Typologies of Sex Work Practice and Associations with the HIV Risk Environment and Risk Behaviors in Kazakhstan.

Women engaged in sex work (WESW) who use drugs are a key population in Kazakhstan's HIV epidemic. Global research suggests susceptibility to HIV varies by sex work environment. This study aims to identify evidence-based typologies of WESW and examine their associations with HIV risk. We surveyed 400 WESW who use drugs in two Kazakhstani cities, including questions on sociodemographic characteristics, social, physical, and economic risk environments, and sexual risk behaviors. Latent class analysis identified four distinct typologies of sex work practice: occasional sex work (n = 61, 15%), professional sex work for money (n = 187, 47%), sex work in exchange for drugs, goods, or other services (n = 117, 29%), and managed sex work under a boss/pimp/madam (n = 35, 9%). We then used logistic regression to examine associations between typologies and risk behaviors. Compared to professional sex work, occasional sex work was associated with lower odds of multiple sexual partners (aOR:0.46[95%CI:0.24,0.90]), of multiple paid clients (aOR:0.25[0.13,0.49]), and of > 1 instance of unprotected sex with a paying partner (aOR:0.33[0.17,0.63]). Compared to professional sex work, sex work for nonmonetary items was associated with higher odds of multiple sexual partners (aOR:1.85[0.96,3.67]) and of > 1 instance of unprotected sex with a paying partner (aOR:1.71[1.01,2.93]). Results suggest heterogeneity among WESW who use drugs in Kazakhstan, and that typologies of sex work are associated with varying HIV risk environment factors and risk behaviors. Effective HIV prevention efforts must be tailored to address these varying risk environments and the resulting variety of needs.

'Change creates change' - older female sex workers' experiences through the early COVID-19 pandemic.

COVID-19 and associated policy responses created unique social, economic and health risks for sex workers. Through semi-structured interviews we explored pre- and early COVID-19 experiences and work practices of ten cisgender female sex workers 50 years of age and older in Queensland, Australia, analysing the findings using a risk environment framework. Throughout early 2020, participants navigated a complex risk environment, managing economic needs, health and safety, occupational stigma and policing. Australia's policy responses altered the risks and opportunities available to participants. Half the participants continued sex work and half stopped sex work with some accessing economic support and withdrawing superannuation savings. Those who continued sex work drew on life and work experience to reassess changing health, stigma, and policing risks, and adapted their work strategies by increasing client screening and modifying services. Participants relied on information from peer networks and organisations to guide work practices but remained wary of contact tracing, police and the media. Decriminalisation of sex work and the strengthening of sex worker organisation and government partnerships are important in embedding equity in responses to ongoing and new public health threats.

Exploring the role of community pharmacies as a harm reduction environment for anabolic-androgenic steroid consumers: triangulating the perspectives of consumers and pharmacists.

BACKGROUND: While community pharmacies have been successful in providing harm reduction support for illicit substance consumers, little research has explored their role in addressing the needs of anabolic-androgenic steroid (AAS) consumers. OBJECTIVE: This study aimed to triangulate the attitudes and experiences of AAS consumers and community pharmacist's regarding AAS harm reduction. METHODS: Semi-structured interviews were conducted with AAS consumers (n = 8) and community pharmacists (n = 15) between December 2022 and August 2023 in Australia. Interview data were analysed using reflexive thematic analysis. RESULTS: While consumers emphasised easy access to pharmacies, particularly in urban areas, challenges were noted in rural regions. AAS consumers expressed a preference for community pharmacies, perceiving them as less confronting and a feasible avenue for accessing professional advice, highlighting the potential role of pharmacists in nurturing therapeutic alliances with AAS consumers. Similarly, pharmacists expressed receptivity to providing harm reduction information but acknowledged knowledge gaps, suggesting a need for tailored education programs to support AAS consumers effectively. CONCLUSIONS: Community pharmacies can be an important environment for AAS harm reduction. Strategies include utilising private spaces for open discussions with AAS consumers and enhancing pharmacists' understanding of AAS to foster trust and support. Further research is needed to address knowledge gaps and training needs for pharmacy staff, with the aim of creating a safer environment for AAS consumers.

