Harm Reduction Journal

A community-based research (CBR) approach is critical to redressing the exclusion of women—particularly, traditionally marginalized women including those who use substances—from HIV research participation and benefit. However, few studies have articulated their process of involving and engaging peers, particularly within large-scale cohort studies of women living with HIV where gender, cultural and linguistic diversity, HIV stigma, substance use experience, and power inequities must be navigated. Through our work on the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), Canada’s largest community-collaborative longitudinal cohort of women living with HIV (n = 1422), we developed a comprehensive, regionally tailored approach for hiring, training, and supporting women living with HIV as Peer Research Associates (PRAs). To reflect the diversity of women with HIV in Canada, we initially hired 37 PRAs from British Columbia, Ontario, and Quebec, prioritizing women historically under-represented in research, including women who use or have used illicit drugs, and women living with HIV of other social identities including Indigenous, racialized, LGBTQ2S, and sex work communities, noting important points of intersection between these groups. Building on PRAs’ lived experience, research capacity was supported through a comprehensive, multi-phase, and evidence-based experiential training curriculum, with mentorship and support opportunities provided at various stages of the study. Challenges included the following: being responsive to PRAs’ diversity; ensuring PRAs’ health, well-being, safety, and confidentiality; supporting PRAs to navigate shifting roles in their community; and ensuring sufficient time and resources for the translation of materials between English and French. Opportunities included the following: mutual capacity building of PRAs and researchers; community-informed approaches to study the processes and challenges; enhanced recruitment of harder-to-reach populations; and stronger community partnerships facilitating advocacy and action on findings. Community-collaborative studies are key to increasing the relevance and impact potential of research. For women living with HIV to participate in and benefit from HIV research, studies must foster inclusive, flexible, safe, and reciprocal approaches to PRA engagement, employment, and training tailored to regional contexts and women’s lives. Recommendations for best practice are offered.

Take-Home Naloxone (THN) is a core intervention aimed at addressing the toxic illicit opioid drug supply crisis. Although THN programs are available in all provinces and territories throughout Canada, there are currently no standardized guidelines for THN programs. The Delphi method is a tool for consensus building often used in policy development that allows for engagement of stakeholders. We used an adapted anonymous online Delphi method to elicit priorities for a Canadian guideline on THN as a means of facilitating meaningful stakeholder engagement. A guideline development group generated a series of key questions that were then brought to a 15-member voting panel. The voting panel was comprised of people with lived and living experience of substance use, academics specializing in harm reduction, and clinicians and public health professionals from across Canada. Two rounds of voting were undertaken to score questions on importance for inclusion in the guideline. Nine questions that were identified as most important include what equipment should be in THN kits, whether there are important differences between intramuscular and intranasal naloxone administration, how stigma impacts access to distribution programs, how effective THN programs are at saving lives, what distribution models are most effective and equitable, storage considerations for naloxone in a community setting, the role of CPR and rescue breathing in overdose response, client preference of naloxone distribution program type, and what aftercare should be provided for people who respond to overdoses. The Delphi method is an equitable consensus building process that generated priorities to guide guideline development.

