'It's just basically a box full of disease'-navigating sterile syringe scarcity in a rural New England state.

BACKGROUND AND AIMS: Injection drug use has increased in non-urban communities in the United States where sterile syringe access is limited. This study aimed to characterize how people who inject drugs in a predominantly rural state navigate syringe scarcity. DESIGN: Qualitative study. SETTING: New Hampshire (NH), USA. At the time of our study, syringe services programs were illegal in NH but pharmacies could sell ≤ 10 syringes without prescription. PARTICIPANTS/CASES: Twenty people aged ≥ 18 years who injected at least once in the past 30 days were recruited through provider referral, street-based recruitment and snowball sampling. MEASUREMENTS: Semi-structured interview guide. Verbatim transcripts were coded based on interview guide constructs and emergent themes. Analysis focused on pharmacy syringe access, unofficial syringe sources and related impacts on syringe sharing and reuse FINDINGS: Participants could identify no local pharmacies that sold syringes without prescription. Pharmacy purchase in neighboring counties, or across state lines, required private transportation and this, along with purchaser identification requirements, presented substantial access barriers. Interstate travel also exposed participants to vigilant policing of interstate highways and potential criminal justice involvement. Many participants thus resorted to informal syringe sources closer to home including purchasing syringes on the street, using discarded syringes, breaking into biohazard containers and constructing improvised syringes out of salvaged syringe parts, metals and plastics. Repeated re-use of syringes until they were no longer operational was common. Overall, syringe scarcity gave participants few options but to engage in syringe sharing and re-use, putting them at risk of serious injection-related infections. CONCLUSIONS: Limited sterile syringe access contributes to an environment in which people who inject drugs report that they are less able to refrain from risky injection practices.

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

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

The Relationship Between Polysubstance Injection Drug Use, HIV Risk Behaviors, and Interest in Pre-Exposure Prophylaxis (PrEP) Among People Who Inject Drugs in Rural West Virginia.

OBJECTIVE: The opioid crisis has increased risks for injection drug use (IDU)-associated HIV outbreaks throughout the United States. Polysubstance use and syringe sharing are common among rural people who inject drugs (PWID). However, little is known about how polysubstance IDU affects engagement in HIV prevention efforts among non-urban PWID. This study assesses the associations between profiles of polysubstance injection, injection-related HIV risk, acquiring syringes from a syringe services program (SSP), HIV testing, and pre-exposure prophylaxis (PrEP) awareness and interest among PWID in rural Appalachia. METHOD: We used survey data from 392 respondents in Cabell County, West Virginia who had injected drugs in the past 6 months. We conducted a latent class analysis using seven measures of IDU and tested for associations with injection-related HIV risk, receiving syringes from an SSP, having been tested for HIV, and PrEP awareness and interest. RESULTS: We identified three classes of polysubstance IDU in our sample: polysubstance use, heroin and crystal methamphetamine use, and crystal methamphetamine and buprenorphine/suboxone use. The polysubstance use class had the highest injection-related HIV risk (81.8% at risk), high syringe acquisition at an SSP (67.7%), and highest rate of HIV testing (60.0%). PrEP awareness was low across the sample (30.0%), but most PWID expressed interest in using PrEP (57.7%). CONCLUSIONS: Patterns of polysubstance IDU have unique relationships with key HIV risk factors and protective behaviors. The expansion of harm reduction services in rural settings is warranted to prevent incident HIV infections.

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use.

BACKGROUND: Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI). METHODS: People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18-29 years. RESULTS: Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI. CONCLUSIONS: Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.

Epidemiology of HIV in Iran.