"Expected to happen": perspectives on post-release overdose from recently incarcerated people with opioid use disorder.

BACKGROUND: Opioid-related overdose is the leading cause of death for people recently released from incarceration, however treatment with medications for opioid use disorder (MOUD) during incarceration can reduce the mortality risk. This study seeks to qualitatively analyze perceptions of post-release overdose risk from the perspectives of people who received MOUD while incarcerated in one of eight Massachusetts jails during 2021-2022 using the Risk Environment Framework to guide analyses. METHODS: N = 38 participants with lived experience of MOUD treatment during incarceration who are now living in the community were interviewed on factors that may contribute to or protect against post-release overdose risk. Themes were identified inductively and deductively using the Risk Environment Framework and its domains, which organizes themes along physical, social, economic, and policy environments on both the micro- and macro- scales. RESULTS: The physical risk environment included loss of opioid tolerance during incarceration, polysubstance use, and the toxicity of the regional drug supply as key producers of increased risk for post-release overdose. Social drivers of risk included peer group risk norms-including peer-driven harm reduction practices and interpersonal relationships between drug sellers and buyers-as well as macro-level social determinants of health such as housing insecurity and availability of mental health services. Economic drivers of post-release overdose risk included lack of income generation during incarceration and employment challenges. Participants discussed several aspects of policy that contribute to post-release overdose risk, including availability of harm reduction supplies, public health services, and broader policy around MOUD. CONCLUSIONS: The perspectives of people with lived experience are vital to understanding the disproportionate risks of overdose for those recently released from incarceration. Our results highlight the intersectional factors that produce and reproduce the post-release overdose risk environment, providing support for interventions across each domain of the Risk Environment Framework. By capturing perspectives from people with lived experience of OUD and incarceration during this critical period of risk, we can better identify interventions that target and mitigate overdose-related harm in this population.

Corporate Social Responsibility and Directors' and Officers' Liability Risk: The Moderating Effect of Risk Environment and Growth Potential.

Theoretical arguments regarding the effect of corporate social responsibility (CSR) on firm liability risk are abundant; however, empirical evidence about this relationship is scarce. We investigate the relationship between CSR and the personal liability risk of a firm's directors and officers. We argue that companies with better CSR performance represent a better underwriting risk for directors' and officers' (D&O) insurance providers and, therefore, have a lower cost of insurance. Our results show that firms with better CSR performance are more likely to purchase D&O insurance and have a lower premium-to-coverage ratio, known as the insurance rate-on-line. We also show that this risk-reduction effect is stronger for firms that operate in a high-risk environment and have higher sales growth. These results provide evidence that CSR can be used as a risk management tool to mitigate liability risk and suggest which firms benefit most from this effect.

Understanding the social and structural context of oral PrEP delivery: an ethnography exploring barriers and facilitators impacting transgender women who engage in street-based sex work in Baltimore, Maryland.

Transgender women who sell sex (TWSS) experience high rates of HIV acquisition. Antiretrovirals for pre-exposure prophylaxis (PrEP) represent an efficacious HIV prevention strategy. The social and structural factors affecting PrEP delivery amongst TWSS are underexplored in the literature. We conducted ethnographic research to examine how multilevel social and structural factors manifest in TWSS's lived experiences and affect PrEP delivery and use. Twenty-four transgender women were recruited from the SAPPHIRE cohort and completed interviews focused on barriers and facilitators to PrEP engagement in the context of street-based sex work. Stakeholder interviews (N = 7) were also conducted. Our findings suggest there are unique features of the risk environment that can collectively impede PrEP use among TWSS.

"I'm not going to lay back and watch somebody die": a qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and overdose education/naloxone distribution intervention.

