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)

Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment.

BACKGROUND: New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis. METHODS: Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data. RESULTS: Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs. CONCLUSIONS: A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

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.

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.

Developing Safe Syringe Exchange Programs: Role of the North Carolina Division of Public Health.

Syringe exchange programs became legal in North Carolina on July 11, 2016. A combination of forces led to this progressive public health measure, including advocacy of the State Health Official, in a state characterized by a conservative political climate. Data collected by the division of public health were a key contributor to the initiative. Nearly 5 North Carolinians died each day from unintentional medication or drug overdose. High rates of coinfection including hepatitis B and C, human immunodeficiency virus, and endocarditis were shown to have substantial economic consequences. The North Carolina Harm Reduction Coalition and use of Moral Foundations Theory in crafting messages were important in influencing legislation. North Carolina now has 30 active syringe exchange programs serving 40 counties. Individuals using intravenous drugs who take advantage of these syringe exchange programs are provided with clean needles to not only help prevent the spread of illness but also learn more about safe health practices.

Evaluation of contingency management as a strategy to improve HCV linkage to care and treatment in persons attending needle and syringe programs: A pilot study.

BACKGROUND: A greater proportion of HCV-infected people who inject drugs (PWID) need to be linked to care for HCV antiviral treatment. This study sets out to evaluate the efficacy of contingency management (CM) for improving HCV linkage to care, treatment initiation, adherence, and cure for PWID recruited from a needle and syringe program. METHODS: Between March 2015 and April 2016, 20 participants were enrolled into the CM arm, and then subsequently enrolled 20 participants in the enhanced standard of care (eSOC) arm. Participants in the eSOC arm received an expedited appointment and a round-trip transit card. Participants enrolled in the CM arm received eSOC plus $25 for up to ten HCV clinical visits and $10 for each returned weekly medication blister pack. Adherence was measured via electronic blister packs. RESULTS: Overall the median age was 47 years; most were men (67%) and Hispanic (69%). There were no significant differences in demographic characteristics between participants in the study arms. In the CM arm 74% were linked to HCV care, compared to 30% in the eSOC arm (p = 0.01). In the CM arm, 75% (9/12) of treatment eligible participants initiated treatment, compared to 100%(4/4) in the eSOC arm (p = 0.53). All patients (9/9) achieved cure in the CM arm, as compared to 75% (3/4) of patients in the eSOC arm. There were no differences in adherence between study arms. CONCLUSIONS: In this pilot study, contingency management led to higher rates of HCV linkage to care for PWID, as compared to standard of care. CM should be considered as a possible intervention to improve the HCV treatment cascade for PWID.

Changing risk and presentation of overdose associated with consumption of street drugs at a supervised injection site in Vancouver, Canada.

BACKGROUND: British Columbia is experiencing a public health emergency due to overdoses resulting from consumption of street drugs contaminated with fentanyl. While the risk of overdoses appears to be increasing, the overdose rate and severity of overdose presentations have yet to be quantified. METHODS: Insite is a supervised injection site in Vancouver. Data from Insite's client database from January 2010 to June 2017 were used to calculate overdose rates as well as the proportion of overdoses involving rigidity and naloxone administration over time in order to estimate changes in the risk and severity of overdose resulting from changes in the local drug supply. RESULTS: The overdose rate increased significantly for all drug categories. Heroin used alone or with other drugs continues to be associated with the highest overdose rate. The overdose rate associated with heroin increased from 2.7/1000 visits to 13/1000 visits over the study period, meaning that clients were 4.8 times more likely to overdose in the most recent period as in the baseline period. The proportion of overdose events involving rigidity, a known complication of intravenous fentanyl use, increased significantly from 10.4% to 18.9%. The proportion of overdoses requiring naloxone administration increased significantly from 48.4% to 57.1% and is now similar across all drug categories. CONCLUSIONS: The risk and severity of overdoses at Insite have increased since the emergence of illicit fentanyl. This information derived from supervised injection site data can be used to inform local harm reduction efforts and the response to the overdose emergency.

Changes in supervised drug-injecting practices following a community-based educational intervention: A longitudinal analysis.

