were digitally recorded and professionally transcribed, and the transcripts were checked for accuracy by the interviewers. The resulting transcripts were coded and analyzed to determine emerging themes. RESULTS: Interviewees mentioned the ability of technology to deliver consistent quality messaging to multiple clients at the same time and the potential to customize or tailor technology-based messaging to specific client populations as positive benefits. Clear barriers to technology use also emerged, in particular regarding privacy, data security, and the need to maintain client trust when discussing sensitive issues (e.g., illicit drug use). CONCLUSIONS: Technology offers the potential to deliver consistently high-quality health communication and maintain contact with clients who may have no other access to care. If designed and managed effectively, technology can also address issues related to providing services during times when physical contact is limited due to COVID-19 social distancing measures.

Providing reproductive health services for women who inject drugs: a pilot program.

BACKGROUND: Needle syringe programs (NSPs), a proven harm reduction strategy for people who inject drugs, frequently offer limited healthcare services for their clients. Women who inject drugs face multiple barriers to accessing reproductive health care in traditional settings: personal histories of trauma, judgmental treatment from providers, and competing demands on their time. Our aim was to implement patient-centered reproductive healthcare services at a Seattle NSP. METHODS: We interviewed clients and staff of an NSP in Seattle and staff of other community-based organizations serving women who inject drugs, then used the Consolidated Framework for Implementation Research to code transcripts deductively. Based on our qualitative work, we implemented reproductive health care at the NSP program 1 day per week. We evaluated the implementation by surveying staff and clients and auditing charts over a 9-month period. RESULTS: Clients and staff (N = 15 for clients, N = 13 for staff) noted a high unmet need for trauma-informed, accessible reproductive health care. We successfully implemented reproductive health care services including short- and long-acting contraception, sexually transmitted disease testing, and cervical cancer screening. Survey data was limited but demonstrated client satisfaction with services. CONCLUSIONS: Integrating reproductive health care into an NSP's clinical services is feasible and can be a source of low-barrier preventive care for women unable to seek gynecologic care elsewhere.

When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report.

BACKGROUND: Syringe services programs (SSPs) are able to offer wrap-around services for people who inject drugs (PWID) and improve health outcomes. CASE PRESENTATION: A 47-year-old man screened positive for a skin and soft tissue infection (SSTI) at an SSP and was referred to a weekly on-site student-run wound care clinic. He was evaluated by first- and third-year medical students, and volunteer attending physicians determined that the infection was too severe to be managed on site. Students escorted the patient to the emergency department, where he was diagnosed with a methicillin-resistant Staphylococcus aureus arm abscess as well as acute HIV infection. CONCLUSION: Student-run wound care clinics at SSPs, in conjunction with ongoing harm reduction measures, screenings, and treatment services, provide a safety-net of care for PWID and help mitigate the harms of injection drug use.

Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL.

BACKGROUND: Blood-borne viral infections, such as HIV and hepatitis C (HCV), are common infections among people who inject drugs (PWID). This study aims to determine the prevalence of HIV and HCV infection among PWID accessing the first legal syringe services program (SSP) in the state of Florida, along with examining baseline correlates of HIV and HCV infection. METHODS: Baseline behavioral enrollment assessments of 837 participants accessing an SSP for the first time were analyzed. Patients self-reporting or testing HIV or HCV positive at the enrollment visit were included. Socio-demographic, drug use, and injection-related risk behaviors in the last 30 days were compared across groups defined by all combinations of HIV and HCV serostatus. Bivariate and multivariable logistic regression models were used to assess correlates of baseline HCV and HIV infection independently. RESULTS: Overall prevalence for HCV and HIV infection were 44.4% and 10.2%, respectively. After adjusting for confounders, the most significant correlates of baseline HCV infection were age (aOR = 1.01), lower education level (aOR = 1.13), currently homeless (aOR = 1.16), injecting more than seven times a day (aOR = 1.14), reusing syringes (aOR = 1.18), and sharing injection equipment (aOR = 1.13). The most significant predictors of baseline HIV infection were age (aOR = 1.01), non-Hispanic Black race (aOR = 1.28), Hispanic ethnicity (aOR = 1.12), gay or bisexual orientation (aOR = 1.22), and methamphetamine injection (aOR = 1.22). In addition, heroin injection (aOR = 0.92) was significantly associated with a lower odds of HIV infection. DISCUSSION/CONCLUSION: Baseline behavioral predictors differed between HIV infection and HCV infection among participants accessing syringe services. Understanding the risk factors associated with each infection should be considered when developing additional harm reduction interventions tailored for diverse PWID populations served at SSPs.

Impact of overdose prevention sites during a public health emergency in Victoria, Canada.