BACKGROUND: Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about participants' experiences with an OEND intervention, and about how participants' perceptions of their rural risk environments influenced the interventions' effects. METHODS: Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework. RESULTS: Participants' naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUDs' confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (responsibility to their community) and physical/healthcare environments (overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations). CONCLUSIONS: By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered support that allowed participants to become a part of the healthcare environment. Findings highlight need for more OEND interventions; outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

Attitudes Toward Injection Practices Among People Who Inject Drugs Utilizing Medical Services: Opportunities for Harm Reduction Counseling in Health Care Settings.

Hospitals are an important setting to provide harm reduction services to people who inject drugs (PWID). This study aimed to characterize PWID's injection practices, the perceived risk and benefits of those practices, and the immediate IDU risk environment among individuals seeking medical care. Surveys were administered to 120 PWID seeking medical services at an urban hospital. Poisson regression was used to examine the effect of perceived risk or importance of injection practices on the rate of engaging in those practices. The mean participant reported "often" reusing syringes and "occasionally" cleaning their hands or skin prior to injection. 78% of participants reported that syringes were extremely risky to share, which was associated with lower likelihood of sharing them (ARR: 0.59; 95% CI: 0.36-0.95). 38% of participants reported it was extremely important to use a new syringe for each injection, and these participants were more likely to report never reusing syringes >5 times (ARR: 1.62, 95% CI: 1.11-2.35). Other factors that may influence injection practices-including fear of arrest, withdrawal, lack of access to supplies, and injecting outdoors-were common among participants. In conclusion, practices that place PWID at risk of injury and infection are common, and risk-benefit perception is associated with some, but not all, injection practices. Injecting in challenging environments and conditions is common. Therefore, harm reduction counseling in medical settings must be accompanied by other strategies to reduce risk, including facilitating access to supplies. Ultimately, structural interventions, such as affordable housing, are needed to address the risk environment.

The group-based law enforcement mistrust scale: psychometric properties of an adapted scale and implications for public health and harm reduction research.

BACKGROUND: Negative encounters with law enforcement-direct and vicarious-fuel mistrust. When considered as part of the 'risk environment' in public health and harm reduction research, law enforcement mistrust may have broad implications. For example, fearing arrest may prevent someone from calling 911 when witnessing an overdose or lead to syringe-sharing and community spread of HIV. For people in the US who identify as Black or African American, these effects may compound, given the ways in which communities of color have been overpoliced. The purpose of this study is to investigate the psychometrics of an adapted scale of law enforcement mistrust-the Group-Based Law Enforcement Mistrust Scale (GBLEMS)-and evaluate its associations with racial and ethnic identity and experiences with law enforcement. METHODS: This cross-sectional survey took place in a small city in the Western United States where only 3% of the population is Black or African American. The sample included Black or African American and Hispanic and Latina women at risk of HIV, and members of their social networks, yielding a diverse sample across racial, ethnic, and gender identities (N = 219). The GBLEMS is a 12-item scale adapted from the Group-Based Medical Mistrust Scale (GBMMS; Thompson et al. 2004). The current analysis evaluated the psychometric properties of the GBLEMS (reliability, exploratory factor analysis) and its associations with demographics, other race-based constructs, and experiences with law enforcement. RESULTS: The GBLEMS demonstrated strong reliability (Cronbach's alpha = 0.92) and exploratory factor analysis indicated that items loaded onto two factors-mistrust and disparities in treatment. There was also support for the scale's construct validity. As hypothesized, GBLEMS scores were higher among respondents who identify as Black or African American, and among those who reported other experiences of racial discrimination, medical mistrust, and negative encounters with law enforcement. CONCLUSIONS: This study yielded support for the reliability and validity of the GBLEMS as a multi-item, two-factor scale measuring group-based law enforcement mistrust. When framing public health and harm reduction research in terms of the risk environment, law enforcement mistrust may be important to measure as part of a comprehensive approach that addresses persistent racial disparities.