BACKGROUND: People who inject drugs face several health issues because of unsafe injecting practices. We aimed to evaluate changes in supervised drug-injecting practices following the implementation of a face-to-face educational intervention. METHODS: The national study ANRS-AERLI was conducted in 17 harm reduction (HR) facilities in France between 2011 and 2013. Eight offered the intervention and nine did not. We conducted a pre-post analysis focusing on injecting practices data, collected in the 8 HR facilities providing the intervention. The intervention consisted of providing face-to-face educational sessions including direct observation of injecting practices, counseling about safer injecting, and shared discussion. Injecting practices were collected following a checklist and classified as safe or unsafe. To assess changes in injecting practices, practices were compared before (at baseline) and after at least one educational session. FINDINGS: Mixed logistic models showed that the 78 participants included were more likely to improve in the following drug-use steps: setting up a clean preparation area (Adjusted Odds Ratio (AOR) = 3.4, 95% Confidence Interval (95% CI) = 1.6-7.6), hand washing (AOR = 7.2, 95% CI = 3.1-16.4), skin cleaning (AOR = 5.6, 95% CI = 2.5-12.1), choice of safe injection site (AOR = 6.5, 95% CI = 1.5-28.8) and post-injection bleeding management (AOR = 12.8, 95% CI = 5.5-29.9). Furthermore, participants were less likely to lick their needles before injecting (AOR = 8.1, 95% CI = 1.5-43.4) and to perform booting/flushing (AOR = 2.5, 95% CI = 1.2-5.3). CONCLUSIONS: The AERLI intervention seems to be effective in increasing safe drug-injecting practices.

Are there differences in individual-level needle and syringe coverage across Australian jurisdictions related to program policy? A preliminary analysis.

INTRODUCTION AND AIMS: Services provided by needle and syringe programs (NSP) within Australia are easily accessible by international standards. However, important variation in NSP policy remains across Australian jurisdictions. The potential impacts of these variations on program operation for clients have not been systematically analysed in Australia. In this paper we conduct a preliminary examination to compare individual-level syringe coverage between and within Australian capital cities. DESIGN AND METHODS: Participants were 2498 people who inject drugs (PWID) recruited from all Australian capital cities as part of the annual Illicit Drug Reporting System PWID survey over the period 2014-2016. Insufficient coverage was defined when <100% of a participant's injecting episodes were 'covered' by sterile needles and syringes. We report the percentage of insufficient coverage for each capital city for each year, and present descriptive statistics for coverage parameters, and an alternative measure for insufficient coverage, as Supporting Information. RESULTS: Differences in behaviours that have the potential to impact syringe coverage were highly variable over time and place leading to variations in levels of insufficient coverage between and within all cities. Overall, insufficient coverage was most evident in larger cities where insufficient coverage varied between 19% and 23% (Sydney) over time, compared to smaller cities with variation from 9% to 12% (Adelaide). DISCUSSION AND CONCLUSIONS: We found no consistent pattern of differences in individual-level needle and syringe coverage between and within Australian capital cities. Further work is needed to fully evaluate whether policy variation between Australian jurisdictions impacts on NSP coverage.

Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.

BACKGROUND: People who inject drugs (PWID) are a key population affected by the global HIV and hepatitis C virus (HCV) epidemics. HIV and HCV prevention interventions for PWID include needle and syringe programmes (NSP), opioid substitution therapy (OST), HIV counselling and testing, HIV antiretroviral therapy (ART), and condom distribution programmes. We aimed to produce country-level, regional, and global estimates of coverage of NSP, OST, HIV testing, ART, and condom programmes for PWID. METHODS: We completed searches of peer-reviewed (MEDLINE, Embase, and PsycINFO), internet, and grey literature databases, and disseminated data requests via social media and targeted emails to international experts. Programme and survey data on each of the named interventions were collected. Programme data were used to derive country-level estimates of the coverage of interventions in accordance with indicators defined by WHO, UNAIDS, and the UN Office on Drugs and Crime. Regional and global estimates of NSP, OST, and HIV testing coverage were also calculated. The protocol was registered on PROSPERO, number CRD42017056558. FINDINGS: In 2017, of 179 countries with evidence of injecting drug use, some level of NSP services were available in 93 countries, and there were 86 countries with evidence of OST implementation. Data to estimate NSP coverage were available for 57 countries, and for 60 countries to estimate OST coverage. Coverage varied widely between countries, but was most often low according to WHO indicators (<100 needle-syringes distributed per PWID per year; <20 OST recipients per PWID per year). Data on HIV testing were sparser than for NSP and OST, and very few data were available to estimate ART access among PWID living with HIV. Globally, we estimate that there are 33 (uncertainty interval [UI] 21-50) needle-syringes distributed via NSP per PWID annually, and 16 (10-24) OST recipients per 100 PWID. Less than 1% of PWID live in countries with high coverage of both NSP and OST (>200 needle-syringes distributed per PWID and >40 OST recipients per 100 PWID). INTERPRETATION: Coverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics. FUNDING: Open Society Foundations, The Global Fund, WHO, UNAIDS, United Nations Office on Drugs and Crime, Australian National Drug and Alcohol Research Centre, University of New South Wales Sydney.