Iran has been one of the active countries fighting against HIV/AIDS in the Middle East during the last decades. Moreover, there is a strong push to strengthen the national health management system concerning HIV prevention and control. In Iran, HIV disease has its unique features, from changes in modes of transmission to improvement in treatment and care programs, which can make it a good case for closer scrutiny. The present review describes the HIV epidemic in Iran from the first case diagnosed until prevention among different groups at risk and co-infections. Not only we addressed the key populations and community-based attempts to overcome HIV-related issues in clinics, but we also elaborated on the efforts and trends in society and the actual behaviors related to HIV/AIDS. Being located in the Middle East and North Africa (MENA) region, given the countryspecific characteristics, and despite all the national efforts along with other countries in this region, Iran still needs to take extra measures to reduce HIV transmission, especially in health education. Although Iran is one of the pioneers in implementing applicable and appropriate policies in the MENA region, including harm reduction services to reduce HIV incidence, people with substance use disorder continue to be the majority of those living with HIV in the country. Similar to other countries in this region, the HIV prevention and control programs aim at 90-90-90 targets to eliminate HIV infection and reduce the transmission, especially the mother-to-child transmission and among other key populations.

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: An exploratory qualitative study.

BACKGROUND: Countries in Sub-Saharan Africa (SSA) have seen rapid increases in injection drug use since 2008. In Uganda, the Global Sate of Harm report and studies conducted by Makerere University Crane Surveys have estimated HIV prevalence among people who inject drugs (PWID) at approximately 17%. The objective of the research was to document injection and other drug-related risks among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention interventions. METHODS: Between August and September 2018, we conducted qualitative interviews among male and female people who use drugs. Interview topics included the availability and accessibility of clean syringes, injection risks, overdose, sexual-risk behaviors, and the availability and accessibility of harm reduction and drug treatment services. RESULTS: Participants reported several injection-related risks including sharing and reusing syringes, pooling and mixing drugs in the same container, measuring drugs using syringes, getting prefilled injections from dealers, being injected by other people who inject drugs, and using contaminated water or blood to dilute drugs. Participants reported a scarcity of harm reduction services, although a few appear to have participated in the syringe exchange pilot conducted by the Uganda Harm Reduction Network (UHRN). Even fewer reported knowing organizations that helped people who use drugs abstain from or reduce their use. Medication assisted therapy (MAT) and naloxone to reverse overdoses are not currently available. CONCLUSIONS: Comprehensive prevention and treatment services are needed in Uganda and should include expanded syringe exchange programs, social network HIV testing, HCV testing, provision of naloxone and MAT, and linkage to and retention in HIV care.

Negative affect, affect-related impulsivity, and receptive syringe sharing among people who inject drugs.

Receptive syringe sharing (RSS) among people who inject drugs (PWID) is a risk factor for hepatitis C virus and HIV infections. PWID with borderline personality disorder (BPD) have increased risk of RSS, but it remains unclear what drives this association. This study used ecological momentary assessment (EMA) to study characteristics associated with BPD, and RSS among PWID. We recruited PWID, ages 18-35, through two Community Outreach Intervention Projects syringe service program sites in Chicago, Illinois. After a baseline interview, participants used a mobile phone app to respond to momentary surveys on mood, substance use, and injection risk behavior for two weeks. For each momentary assessment, ratings on negative mood descriptors were combined to create measures of total negative affect (NA), and NA components of dejection, shame, anger, irritability, and worry. RSS was defined by participant responses indicating that they had used a syringe that someone else had used. We estimated mixed effects logistic models, regressing RSS on baseline affect-related impulsivity, lagged momentary NA, and the interaction term. Out of 163 participants who completed at least two EMA assessments, 152 (93%) reported at least one injection event and had valid pre-injection mood assessments required to be included in the analysis. We found that affect-related impulsivity, combined with worried mood in the hours preceding the injection episode, predicted increased risk of RSS. PWID having difficulties with emotion regulation may be at increased risk of RSS during periods of anxiety or tension. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

HIV and drug related stigma and risk-taking behaviors among people who inject drugs: a systematic review and meta-analysis.