A qualitative study on pharmacy policies toward over-the-counter syringe sales in a rural epicenter of US drug-related epidemics.

BACKGROUND: Expanding access to sterile syringes in rural areas is vital, as injection-related epidemics expand beyond metropolitan areas globally. While pharmacies have potential to be an easily accessible source of sterile syringes, research in cities has identified moral, legal and ethical barriers that preclude over-the-counter (OTC) sales to people who inject drugs (PWID). The current study builds on prior urban-based research by elucidating (1) pharmacy OTC policies and (2) pharmacists' rationale for, and barriers and facilitators to, OTC syringe sales in a US rural area hard hit by drug-related epidemics. METHODS: We conducted 14 semi-structured interviews with pharmacists recruited from two Eastern Kentucky health districts. Interview domains included experiences with, and attitudes toward, selling OTC syringes to PWID. Constructivist grounded theory methods were used to analyze verbatim transcripts. RESULTS: Most pharmacists operated "restrictive OTC" pharmacies (n = 8), where patients were required to have a prescription or proof of medical need to purchase a syringe. The remainder (n = 6) operated "open OTC" pharmacies, which allowed OTC syringe sales to most patients. Both groups believed their pharmacy policies protected their community and pharmacy from further drug-related harm, but diverging policies emerged because of stigma toward PWID, perceptions of Kentucky law, and belief OTC syringe sales were harmful rather than protective to the community. CONCLUSION: Our results suggest that restrictive OTC pharmacy policies are rooted in stigmatizing views of PWID. Anti-stigma education about substance use disorder (SUD), human immunodeficiency virus (HIV), and Hepatitis C (HCV) is likely needed to truly shift restrictive pharmacy policy.

Substance use, injection risk behaviors, and fentanyl-related overdose risk among a sample of PWID post-Hurricane Maria.

BACKGROUND: While natural disasters like hurricanes are increasingly common, their long-term effects on people who inject drugs are not well understood. Although brief in duration, natural disasters can radically transform risk environments, increasing substance use and drug-related harms. METHODS: Based on a study of people who inject drugs (PWID) and injection risk behaviors in rural Puerto Rico, the present study uses data from two different phases of the parent study. Data for 110 participants were collected from December 2015 to January 2017, soon before Hurricane Maria landed in September 2017; the 2019 phase, in the aftermath of the hurricane, included a total of 103 participants. The present study's main analyses used data from 66 PWID who participated in both the pre-Maria and post-Maria interviews (66 individuals measured at two time points, for a total of 132 observations), using mixed-effects binomial logistic regression to examine recent overdose experiences pre- and post-Maria. A separate descriptive analysis included all 103 participants from the 2019 interview. RESULTS: After Hurricane Maria, some declines in injection frequency were observed (the percentage of people reporting injecting monthly or less increased from 3.0% before Hurricane Maria to 22.7% after Hurricane Maria). However, fewer PWID reported using a new needle for most or all injections. In the pre-Maria interview, 10.6% of participants indicated they had experienced an overdose during the year of the interview and/or the calendar year prior, and this figure increased to 24.2% in the post-Maria interview. In the regression analysis, the odds of reporting an overdose during the interview year and/or calendar year prior were three times as high post-Maria, relative to pre-Maria (odds ratio 3.25, 95% confidence interval 1.06-9.97). CONCLUSION: Substance use patterns, injection risk behaviors, and overdose episodes and deaths differed after Hurricane Maria, relative to before the hurricane, yet it is unclear to what extent these changes also reflect the simultaneous arrival of fentanyl. In preparation for future natural disasters, it is imperative to strengthen the health infrastructure by enhancing access and curbing barriers to syringe services programs and medications for opioid use disorder, particularly in rural or underserved locations.

"It's on every corner": assessing risk environments in Baltimore, MD using a racialized risk environment model.