Supervised injection facilities in Canada: past, present, and future.

Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada's first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.

Longitudinal analysis of change in individual-level needle and syringe coverage amongst a cohort of people who inject drugs in Melbourne, Australia.

BACKGROUND: Needle and syringe program (NSP) coverage is often calculated at the individual level. This method relates sterile needle and syringe acquisition to injecting frequency, resulting in a percentage of injecting episodes that utilise a sterile syringe. Most previous research using this method was restricted by their cross-sectional design, calling for longitudinal exploration of coverage. METHODS: We used the data of 518 participants from an ongoing cohort of people who inject drugs in Melbourne, Australia. We calculated individual-level syringe coverage for the two weeks prior to each interview, then dichotomised the outcome as either "sufficient" (≥100% of injecting episodes covered by at least one reported sterile syringe) or "insufficient" (<100%). Time-variant predictors of change in recent coverage (from sufficient to insufficient coverage) were estimated longitudinally using logistic regression with fixed effects for each participant. RESULTS: Transitioning to methamphetamine injection (AOR:2.16, p=0.004) and a newly positive HCV RNA test result (AOR:4.93, p=0.001) were both associated with increased odds of change to insufficient coverage, whilst change to utilising NSPs as the primary source of syringe acquisition (AOR: 0.41, p=0.003) and opioid substitution therapy (OST) enrolment (AOR:0.51, p=0.013) were protective against a change to insufficient coverage. CONCLUSIONS: We statistically tested the transitions between time-variant exposure sub-groups and transitions in individual-level syringe coverage. Our results give important insights into means of improving coverage at the individual level, suggesting that methamphetamine injectors should be targeted, whilst both OST prescription and NSP should be expanded.

Death from liver disease in a cohort of injecting opioid users in a Swedish city in relation to registration for opioid substitution therapy.

INTRODUCTION AND AIMS: Injecting opioid users are at elevated risk of death. Although liver disease (especially hepatitis C) is common, its impact on mortality is low in active injectors. Because opioid substitution therapy (OST) reduces the risk of death from directly drug related causes, we hypothesised that the proportion of liver-related deaths would increase in subjects receiving OST. We investigated liver-related mortality in a cohort of injecting opioid users attending a needle exchange program (NEP) in a Swedish city in relation to OST exposure. DESIGN AND METHODS: Participants enrolled in the NEP between 1987 and 2011 with available national identity numbers, and registered use of opioids, were included. Linkage based on national identity numbers was performed with national registers for death, emigration and prescription of OST. Participants were categorised as non-OST recipients until the registered date of first OST prescription, and hence as OST recipients. Hazard ratios were calculated by Cox regression for overall and liver-related mortality in relation to OST, with OST as a time-dependent variable. RESULTS: Among 4494 NEP participants, 1488 opioid users were identified; 711/1488 had been prescribed OST. During a follow-up period of 15 546 person-years 368 deaths occurred. Sixteen deaths were caused by liver disease; 10 of these occurred in OST recipients. The risk of liver-related death was significantly increased in OST receiving participants (hazard ratio 3.08, 95% confidence interval [1.09, 8.68], P = 0.03). CONCLUSIONS: Liver related mortality among opioid users was significantly elevated in OST recipients, showing the long-term importance of chronic liver disease in this population. [Jerkeman A, Håkansson A, Rylance R, Wagner P, Alanko Blomé M, Björkman P. Death from liver disease in a cohort of injecting opioid users in a Swedish city in relation to registration for opioid substitution therapy. Drug Alcohol Rev 2017;36:424-431].