Electronic cigarettes are a harm reduction strategy for individuals who smoke cigarettes who cannot or do not want to quit using FDA-approved cessation methods. Identifying perceived facilitators and barriers to switching among people who smoke cigarettes is critical to optimizing health impact. This is particularly important for the most dominant e-cigarette device, nicotine salt pod electronic cigarettes. We investigate the experience using pod electronic cigarettes among African American and Latinx individuals who smoke, the two largest racial/ethnic minority groups who experience significant health disparities. From July 2018 to May 2019, adults who smoked cigarettes, age 21 + (N = 114; M age = 44.6, 59.6% male, 52.6% African American from Kansas City, 47.4% Latinx from San Diego) received JUUL-brand electronic cigarettes (referred to hereafter as JUUL) for 6 weeks and answered interview questions at week six. We inquired what they liked and disliked about using JUUL, what helped with switching and made switching difficult, future intentions for continued JUUL use, and how JUUL compared to past smoking reduction methods. Responses were coded into themes by independent raters. Theme frequencies were analyzed separately by race/ethnicity and week 6 use trajectory (exclusive JUUL use, dual JUUL and cigarette use, exclusive cigarette use). Clean/smell was the aspect of using JUUL most commonly liked (23%), followed by convenience (19%). Coughing/harshness was a more common barrier to switching for African American (44%) than Latinx (9%), and for continuing cigarette use (56%) than for those who exclusively switched or dually used JUUL and combustible cigarettes (15–21%). Most (78% African American; 90% Latinx) reported that the benefits of using JUUL outweighed barriers, and this varied by JUUL use trajectory: 94% exclusive switch, 86% dual use, and 42% continued cigarette use. The majority said they would continue using JUUL to replace cigarettes (83% African American; 94% Latinx) and that JUUL worked better than other methods to reduce cigarettes (72%). African American and Latinx individuals who smoked experience using pod electronic cigarettes was generally positive. Understanding facilitators and impediments to switching to electronic cigarettes among racial/ethnic minority people who smoke can inform harm reduction interventions and reduce tobacco-related health disparities. Trial Registration ClinicalTrials.gov Identifier: NCT03511001 posted April 27, 2018.

Out of 20,887 persons who use drugs that came into contact with the National Anti-Drugs Agency (NADA) officials in the year 2013, 3.2 % were women. Because women who use drugs (WWUD) are often a hidden population, this may be an underestimate. International literature shows that women who use drugs face increased risk of HIV, intimate partner violence, and mental health issues. Similar literature in Malaysia is lacking, and thus, the objective of our study was exploratory in nature. Thirty-eight women who use drugs were interviewed using a semi-structured topic guide in Kelantan, Penang, Johor, Kuala Lumpur, and Selangor. Locations were chosen purposively. Nineteen women were interviewed individually and the remaining 19 were in focus group discussions (FGDs). All interviews were transcribed verbatim, translated to English, and analyzed with NVivo. Median age of respondents was 35.5 years old, 89.5 % ethnic Malays, majority having married below the age of 20, and were of low socioeconomic backgrounds. Youngest age of initiation into drug use was 9 years old. Most reported is inhalation of amphetamine-type substances. Seven reported ever injecting. Three themes emerged: (a) repeating patterns of fluid family structures and instability; (b) “pain” and “difficulty” as features of home life; and (c) seeking marriage as a source of stabilization and practices of power within those marriages. Respondents often came from very fluid family environments and married to find stability, only to be drawn into a similar cycle. None of the women who had been separated from their children either institutionally, by family members, or by third parties, had accessed legal recourse for the loss of their parental rights. Unstable familial relationships or environments contributed to earlier initiation of drug use which raised questions about support services for WWUD and children who use drugs. Respondents were drawn into unstable and/or abusive relationships, perpetuating social inequalities that marked their own familial environments during childhood. These findings support the need for additional services to support the unique needs of WWUD, including domestic violence services, financial and life skills, parental rights assistance, and empowerment programs.

Few studies have investigated the service needs of persons who inject drugs (PWID) who live in less populated regions of Canada. With access to fewer treatment and harm reduction services than those in more urban environments, the needs of PWID in smaller centres may be distinct. As such, the present study examined the needs of PWID in Prince Edward Island (PEI), the smallest of Canada's provinces. Eight PWID were interviewed about the services they have accessed, barriers they faced when attempting to access these services, and what services they need that they are not currently receiving. Participants encountered considerable barriers when accessing harm reduction and treatment services due to the limited hours of services, lengthy wait times for treatment, and shortage of health care practitioners. They also reported experiencing considerable negativity from health care practitioners. Participants cited incidences of stigmatisation, and they perceived that health care practitioners received insufficient training related to drug use. Recommendations for the improvement of services are outlined. The findings indicate that initiatives should be developed to improve PWID's access to harm reduction and treatment services in PEI. Additionally, health care practitioners should be offered sensitisation training and improved education on providing services to PWID. The findings highlight the importance of considering innovative alternatives for service provision in regions with limited resources.