Physical, social, economic, and political environments can increase harm and risk among people who use drugs. These factors may be exacerbated in urban environments with a history of systemic inequality toward African Americans. However, racialized risk environment models have rarely been used within substance use research. To fill this gap, the current qualitative study sought to describe the racialized risk environment of an African American sample of 21 adults with a history of illicit drug use living in Baltimore, MD. Semi-structured interviews were conducted. Data were analyzed using qualitative content analysis to identify themes related to illicit drug use, neighborhood context, violence, social interactions, and income generation. Themes related to the physical (e.g., the increased visibility of drug markets), social (e.g., normalization of drug use within social networks), and economic (e.g., financial hardships) risk environments emerged from this sample. These perceptions and themes can aid in developing and refining substance use programming within racialized settings.

Young Adults with Mild Asthma in a High-Risk Occupation: Incidence and Risk Factors for Exacerbation.

BACKGROUND: The effects of high-risk environment on young adults with mild asthma were never fully tested in practice, as most high-risk occupations do not welcome them. This study examines the effect of combat training on asthma worsening in the Israeli Defense Forces. METHODS: Persons with asthma in remission and mild intermittent asthma who underwent combat training between 2014 and 2017 were compared in terms of disease worsening to their counterparts performing clerical duties during a follow-up of 8 months. Among combat trainees, exposure to known triggers for asthma exacerbation and health status on enlistment were assessed as risk factors for asthma exacerbation. RESULTS: Asthma worsening among persons with asthma in remission was twice as common among those who are undergoing training compared to persons performing clerical duties. This difference was smaller among mild intermittent asthmatics. For both asthma severities, rates of asthma exacerbation requiring emergency room treatment were several times higher among the training group. Among individuals undergoing training, mild intermittent asthma was a significant risk factor for asthma worsening compared to asthma in remission (OR 1.99 [1.44-2.75]) while age (OR 0.67 [0.53-0.85]) and immigration to Israel (OR 0.55 [0.31-0.95]) were significant protective factors. INTERPRETATION: Young adults with mild asthma are at significant risk for severe exacerbations when exposed to high-risk environment even among individuals who have long been symptom free. No single risk factor was found to have an independent effect suggesting a synergistic mechanism that is harder to mitigate.

The role of local business employees and community members in the HIV risk environment of female sex workers in an urban setting: associations between negative interactions and inconsistent condom use.

BACKGROUND: The role of business employees and community members in the HIV risk environment of female sex workers (FSW) is underexplored, despite sex work often located in commercial and residential urban areas. We explored the effect of negative interactions between business employees and community members on inconsistent condom use with clients of female sex workers. METHODS: This study uses baseline data from the EMERALD study, a community empowerment intervention with FSW. We recruited a sample of 361 FSW in Baltimore, Maryland using targeted sampling techniques in ten zones characterized by high rates of sex work, located throughout the city. Participants were recruited between September 2017 and January 2019 and completed a survey, HIV rapid testing, and self-administered gonorrhea and chlamydia testing. The outcome, inconsistent condom use, was defined as not reporting "always" using condoms with paying clients. Poisson regressions with robust variance were used to model the effect of business employee and/or community member interactions on inconsistent condom use. RESULTS: Over half (54%) the sample was between 18 and 40 years old, 44% Black or another race, and experienced a range of structural vulnerabilities such as housing instability and food insecurity. Forty-four percent of the sample reported inconsistent condom use with clients. FSW reported being reported to the police weekly or daily for selling drugs (14% by employees, 17% by community), for selling sex (19% by employees, 21% by community), and experiencing weekly or daily verbal or physical threats (18% by employees, 24% by community). In multivariable models, being reported to the police for selling sex weekly or daily by community members (vs. never, aRR = 1.42, 95% CI = 1.08, 1.86) and business owners (vs. never, aRR = 1.36, 95% CI = 1.05, 1.76) increased risk of inconsistent condom use, as did monthly verbal or physical threats by community members (vs. never, aRR = 1.43, 95% CI = 1.08, 1.91). CONCLUSIONS: Results show that both actors play important roles in FSWs' HIV risk environment. Businesses and community members are important targets for holistic HIV prevention interventions among FSW in communities where they coexist in close proximity.

