Association between public injecting and drug-related harm among HIV-positive people who use injection drugs in a Canadian setting: A longitudinal analysis

Abstract

Background and Aims Injecting illicit drugs in public settings has been linked to a higher risk of a range of drug-related harms, including overdose and HIV infection. However, the factors associated with public injecting among HIV-positive individuals have not been previously explored. We investigated the links between public drug injecting, drug-related harm, and HIV treatment measures among a cohort of HIV-positive persons who inject drugs (PWID) in a Canadian setting. Methods We used data from a prospective cohort of HIV-positive PWID recruited from community settings in Vancouver, Canada, linked to comprehensive clinical monitoring data in the context of an ongoing Treatment-as-Prevention (TasP) initiative to examine harms associated with public injecting. We used generalized linear mixed-effects analyses to identify longitudinal factors associated with self-reported public drug injection. Results Between 2005 and 2014, 626 HIV-seropositive PWID were recruited, of whom 213 (34%) reported public injection in the preceding 180 days. In a longitudinal multivariable model, public injection was positively associated with daily heroin injection (Adjusted Odds Ratio [AOR] = 2.63), incarceration (AOR = 1.78), and detectable plasma HIV-1 RNA viral load (VL, AOR = 1.42). Conclusions Public injecting was linked to numerous drug-related harms among HIV seropositive PWID in this setting. Given its link with detectable VL, an important marker of poor HIV treatment outcomes, our findings support prioritizing individuals engaged in public injecting with harm reduction strategies as well as clinical and social supports as a part of TasP-based efforts to prevent HIV-related morbidity and mortality, and HIV transmission.

Opioid agonist treatment and the process of injection drug use initiation

“…Vancouver, Canada, like other settings in North America, is experiencing an acute increase in overdose mortality due primarily to the rising availability and use of fentanyl (Hayashi et al, 2018), a high-potency opioid analogue, among a large population of street-involved PWID (DeBeck et al, 2009). There is a scientific consensus that OAT effectively reduces the frequency of opioid injecting (Gowing et al, 2011; Karki et al, 2016; Volkow et al, 2014), and it has also been shown to reduce public injecting (Ickowicz et al, 2017). As such, we hypothesize that active OAT enrollment may also be associated with a decreased risk that PWID assist others in their first injection in Vancouver, Canada, a setting disproportionately impacted by public injecting and untreated OUD.…”

Opioid agonist treatment scale-up and the initiation of injection drug use: A dynamic modeling analysis

“…While this recent evidence indicates that PWID enrollment in OAT is associated with a decreased likelihood of providing assistance with IDU initiation, the causal pathways that underlie this effect remain unclear. One explanation is that OAT enrollment has been found to reduce the frequency of both opioid injecting [18,19] and public injecting [20]. As such, OAT enrollment may decrease the overall frequency of injection events by PWID, including a reduction in the overall frequency of public IDU events that are visible to injection-naïve individuals.…”

Safe and unsafe spaces: Non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City

“…Public injection is defined as injecting behavior that occurs in any public place, including alleyways, hidden alcoves, and public toilets. The practice of public injecting has been associated with increased potential for physical assault, robbery and police intervention, which in turn precipitates rushed injection and unsafe or less hygienic injection practices (Ickowicz et al, 2017). Research has demonstrated that public injection is significantly associated with detectable HIV viral load among PWID with HIV infection, greater risk injection practices, as well as greater likelihood of overdose, abscesses, vein damage, and blood-borne viruses including Hepatitis C (Ickowicz et al, 2017; Klee, 1995; Marshall, Kerr, Qi, Montaner, & Wood, 2010; Rhodes et al, 2006; Small et al, 2007).…”