The primary objective of this study was to examine the impacts associated with implementation of overdose preventions sites (OPSs) in Victoria, Canada during a declared provincial public health overdose emergency. A rapid case study design was employed with three OPSs constituting the cases. Data were collected through semi-structured interviews with 15 staff, including experiential staff, and 12 service users. Theoretically, we were informed by the Consolidated Framework for Implementation Research. This framework, combined with a case study design, is well suited for generating insight into the impacts of an intervention. Zero deaths were identified as a key impact and indicator of success. The implementation of OPSs increased opportunities for early intervention in the event of an overdose, reducing trauma for staff and service users, and facilitated organizational transitions from provision of safer supplies to safer spaces. Providing a safer space meant drug use no longer needed to be concealed, with the effect of mitigating drug related stigma and facilitating a shift from shame and blame to increasing trust and development of relationships with increased opportunities to provide connections to other services. These impacts were achieved with few new resources highlighting the commitment of agencies and harm reduction workers, particularly those with lived experience, in achieving beneficial impacts. Although mitigating harms of overdose, OPSs do not address the root problem of an unsafe drug supply. OPSs are important life-saving interventions, but more is needed to address the current contamination of the illicit drug supply including provision of a safer supply.

Hospital admissions among people who inject opioids following syringe services program implementation.

BACKGROUND: Syringe services programs (SSPs) are an evidence-based harm reduction strategy that reduces dangerous sequelae of injection drug use among people who inject drugs (PWID) such as overdose. SSP services include safer injection education and community-based naloxone distribution programs. This study evaluates differences in overdose-associated hospital admissions following the implementation of the first legal SSP in Florida, based in Miami-Dade County. METHODS: We performed a retrospective analysis of hospitalizations for injection drug-related sequelae at a county hospital before and after the implementation of the SSP. An algorithm utilizing ICD-10 codes for opioid use and sequelae was used to identify people who inject opioids (PWIO). Florida Department of Law Enforcement Medical Examiners Commission Report data was used to analyze concurrent overdose death trends in Florida counties. RESULTS: Over the 25-month study period, 302 PWIO admissions were identified: 146 in the pre-index period vs. 156 in the post-index period. A total of 26 admissions with PWIO overdose were found: 20 pre-index and 6 post-index (p = 0.0034). CONCLUSIONS: Declining overdose-associated admissions among PWIO suggests early impacts following SSP implementation. These results indicate a potential early benefit of SSP that should be further explored for its effects on future hospital admission and mortality.

Naloxone counseling: Confidence and attitudes of student pharmacists after a volunteer syringe exchange experience.

INTRODUCTION: Our objective was to assess how a naloxone counseling experience impacted student pharmacists' confidence in counseling patients on naloxone use and their attitudes towards people who use drugs. METHODS: Students who completed a naloxone counseling experience at a syringe exchange program were recruited to conduct individual interviews. Investigators asked student participants open-ended questions to identify their perceptions in the following domains: experiences with naloxone, reported impact of naloxone counseling experience on confidence, experiences with people who use drugs, value of the experience, and suggestions for improvement for the experience. RESULTS: Fifteen student pharmacists participated in semi-structured interviews. Fourteen of these students reported the experience as extremely valuable in developing their confidence with naloxone. The average change in confidence was 5.2 points on a 1 through 10 scale, and seven of the student pharmacists independently suggested that a naloxone counseling experience be incorporated the required doctor of pharmacy curriculum. The qualitative themes that emerged from student feedback were breaking down the stigma of addiction and feeling useful during this experience. CONCLUSIONS: Participation in a naloxone counseling experience at a syringe exchange program was perceived as helpful in improving student pharmacist confidence in counseling patients on naloxone use. Incorporation of required experiential learning about naloxone and people who use drugs may positively impact student pharmacists by giving them more confidence and experience with this underserved population.

Needling Policy Makers and Sharpening the Debate: Do Syringe Exchange Programs Improve Health at the Population Level?

CONTEXT: In the midst of the current opioid epidemic, states have selected differing legislative routes implementing pathways to ensure access to clean needles and syringes. OBJECTIVE: To determine whether states that implemented laws supporting syringe exchange programs (SEPs) had reductions in transmission rates of hepatitis B, hepatitis C, and HIV infection compared with states without such laws. DESIGN AND SETTING: Utilizing a longitudinal panel design, we determined the legal status of SEPs in each state for years 1983-2016. Disease transmission rates for this period were estimated via a simple Poisson regression, with transmitted cases as the dependent variable, law categories as the predictor variables, and the log of state population as the exposure. The mean number of incident cases per state-year was also calculated. PARTICIPANTS: US states were utilized as the unit of analysis. RESULTS: Hepatitis B and hepatitis C mean transmission rate per 100 000 population declined in states with local ordinances/decriminalized statutes and legalized SEPs (hepatitis B: 71% and 81%, respectively, differences P < .001; hepatitis C: 8% and 38%, respectively, differences P < .001). Reductions in mean incident cases per state-year mirrored these findings. HIV infection among injection drug users yielded inconsistent results. CONCLUSIONS: Hepatitis B and hepatitis C transmission were reduced at the population level in states with SEP laws in a pattern reflecting the degree of legal intervention. HIV infection, based upon a smaller data set, showed a mixed impact. POLICY IMPLICATIONS: The results show promise that SEPs have population-level effects on disease transmission. States lacking SEPs should reconsider current policies.