"I would rather do it myself": injection initiation and current injection patterns among women who inject drugs in Tijuana, Mexico.

BACKGROUND: Women who inject drugs (WWID) experience unique risks and adverse health outcomes related to injection initiation and patterns of injection drug use. However, there is limited information on injection initiation experiences and injection patterns among women and the protective strategies employed to limit injection-related harms, especially in low- and middle-income settings. Therefore, this study sought to explore injection initiation and current injection patterns (e.g., relying on someone else to inject) among women who inject drugs and engage in sex work in Tijuana, Mexico. METHODS: Semistructured in-depth interviews were conducted with 30 WWID on the following topics: injection initiation, current injection patterns, places where women inject, and protective strategies (i.e., risk reduction). All interviews were audio-recorded, transcribed, and de-identified. An inductive thematic analysis was conducted to identify and compare common themes and patterns across participants. RESULTS: The interviews revealed that the vast majority of study participants were first initiated by another person who injects drugs (PWID), often a male sexual partner. However, the majority of the women transitioned to become self-injectors in order to avoid risks associated with relying on others for injection, including overdose, interpersonal violence, sexual abuse, and wounds. Those who relied on others indicated that they would prefer to inject themselves without assistance from others if they were able to. CONCLUSIONS: The narratives uncovered in this study reveal the importance of multiple risk environments in shaping perceived risks associated with injection drug use among women in Tijuana, Mexico. Specifically, the interviews elucidate the connection between interpersonal relationships with other PWID and protective strategies used to minimize risk and harm. These findings highlight the need for women-centered harm reduction programs to facilitate the development of safer drug use environments among WWID in Tijuana, Mexico.

Novel Routes of Potential Hepatitis C Virus Transmission among People Who Inject Drugs: Secondary Blood Exposures Related to Injection Drug Use.

BACKGROUND: The US is in the midst of a national Hepatitis C Virus (HCV) epidemic that appears to be driven by new cases among people who inject drugs (PWID). While HCV transmission among PWID is believed to occur mostly through direct sharing of syringes, some infections may be spread via secondary processes and materials involved in injecting. OBJECTIVES: Here, we present the prevalence of secondary blood exposures on clothing and nearby surfaces after injection episodes and examine the correlations of these exposures to lifetime HCV infection among a targeted sample of 553 PWID in Los Angeles and San Francisco, California in 2016-18. RESULTS: In multivariate logistic regression models, higher odds of blood on clothing in the last 30 days was significantly (p < 0.05) associated with lifetime positive HCV status, opioids as primary drug, injecting with others, sharing cookers, and receptive syringe sharing. Higher adjusted odds of blood on nearby surfaces in the last 30 days was significantly associated with lifetime positive HCV status, sharing cookers, and receptive syringe sharing. Native American race was associated with significantly lower adjusted odds of both outcome variables. Conclusions/Importance: Results indicate the relevance of physical and social micro-environments to the potential for blood exposures secondary to injection episodes. Individuals with chronic HCV seropositivity are potentially more likely to expose others to blood due to decreases in the blood's ability to clot. This highlights the need for increased HCV testing at harm reduction sites and increased supply of first aid and wound-care materials to help stop potential blood exposures after injection episodes.

Risk behaviour and access to HIV/AIDS prevention services among formerly homeless young adults living in housing programmes.