The impact of HIV-related stigma on people living with HIV has been well documented, but there have been few studies examining how drug-related stigma impacts risk-taking in the lives of people who inject drugs (PWID). This meta-analysis aimed to determine HIV and drug-related stigma and the association it has with risk-taking behaviors among PWID. We searched PubMed, Science Direct, Web of Science, and Cochrane electronic databases independently in March 2019. After reviewing for any study duplicates the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR) and 95% confidence intervals. After a detailed assessment, a total of 14 studies containing 13,689 participants met the eligibility criteria. Among the potential risk factors: employment status, depression and sharing injecting paraphernalia had a significant relationship with HIV and drug stigma among PWIDs respectively (OR = 0.78, 95%CI = 0.62-0.98), (OR = 1.84, 95%CI = 1.45-2.33) and (OR = 2.20, 95%CI = 1.84-1.63). Illicit drug use related stigma was found to be associated with several concurrent effects. The impact of stigma should be considered in the development of drug use prevention strategies. Perceived stigma is correlated with numerous negative consequences in other populations including people living with HIV/AIDS. These data suggest this could also be generalized to people who inject drugs because it seems that individuals with internalized stigma experience drug dependence, reduced comfort in seeking help from services and higher rates of depression.

Association between mental health service utilisation and sharing of injection material among people who inject drugs in Montreal, Canada.

BACKGROUND: High-risk injection behaviors are associated with high prevalence of mental health problems among people who inject drugs (PWID). However, whether the use of mental health services is associated with lower risk of sharing injection material remains undetermined. This study aims to examine the association between mental health service utilisation and receptive sharing risk, and determine the potential modifying effect of psychological distress on this association. METHODS: Participants answered an interviewer-administered questionnaire at 3-month intervals gathering information on sociodemographic characteristics, substance use and related behaviors, services utilisation and significant mental health markers. Relationship between the use of mental health services and receptive sharing was modeled using the generalized estimating equation (GEE), controlling for age at baseline, gender, and other potential confounders. Psychological distress was estimated using the Kessler Psychological Distress Scale (K10). Effect modification was investigated by adding an interaction term in the univariate GEE analysis. RESULTS: 358 participants contributed to 2537 visits (median age 40.3, 82% male). Mental health service utilisation was reported in 631 visits (25%), receptive sharing in 321 visits (13%) and severe psychological distress in 359 visits (14%). In multivariate GEE analyses, a significant association was identified between receptive sharing and the use of mental health services (aOR = 0.69; 95% CI = 0.50-0.94). We found no evidence of effect modification by psychological distress. CONCLUSION: Among PWID, mental health service utilisation was associated with lower likelihood of receptive sharing, regardless of level of psychological distress. These findings should be taken into account when designing harm reduction strategies for this population.

Vital Signs: HIV Transmission Along the Continuum of Care - United States, 2016.

BACKGROUND: In 2016, an estimated 1.1 million persons had human immunodeficiency virus (HIV) infection in the United States; 38,700 were new infections. Knowledge of HIV infection status, behavior change, and antiretroviral therapy (ART) all prevent HIV transmission. Persons who achieve and maintain viral suppression (achieved by most persons within 6 months of starting ART) can live long, healthy lives and pose effectively no risk of HIV transmission to their sexual partners. METHODS: A model was used to estimate transmission rates in 2016 along the HIV continuum of care. Data for sexual and needle-sharing behaviors were obtained from National HIV Behavioral Surveillance. Estimated HIV prevalence, incidence, receipt of care, and viral suppression were obtained from National HIV Surveillance System data. RESULTS: Overall, the HIV transmission rate was 3.5 per 100 person-years in 2016. Along the HIV continuum of care, the transmission rates from persons who were 1) acutely infected and unaware of their infection, 2) non-acutely infected and unaware, 3) aware of HIV infection but not in care, 4) receiving HIV care but not virally suppressed, and 5) taking ART and virally suppressed were 16.1, 8.4, 6.6, 6.1, and 0 per 100 person-years, respectively. The percentages of all transmissions generated by each group were 4.0%, 33.6%, 42.6%, 19.8%, and 0%, respectively. CONCLUSION: Approximately 80% of new HIV transmissions are from persons who do not know they have HIV infection or are not receiving regular care. Going forward, increasing the percentage of persons with HIV infection who have achieved viral suppression and do not transmit HIV will be critical for ending the HIV epidemic in the United States.

