A socio-structural approach to preventing injection drug use initiation: rationale for the PRIMER study

Abstract

BackgroundInjection drug use remains a primary driver of HIV and HCV-related harms globally. However, there is a gap in efforts to prevent individuals from transitioning into injecting. People who inject drugs (PWID) play a key role in the transition of others into injecting, and while behavioral interventions have been developed to address this phenomenon, socio-structural approaches remain unexplored. To that end, we hypothesize that certain interventions designed to reduce injecting-related risk behaviors may also reduce the risk that PWID expose and introduce others into injecting. Identifying the preventive potential of existing interventions will inform broader efforts to prevent injecting and related harms.MethodsThe Preventing Injecting by Modifying Existing Responses (PRIMER) study is a multi-country mixed methods study with an aim to investigate whether specific interventions (e.g., opioid substitution therapy, supervised injection facilities, stable housing, incarceration environments) and related factors (e.g., public injecting and gender) influence the likelihood that PWID initiate others into injecting. This study will (1) investigate the PWID participation in injection initiation; (2) identify factors influencing the risk that PWID expose others to or facilitate injection initiation; (3) describe drug scene roles that increase the risk of PWID facilitating injection initiation; and (4) evaluate the impact of structural, social, or biomedical interventions on the risk that PWID facilitate injection initiation. It does so by pooling observational data from cohort studies of PWID in six cities: Vancouver, Canada; San Diego, USA; Tijuana, Mexico; Paris, Marseille, and Bordeaux, France.ResultsTeam members are conducting a prospective, multi-site study of PWID (n = 3050) in North America and France that includes quantitative and qualitative data collection through four separate cohort studies of PWID (San Diego, STAHR II; Tijuana, El Cuete IV; Vancouver, V-DUS; Bordeaux, Marseille, Paris and Strasbourg, COSINUS).ConclusionsPRIMER is the largest study of injection initiation to date and the first to investigate structural approaches to preventing injection drug use initiation. Findings have the potential to inform the development and scale up of new and existing interventions to prevent transitions into injecting.Trial registrationPreventing Injecting by Modifying Existing Responses (PRIMER), NIDA DP2-DA040256-01.

Preventing Injection Drug use Initiation: State of the Evidence and Opportunities for the Future

“…Interventions to prevent the initiation of injection drug use: a systematic review Werb et al [18] 2014 BChange the Cycle^intervention Strike et al [19] 2015 Next steps in research on injection initiation incidence and prevention Bluthenthal and Kral [20] 2015 US NIDA Avant Garde Award: BCombined prevention to reduce initiation into injecting drug use^Forthcoming 2015 US NIDA Avenir Award: BPreventing injecting by modifying existing responses^Werb et al [21] 2015 US NIDA R01: BPreventing injection initiation: the Change the Cycle randomized controlled trial^Forthcoming be persistent [36]. Therefore, preventing transitions into injecting should address both the need to prevent people from seeking out injecting and the need to prevent PWID from initiating others into this behavior.…”

“…Indeed, individuals who inject drugs will not necessarily experience all or even some of these behaviors or conditions prior to their initiation of injecting. By contrast, there is a nearconsensus across scientific studies that exposure to injection drug use is a key risk factor for injection initiation (though it appears an insufficient cause in isolation) [19,21,24,[40][41][42][43][44]. The growing understanding of these mechanisms has two major implications for the prevention of HIV and viral hepatitis.…”

“…Low availability of stable housing for PWID and injection-naive people who use drugs may result in their shared use of shooting galleries or other drug use venues, thereby increasing the risk of exposure to injecting and, ultimately, initiation of this behavior [13]. Clearly, the level of access that PWID have to public health programming and ancillary services is likely to influence their risk of exposing others to injection, and this topic is the focus of a six-city longitudinal study (Werb: NIDA DP2 DA040256-01); this study, named PRIMER (Preventing Injecting by Modifying Existing Responses), pools data from cohort studies of PWID from Vancouver (Canada), San Diego (USA), Tijuana (Mexico), as well as Marseille, Paris, and Bordeaux (France) and seeks to determine whether housing status, a history of incarceration, enrolment into medication-assisted therapy (MAT), and medically supervised injection facilities (SIF) access impact the risk that PWID initiate others into injecting [21]. Characterizing the influence of these on the risk that PWID expose and initiate injectionnaive individuals can then provide policymakers with critical evidence on how scaling up existing structural interventions known to reduce injection-related risk behaviors may also prevent the incidence of injection initiation [51].…”

“…Beyond avoiding a repetition of past ineffectiveness, future interventions must also ensure that they do not inadvertently increase the stigma around drug injecting while seeking to prevent this behavior. While obvious tensions exist between these two goals, they can be balanced by ensuring that prevention efforts recognize that the vast majority of PWID report an unwillingness to initiate others but nevertheless find themselves unable to avoid doing so as a result of constraining socioeconomic contexts [21,41,61].…”

Injection Drug Use Trajectories among Migrant Populations: A Narrative Review

“…Exposure to injecting behaviors is a key risk factor for IDU initiation (Robertson, Lozada, Pollini, Rangel, & Ojeda, 2012; Sherman, Smith, Laney, & Strathdee, 2002; Werb et al, 2016). Experts have therefore described injecting as a socially communicable condition: a condition spread between individuals through social exposure in an enabling environment (Robertson et al, 2012; Sherman, Smith, Laney, & Strathdee, 2002; Small, Fast, Krusi, Wood, & Kerr, 2009).…”