Young adults who experience homelessness have high rates of sexually transmitted infections (STIs) including HIV. Homelessness services programmes that provide housing to young adults have the capacity to reduce STI risk profiles. This study analysed data from 140 formerly homeless adults who moved into a housing programme in Los Angeles County between the ages of 18 and 25 years to investigate risk behaviour and access to HIV/AIDS prevention services. More than three quarters of participants reported sexual activity (vaginal or anal sex) in the prior 3 months, with 63% reporting any unprotected vaginal or anal sex, 29% reporting unprotected sex with a nonserious partner, 40% reporting multiple partners, and 11% reporting exchange sex. About three quarters reported a past-year HIV test. About half of the sample had never heard of pre-exposure prophylaxis (PrEP), 12% had heard of it but didn't know what it was, 25% reported knowing a little bit, and 15% said they knew a lot about PrEP. Slightly more than 4% of the overall sample reported being HIV positive. These findings suggest that housing programmes may be a prime location to implement HIV prevention services.

"Caballo": risk environments, drug sharing and the emergence of a hepatitis C virus epidemic among people who inject drugs in Puerto Rico.

BACKGROUND: Sharing drug injection equipment has been associated with the transmission of HCV among PWID through blood contained in the cooker and cotton used to prepare and divide up the drug solution. While epidemiologists often subsume this practice under the sharing of "ancillary equipment," more attention should be paid to the fact that indirect sharing takes place within the process of joint drug acquisition and preparation. METHODS: We employed an ethnographic approach observing active PWID (N = 33) in four rural towns in Puerto Rico in order to document drug sharing arrangements involved in "caballo", as this practice is locally known. We explored partners' motivation to engage in drug sharing, as well as its social organization, social roles and existing norms. FINDINGS: Findings suggest that drug sharing, is one of the main drivers of the HCV epidemic in this population. Lack of financial resources, drug packaging, drug of choice and the desire to avoid the painful effects of heroin withdrawal motivates participants' decision to partner with somebody else, sharing injection equipment-and risk-in the process. Roles are not fixed, changing not only according to caballo partners, but also, power dynamics. CONCLUSION: In order to curb the HCV epidemic, harm reduction policies should recognize the particular sociocultural contexts in which people inject drugs and make decisions about risk. Avoiding sharing of injection equipment within an arrangement between PWID to acquire and use drugs is more complex than assumed by harm reduction interventions. Moving beyond individual risk behaviors, a risk environment approach suggest that poverty, and a strict drug policy that encourage users to carry small amounts of illicit substances, and a lack of HCV treatment among other factors, contribute to HCV transmission.

Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency.

BACKGROUND: West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state's drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston's needle and syringe program was forced to close. This paper considers the risk environment in which the state's drug-related loss of life, and those attempting to prevent it, exist. METHODS: This rapid ethnographic study involved semi-structured interviews (n = 21), observation and video recordings of injection sequences (n = 5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n = 2) with individuals involved in service provision were also carried out. RESULTS: PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH. CONCLUSIONS: Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

The Risk Environment for Adopting and Continuing Injecting Drug Use: A Qualitative Study in Uyo, Nigeria.

Background: The bulk of research on adoption of injecting is from Europe and America, despite the existence of syndemics of drug injecting, HIV, and viral hepatitis globally. Objectives: This study explores adoption and continuation of injecting drug use. Methods: The study draws on in-depth interviews with 41 (n = 41) current male and female people who inject drugs recruited via snow-ball sampling in Uyo, Nigeria. A thematic and descriptive analysis was undertaken informed by the risk environment framework and focused on accounts of the factors influencing the process. Results: Accounts emphasized injecting adoption and continuation as a process influenced by individual, social, and structural factors within the risk environment, including concerns for pleasure/efficiency, prestige, exposure to/support for injecting within peer and sexual relationships, availability and purity of drugs, and dependence and increased cost of drug use. Conclusions/implications: Findings highlight the need to prevent adoption of injecting, reduce prevalence of injecting, and promote safe injecting through multi-level interventions, including peer-driven education, drug treatment services, needle and syringe distribution, oral drug substitution, and law enforcement targeting drug suppliers. The need for equivalent pleasure with minimal risk points to the strategic importance of peer interactions for inculcating new understandings of drug use and pleasure.