Health risk and health seeking behaviours among people who inject performance and image enhancing drugs who access needle syringe programs in Australia.

INTRODUCTION AND AIMS: People who use performance and image enhancing drugs (PIED) are a growing population in needle syringe programs (NSP) in Australia. Previous international research has identified heterogeneity among the PIED-using population. This study investigated health behaviours among NSP attendees who had recently (last 12 months) injected PIEDs and examined differences among this group according to recent psychoactive drug use. DESIGN AND METHODS: The Australian Needle and Syringe Program Survey is an annually repeated cross-sectional survey conducted at approximately 50 NSPs nationally. In 2015, respondents provided information on their demographic characteristics, health risk and health monitoring behaviours, and provided a capillary dried blood spot for HIV and hepatitis C virus antibody testing. Univariable and multivariable logistic regressions assessed factors associated with recent (last 12 months) use (all routes of administration) of psychoactive drugs. RESULTS: Among recent PIED injectors (n = 156), 59% had recently used psychoactive substances. Those who had recently used psychoactive drugs were significantly younger, less educated and more likely to have experienced redness at an injection site in the previous 12 months but were more likely to report recent HIV/hepatitis C virus testing. DISCUSSION AND CONCLUSIONS: This study identified significant differences in demographic characteristics, risk and health seeking behaviour among PIED users who did and did not also use psychoactive substances. There is a need to enhance and tailor harm reduction efforts and to build the capacity of NSP staff to better meet the needs of this diverse group.

Unsafe injecting practices, sexual risk behaviours and determinants of HIV among men who inject drugs: Results from Integrated Biological and Behavioural Surveillance in India.

In India, while an overall reduction in HIV is achieved among most key populations, the continued higher prevalence among people who inject drugs (PWIDs) is an area of concern. This paper analyses unsafe injecting and sexual risk behaviours in male PWIDs according to HIV status and also examines the determinants of HIV infection in this high-risk group. Data from India's Integrated Biological and Behavioural Surveillance, conducted across 29 Indian states and Union Territories among 19,902 male PWIDs, were used. Informed consent was obtained and men aged 15 years or more, who used psychotropic substances or drugs in the past three months for non-medical reasons were recruited for the survey. Results from the multivariable analysis suggest that drug use debut at age 25 years or above (adjusted odds ratio [AOR]: 1.41, confidence interval [CI]: 1.05-1.88), engagement in drug use for a longer duration (AOR: 1.81, CI: 1.32-2.48), injecting three times or more per day (AOR: 1.53, CI: 1.1-2.12), sharing of needle/syringes (AOR: 1.34, CI: 1.02-1.76), self-reported sexually transmitted infections (AOR: 1.55, CI: 1.12-2.14) and higher self-risk perception for exposure to HIV (AOR: 2.08, CI: 1.58-2.75) increase the likelihood of HIV infection. Sustained higher prevalence, unsafe injecting and risky sexual practices are major challenges which may prevent India from reaching the 'end of AIDS' by 2030. This underscores the need for adoption of a tailored, evidence-driven HIV prevention approach that adequately addresses local needs to limit the spread of HIV within this population, and thereby prevents the onward transmission of HIV to the general population.

Practices of partnership: Negotiated safety among couples who inject drugs.