Trend Analyses of Users of a Syringe Exchange Program in Philadelphia, Pennsylvania: 1999-2014.

This study examines trends of injection drug users' (IDUs) use of a Philadelphia, Pennsylvania, syringe exchange program (SEP) from 1999 to 2014, including changes in demographics, drug use, substance abuse treatment, geographic indicators, and SEP use. Prevention Point Philadelphia's SEP registration data were analyzed using linear regression, Pearson's Chi square, and t-tests. Over time new SEP registrants have become younger, more racially diverse, and geographically more concentrated in specific areas of the city, corresponding to urban demographic shifts. The number of new registrants per year has decreased, however syringes exchanged have increased. Gentrification, cultural norms, and changes in risk perception are believed to have contributed to the changes in SEP registration. Demographic changes indicate outreach strategies for IDUs may need adjusting to address unique barriers for younger, more racially diverse users. Implications for SEPs are discussed, including policy and continued ability to address current public health threats.

Veni, vidi, vici: The appearance and dominance of new psychoactive substances among new participants at the largest needle exchange program in Hungary between 2006 and 2014.

BACKGROUND: There has been an almost exponential growth in the number of new psychoactive substances (NPS) on the drug markets in Europe during the past decade. While most users of NPS use them by routes other than injecting, percutaneous use of NPS is associated with very frequent injecting episodes and paraphernalia sharing. METHODS: We assessed to what extent new clients between 2006 and 2014 (N=3680) at Blue Point, Hungary's largest needle exchange program, exhibited a shift during these years in the drugs they primarily injected. RESULTS: Until 2010, 99% of clients injected either heroin or amphetamines. After 2010, however, there was a "replacement chain" of new substances, with one appearing and disappearing after the other: between 2010 and 2014, NPS under five names appeared and gained dominant prevalence (from 0% to 80%), and gradually replaced first the two "traditional" drugs amphetamine and heroin (which diminished to 17% together in 2014) and later each other. We also saw an increase in the proportion of female and older clients. CONCLUSIONS: While our findings are restricted to injected NPS, they suggest that NPS affect the vast majority of the population of people who inject drugs not only in terms of drug use patterns, but maybe also in terms of demographics. Given that over 80% of people who inject drugs use NPS and injecting NPS is associated with increased injecting risks, harm reduction services should be made more available to avoid an epidemic of blood-borne infections.

Drug analysis of residual content of used syringes: a new approach for improving knowledge of injected drugs and drug user practices.

BACKGROUND: Since their inception, harm reduction services, including needle exchange programs, have aimed to improve and update knowledge about illicit drug consumption and injection practices in order to assess and regularly revise the effectiveness of preventive strategies. METHODS: In this paper we describe the development of a scientific approach to obtaining this type of information through analysis of the residual content of used syringes. This was done using a validated liquid chromatography method with mass spectrometry detection to identify different molecules. Used syringes were collected from automatic injection kit dispensers at 17 sites in Paris and the surrounding suburbs each month for one year. RESULTS: In total, 3489 syringes were collected. No compounds were detected in 245 syringes. Heroin was the most commonly observed compound (42%), followed by cocaine (41%), buprenorphine (29%) and 4-methylethylcathinone (23%). These analyses also showed the increased appearance of 4-methylethylcathinone between the summer and winter of 2012. CONCLUSIONS: Despite the bias involved in this approach, the method can provide rapid data on patterns of drug consumption for specific time periods and for well-defined locations. This kind of analysis enables the detection of new substances being injected and thus enables harm reduction services to revise and adapt prevention strategies.

Supervised injection services: what has been demonstrated? A systematic literature review.

BACKGROUND: Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking. AIMS: To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm. METHODS: A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")]. RESULTS: Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney. CONCLUSION: SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.

What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010-2012? A review of the six highest burden countries.

OBJECTIVE: In 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an "accountability matrix", focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress. DESIGN: We searched peer-reviewed literature, conducted online searches, and contacted experts for 'grey' literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews. RESULTS: Policy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs. CONCLUSIONS: Prevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.