Due to concerns over potential interactions between some hepatitis C direct-acting antivirals (DAAs) and opioids, we describe adverse event (AE) reports of concomitant use of opioids and DAAs. AEs reported (July 28, 2017–December 31, 2021) with the administration of the DAAs glecaprevir/pibrentasvir, sofosbuvir/velpatasvir, ledipasvir/sofosbuvir, sofosbuvir/velpatasvir/voxilaprevir, and elbasvir/grazoprevir as suspect products were downloaded from the US Food and Drug Administration AE Reporting System Public Dashboard. The number of AE reports containing opioids (fentanyl, hydrocodone, oxycodone) as co-suspect products/concomitant products were counted and summarized by severity, reporting country and whether an outcome of death was reported. Overdose AEs were counted irrespective of opioid use, and changes over time were assessed. In total, 40 AEs were reported for DAAs and concomitant fentanyl use, 25 (62.5%) were in the USA, 35 (87.5%) were considered serious, and 14 (35.0%) resulted in death; and 626 were reported with concomitant oxycodone/hydrocodone use, 596 (95.2%) were in the USA, 296 (47.3%) were considered serious, and 28 (4.5%) resulted in death. There were 196 overdose AEs (32 [16%] deaths) declining from 2018 (N = 56) to 2021 (N = 29). Treating people with hepatitis C virus (HCV) infection who use drugs is key to achieving HCV elimination. Low numbers of DAA AE reports with opioids may provide reassurance to prioritize HCV treatment in this population. These data contribute to evidence supporting the continued scale-up of DAA treatment among people who use drugs to achieve HCV elimination goals.

Alcohol use is a common practice of almost all communities worldwide and it is more common among persons with HIV infection. Alcohol consumption among people with HIV/AIDS may result in poor treatment adherence, further immunity suppression and increase the risk of comorbid illness (diseases) which collectively diminish the anti-retroviral therapy responses. Although there are separate studies conducted regarding alcohol use among people with HIV/AIDS in Ethiopia, the finding results are highly variable and inconsistent. Therefore, conducting a systematic review and meta-analysis has a paramount importance to show the pooled prevalence of alcohol use and to identify its determinants among people with HIV/AIDS. A systematic search of electronic databases of PubMed/Medline, Science Direct, Hinnari and Cochrane library was employed. Additionally, the grey literature was searched from Google and Google Scholar. Data were extracted using a standardized data extraction format prepared in Microsoft Excel . STATA-version 14 statistical software was used for analysis. Heterogeneity of primary studies was found as evaluated using the I2 test result. As a result, a random-effect meta-analysis model was used to estimate the pooled prevalence of alcohol use. A total of 22 primary studies which comprises 8,368 study participants were included in this systematic review and meta-analysis. The pooled prevalence of lifetime, current and hazardous alcohol use among HIV patients in Ethiopia were 36.42% [95% CI (19.96, 52.89)], 19.00% [95% CI (12.98, 25.01)] and 21.64% [95% CI (12.72, 30.55)], respectively. Khat chewing [OR = 3.53, (95% CI 1.31, 9.51)] and cigarette smoking [OR = 7.04, (95% CI 3.53, 14.04)] were found as statistically significant determinants of hazardous alcohol use among people with HIV infection. The result of this review showed that alcohol drinking is highly practiced among people with HIV/AIDS in Ethiopia. The magnitude of alcohol use was highly variable based on the screening methods used to measure alcohol use. Comorbid substance use (khat and cigarette) increases the risk of alcohol consumption among HIV patients. This suggests a need for designing appropriate and culturally applicable intervention programs and policy responses. Trial registration PROSPERO 2019, “CRD42019132524.”