Despite the majority of needle-syringe sharing occurring between sexual partners, the intimate partnerships of people who inject drugs have been largely overlooked as key sites of both hepatitis C virus prevention and transmission, and risk management more generally. Drawing on interviews with 34 couples living in inner-city Australia, this article focuses on participants' accounts of 'sharing'. While health promotion discourses and conventional epidemiology have tended to interpret the practice of sharing (like the absence of condom use) in terms of 'noncompliance', we are interested in participants' socially and relationally situated 'rationalities'. Focussing on participants' lived experiences of partnership, we endeavour to make sense of risk and safety as the participants themselves do.How did these couples engage with biomedical knowledge around hepatitis C virus and incorporate it into their everyday lives and practices? Revisiting and refashioning the concept of 'negotiated safety' from its origins in gay men's HIV prevention practice, we explore participants' risk and safety practices in relation to multiple and alternative framings, including those which resist or challenge mainstream epidemiological or health promotion positions. Participant accounts revealed the extent to which negotiating safety was a complex and at times contradictory process, involving the balancing or prioritising of multifarious, often competing, risks. We argue that our positioning of participants' partnerships as the primary unit of analysis represents a novel and instructive way of thinking about not only hepatitis C virus transmission and prevention, but the complexities and contradictions of risk production and its negotiation more broadly.

Cross-border migration and initiation of others into drug injecting in Tijuana, Mexico.

INTRODUCTION AND AIMS: Efforts to prevent injection drug use (IDU) are increasingly focusing on the role that people who inject drugs (PWID) play in facilitating the entry of others into this behaviour. This is particularly relevant in settings experiencing high levels of IDU, such as Mexico's northern border region, where cross-border migration, particularly through forced deportation, has been found to increase a range of health and social harms related to injecting. DESIGN AND METHODS: PWID enrolled in a prospective cohort study in Tijuana, Mexico, since 2011 were interviewed semi-annually, which solicited responses on their experiences initiating others into injecting. Univariate and multivariable logistic regression analyses were conducted at the Preventing Injection by Modifying Existing Responses (PRIMER) baseline, with the dependent variable defined as reporting ever initiating others into injection. The primary independent variable was lifetime deportation from the USA to Mexico. RESULTS: Among 532 participants, 14% (n = 76) reported initiating others into injecting, the majority of participants reporting initiating acquaintances (74%, n = 56). In multivariable analyses, initiating others into injecting was independently associated with reporting living in the USA for 1-5 years [adjusted odds ratio (AOR) = 2.42; 95% confidence interval (CI) 1.22-4.79, P = 0.01], and methamphetamine and heroin injection combined (AOR = 3.67; 95% CI 1.11-12.17, P = 0.03). Deportation was not independently associated with initiating others into injecting. DISCUSSION AND CONCLUSIONS: The impact of migration needs to be considered within binational programming seeking to prevent the expansion of epidemics of injecting and HIV transmission among mobile populations residing in the Mexico-USA border region.

The association between neighborhood socioeconomic disadvantage and high-risk injection behavior among people who inject drugs.

BACKGROUND: Although much research has been conducted on the determinants of HIV risk behavior among people who inject drugs (PWID), the influence of the neighborhood context on high-risk injection behavior remains understudied. To address this gap in the literature, we measured associations between neighborhood socioeconomic disadvantage and high-risk injection behavior, and determined whether these associations were modified by drug-related police activity and syringe exchange program (SEP) accessibility. METHODS: Our sample was comprised of 484 pharmacy-recruited PWID in New York City. Measures of neighborhood socioeconomic disadvantage were created using data from the 2006-2010 American Community Survey. Associations with high-risk injection behavior were estimated using multivariable Poisson regression. Effect modification by drug-related police activity and SEP accessibility was assessed by entering cross-product terms into adjusted models of high-risk injection behavior. RESULTS: Neighborhood socioeconomic disadvantage was associated with decreased receptive syringe sharing and unsterile syringe use. In neighborhoods with high drug-related police activity, associations between neighborhood disadvantage and unsterile syringe use were attenuated to the null. In neighborhoods with high SEP accessibility, neighborhood disadvantage was associated with decreased acquisition of syringes from an unsafe source. CONCLUSIONS: PWID in disadvantaged neighborhoods reported safer injection behaviors than their counterparts in neighborhoods that were relatively better off. The contrasting patterns of effect modification by SEP accessibility and drug-related police activity support the use of harm reduction approaches over law enforcement-based strategies for the control of blood borne virus transmission among PWID in disadvantaged urban areas.