Young people who inject drugs in Mozambique: should we emphasize them in the National Harm Reduction Plan?

Mozambique has one of the highest burdens of HIV globally, and people who inject drugs (PWID) have one of the highest HIV infection rates in Africa. After the implementation of the first Biological Behavioral Surveillance (BBS) Survey among PWID in Mozambique, the Ministry of Health started the development of a National Harm Reduction Plan. Although the findings from the BBS survey highlighted the specific needs of young PWID, the proposed Harm Reduction Plan does not explicitly focus on reducing high-risk behaviors of young PWID. We outline the importance of the inclusion of age-specific interventions focused on the needs of young PWID in Mozambique, and how a comprehensive Harm Reduction Plan can reduce the HIV epidemic in this population. There is a unique opportunity to advocate for the Harm Reduction Plan to include "youth-friendly" cost-effective and evidence-based interventions that are targeted to this important sub-group within an already vulnerable population.

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.

Young people who inject drugs in Mozambique: should we emphasize them in the National Harm Reduction Plan?

Mozambique has one of the highest burdens of HIV globally, and people who inject drugs (PWID) have one of thehighest HIV infection rates in Africa. After the implementation of the first Biological Behavioral Surveillance (BBS) Survey among PWID in Mozambique, the Ministry of Health started the development of a National Harm Reduction.Plan. Although the findings from the BBS survey highlighted the specific needs of young PWID, the proposed Harm,Reduction Plan does not explicitly focus on reducing high-risk behaviors of young PWID. We outline the importance of the inclusion of age-specific interventions focused on the needs of young PWID in Mozambique, and how a comprehensive.Harm Reduction Plan can reduce the HIV epidemic in this population. There is a unique opportunity to advocate for the Harm Reduction Plan to include "youth-friendly" cost-effective and evidence-based interventions that are targeted to this important sub-group within an already vulnerable population

Supervised injection facility use and all-cause mortality among people who inject drugs in Vancouver, Canada: A cohort study.

BACKGROUND: People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada. METHODS AND FINDINGS: Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33-46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24-123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7-27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27-42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26-0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings. CONCLUSIONS: We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.

Police officer attitudes towards syringe services programming.

BACKGROUND: As the United States experiences a drug overdose epidemic, syringe services programs (SSPs) have been utilized to reduce rates of infectious disease and improve treatment outcomes for people who inject drugs (PWID). Police officer support of SSPs is crucial to program success. One way to improve officer support and collaboration is to develop officer training presentations about SSP services and procedures as well as information on officers' roles in program implementation. METHODS: Researchers accompanied staff from the Marion County Safe Syringe Access and Support Program as they provided SSP training presentations to Indianapolis Metropolitan Police Department officers at district roll calls. Immediately following each presentation, officers completed a survey measuring attitudes toward SSPs, PWID, and the information presented. RESULTS: Of the 339 completed surveys returned, most officers expressed support for the SSP and a desire to help PWID. However, those with experience of a needle stick injury were more critical of the program, reporting it enables drug use. Approximately half of respondents reported limited knowledge of SSPs, even after the training. Qualitative data indicate about half of officers reported they could use discretion in deciding whether to arrest for illegal possession of a syringe. CONCLUSIONS: Overall findings indicate positive attitudes towards SSPs; however, officer feedback identifies several concerns and areas for improvement. Public health agencies must develop comprehensive, tailored presentations that address common officer concerns and misconceptions regarding SSPs, PWIDs, and harm reduction strategies to improve officer support.

Take-home naloxone possession among people who inject drugs in rural West Virginia.

BACKGROUND: Take-home naloxone (THN) possession among people who inject drugs (PWID) in rural communities is understudied. Better understanding the nature of THN possession among rural PWID could inform the implementation of overdose prevention initiatives. The purpose of this research is to determine factors associated with rural PWID having recently received THN. METHODS: Data from a PWID population estimation study implemented in Cabell County, West Virginia were used for this research. Multivariable Poisson regression with a robust variance estimator was used to evaluate the independent effects of several measures (e.g., sociodemographics, structural vulnerabilities, substance use) on PWID having received THN in the past 6 months. RESULTS: Forty-eight percent of our sample (n = 371) of PWID reported having received THN in the past 6 months. Factors associated with having received THN were: age (adjusted Prevalence Ratio [aPR] = 1.02; 95% Confidence Interval [CI]: 1.01-1.03), having recently accessed sterile syringes at a needle exchange program (aPR = 1.82; 95% CI: 1.35-2.46), believing that doctors judge people who use drugs (aPR = 1.50; 95% CI: 1.07-2.12), and having witnessed at least one non-fatal overdose in the past 6 months (aPR = 1.44; 95% CI: 1.06-1.94). Greater numbers of overdose events in the past 6 months were also associated with having received THN. CONCLUSIONS: Among rural PWID in West Virginia, slightly less than half received THN in the past 6 months. Rural communities need overdose prevention interventions that are responsive to the unique needs of rural PWID, decrease stigma, and ensure PWID have access to harm reduction services and drug treatment programs.