A Study of Sexual Relationship Power among Young Women Who Inject Drugs and Their Sexual Partners.

BACKGROUND: To date, research applying the Sexual Relationship Power Scale (SRPS) has been limited to sexual risk behaviors. OBJECTIVE: We measured levels of sexual relationship power and examined associations between sexual relationship power and injecting and sexual behaviors that place women at increased risk for blood borne infections. METHODS: Using data from a cross-sectional study of young women who inject drugs (WWID) in San Francisco, USA, logistic regression analysis identified independent associations between SRPS and subscale scores (relationship control [RC] and decision making dominance [DMD]) and injecting and sexual behaviors. RESULTS: Of the 68 young WWID, 24 (34%) reported receptive syringe sharing, 38 (56%) reused/shared a cooker to prepare drugs, and 25 (37%) injected someone else's drug residue during the three-months prior to enrollment. Most (60, 88%) reported condomless sex with main sex-partner, 8 (12%) reported transactional sex, and 36 (53%) had two or more recent sex partners. The median SRPS score was 2.98 (IQR: 2.65, 3.18), 3.23 (IQR: 3.23, 3.57) for RC and 2.40 (IQR: 2.20, 2.60) for DMD. No significant associations were detected between SRPS or DMD and injecting or sexual risk behaviors. After adjusting for gender and years injecting, for every one-point increase in RC, women had a 6.70 lower odds of recent condomless sex (95%CI: 0.92, 50.00, p = 0.06), and a 3.90 lower odds of recent transactional sex (95%CI: 1.22, 12.50, p = 0.02). CONCLUSION: Our study findings suggest that some components of sexual relationship power may play a role in sexual risk, but not in injecting risk.

'Affording' new approaches to couples who inject drugs: A novel fitpack design for hepatitis C prevention.

BACKGROUND: In the West, hepatitis C is predominantly transmitted via the sharing of contaminated drug-injecting equipment. Although the majority of this sharing occurs between sexual partners, the responsibility for avoiding transmission has long been conceived as an individual responsibility, with prevention measures such as the distribution of sterile injecting equipment such as injecting packs ('fitpacks') aimed at individuals without regard for the social contexts of injecting. In this article we draw on the work of Bruno Latour to reconceptualise the fitpack. We argue that the fitpack is not inert or neutral in its meaning or effects, that instead it 'affords' particular meanings and actions, for example, that injecting is an individual practice and safety an individual responsibility. METHOD: To challenge these affordances, we developed a new fitpack prototype aimed at couples, along with related health promotion messages. We asked 13 couples who inject drugs to examine and reflect on these new objects and messages. RESULTS: Overall, we found a high level of support for the broad idea of couples-oriented materials, as well as for our prototype and associated materials. Participants identified opportunities for improving the materials and commented on implications of the symbols and language used. Together the interviews demonstrated ways in which the new fitpacks and messages could afford couples-oriented safe injecting, and better recognition of relationships that are often dismissed by researchers and health care providers as insincere. CONCLUSIONS: These findings demonstrate that first, there is a need and desire for a greater range in harm reduction resources. Second, it is essential to find ways of better acknowledging the validity and value of relationships between people who inject. Third, and more broadly, recognition must be given to the role of technological objects in materialising meanings and, as Latour might put it, 'moralities', and in turn to interrogating these meanings and moralities.

Development and validation of a novel scale for measuring interpersonal factors underlying injection drug using behaviours among injecting partnerships.

BACKGROUND: People who inject drugs with sexual partners or close friends have high rates of syringe/ancillary equipment sharing and HIV and hepatitis C virus (HCV) infection. Although evidence suggests that interpersonal factors underlie these higher risk profiles, there is no quantitative measure of how interpersonal factors operate within injecting relationships. We aimed to develop and validate a quantitative scale to assess levels of injecting drug-related interpersonal factors associated with risky injecting behaviours within injecting partnerships. METHODS: We conducted qualitative interviews with 45 people who inject drugs (PWID) who reported having injecting partners to inform item development, and tested these items in a quantitative study of 140 PWID from San Francisco, USA, to assess internal reliability (Cronbach's alpha) and validity (convergent, and discriminant validity). RESULTS: With results from the qualitative interview data, we developed the Interpersonal Dynamics in Injecting Partnerships (IDIP) scale with 54 final items for 5 subscales of injecting-related interpersonal factors. Exploratory factor analysis revealed 5 factors ("trust", "power", "risk perception", "intimacy", and "cooperation") with eigenvalues of 14.32, 6.18, 3.55, 2.46, and 2.14, explaining 57% of the variance, and indicating good internal reliability (alpha: 0.92-0.68). Strong convergent validity was observed in bivariate logistic regression models where higher levels of trust, intimacy, and cooperation within partnerships were positively associated with partners sharing needles and injecting equipment, whereas higher levels of power and risk perception were negatively associated with partners sharing needles and injecting equipment. CONCLUSIONS: These findings offer strong evidence that the IDIP scale provides a psychometrically sound measure of injecting drug-related interpersonal dynamics. This measurement tool has the potential to facilitate additional investigations into the individual and collective impact of trust, intimacy, power, cooperation, and risk perception on injection drug using behaviours and engagement in HIV and HCV testing and treatment among PWID in a variety of settings.

The naked truth about HIV and risk taking in Swedish prisons: A qualitative study.

BACKGROUND: This qualitative study explores former prison inmates' perceptions and attitudes towards HIV risk inside Swedish prisons. METHOD: In 2014, eight semi-structured interviews were conducted with former male prisoners to gain a deeper understanding of situations perceived to be associated with risk of HIV transmission. The material gathered from the interviews was analyzed by manifest and latent qualitative content analysis. RESULTS: The findings revealed that risky behavioral practices, such as sharing needles, unprotected sexual activity, and lack of openness about HIV status represented potential health threats with regard to the risk of HIV transmission. CONCLUSIONS: Evidence from the study indicates that educational interventions regarding HIV and the transmission routes are required for HIV prevention in Swedish prisons.

An analysis of respondent-driven sampling with injecting drug users in a high HIV prevalent state of India.

BACKGROUND: Personal networks are significant social spaces to spread of HIV or other blood-borne infections among hard-to-reach population, viz., injecting drug users, female sex workers, etc. Sharing of infected needles or syringes among drug users is one of the major routes of HIV transmission in Manipur, a high HIV prevalence state in India. This study was carried out to describe the network characteristics and recruitment patterns of injecting drug users and to assess the association of personal network with injecting risky behaviors in Manipur. METHODS: A total of 821 injecting drug users were recruited into the study using respondent-driven sampling (RDS) from Bishnupur and Churachandpur districts of Manipur; data on demographic characteristics, HIV risk behaviors, and network size were collected from them. Transition probability matrices and homophily indices were used to describe the network characteristics, and recruitment patterns of injecting drug users. Univariate and multivariate binary logistic regression models were performed to analyze the association between the personal networks and sharing of needles or syringes. RESULTS: The average network size was similar in both the districts. Recruitment analysis indicates injecting drug users were mostly engaged in mixed age group setting for injecting practice. Ever married and new injectors showed lack of in-group ties. Younger injecting drug users had mainly recruited older injecting drug users from their personal network. In logistic regression analysis, higher personal network was found to be significantly associated with increased likelihood of injecting risky behaviors. CONCLUSION: Because of mixed personal network of new injectors and higher network density associated with HIV exposure, older injecting drug users may act as a link for HIV transmission or other blood-borne infections to new injectors and also to their sexual partners. The information from this study may be useful to understanding the network pattern of injecting drug users for enriching the HIV prevention in this region.