The art in law, like medicine, is in its humanity. Nowhere is the humanity in law more poignant than in BC Supreme Court Justice Ian Pitfield's recent judgment in the legal case aimed at protecting North America's only supervised injection facility (SIF) as a healthcare program: PHS Community Services Society versus the Attorney General of Canada. In order to protect the SIF from politicization, the PHS Community Services Society, the community organization that established and operates the program, along with two people living with addiction and three lawyers working for free, pro bono publico, took the federal government of Canada to court. The courtroom struggle that ensued was akin to a battle between David and Goliath. The judge in the case, Justice Pitfield, ruled in favour of the PHS and gave the Government of Canada one year to bring the Controlled Drugs and Substances Act (CDSA) into compliance with the country's Charter of Rights and Freedoms. If parliament fails to do so, then the CDSA will evaporate from enforceability and law in June of 2009. Despite the fact that there are roughly twelve million intravenous drug addiction users in the world today, politics andprejudice oards harm reduction are still a barrier to the widespread application of the "best medicine" available for serious addicts. Nowhere is this clearer than in the opposition by conservative Prime Minister Stephen Harper and his faithful servant, federal health minister Tony Clement, towards Vancouver's SIF ("Insite"). The continued angry politicization of addiction will only lead to the tragic loss of life, as addicts are condemned to death from infectious diseases (HIV & hepatitis) and preventable overdoses. In light of the established facts in science, medicine and now law, political opposition to life-saving population health programs (including SIFs) to address the effects of addiction is a kind of implicit capital punishment for the addicted. This commentary examines the socio-political context of the legal case and the major figures that contributed to it. It reviews Justice Pitfield's ruling, a judgment that has brought Canada one step closer to putting a stop to addiction's death row where intravenous drug users are needlessly, for political and ideological reasons alone, forced to face increased risks of death due to AIDS, hepatitis and overdose.

Những người nhiễm HIV và tiêm chích ma túy (PWID) phải đối mặt với những thách thức trong việc khởi đầu và tuân thủ điều trị bằng thuốc kháng virus (ART). Tư vấn sử dụng kỹ thuật phỏng vấn động lực (MI) có thể giúp họ hình thành các chiến lược cá nhân hóa và thực hiện các hành động để giải quyết những thách thức này một cách hợp tác với các nhà cung cấp dịch vụ. Chúng tôi đã đánh giá khả năng chấp nhận MI từ một cuộc triển khai thí điểm tại ba cơ sở y tế công cộng ở Indonesia. Dựa trên cấu trúc khả năng chấp nhận do Sekhon (2017) phát triển, chúng tôi đã đánh giá khả năng chấp nhận của các khách hàng HIV dương tính PWID (n = 12) và nhà cung cấp (n = 10) qua bốn cấu trúc tổng hợp: động lực (các yếu tố thúc đẩy sự tham gia); cân nhắc chi phí (những hy sinh cần có để tham gia MI); hiểu biết đã học (cơ chế hoạt động); và kết quả (khả năng tác động đến sự thay đổi thông qua sự tham gia). Chúng tôi đã bao gồm tất cả các nhà cung cấp và khách hàng đã hoàn thành ít nhất 2 cuộc phỏng vấn MI. Phân tích định tính với một khuôn khổ giải thích đã được sử dụng để rút ra và phân loại các chủ đề theo các cấu trúc này. Về động lực, các khách hàng đánh giá cao phong cách giao tiếp cởi mở của MI, trong khi các nhà cung cấp đánh giá cao sự mới mẻ của nó trong việc cung cấp cấu trúc nhất quán với các ranh giới rõ ràng. Về cân nhắc chi phí, cả hai nhóm đều gặp khó khăn trong việc thực hiện các cuộc phỏng vấn MI do sự tiếp cận hoặc sự tham gia vào các lĩnh vực chăm sóc sức khỏe khác. Về hiểu biết đã học, khách hàng hiểu rằng MI có tác dụng xác định những lĩnh vực cuộc sống có vấn đề có thể thay đổi để hỗ trợ việc điều trị ART dài hạn, với việc thực hiện hòa giải trong cuộc sống gia đình là sự thay đổi được nhắm đến nhiều nhất. Ngược lại, các nhà cung cấp lại thích nhắm đến những kết quả sức khỏe hữu hình hơn là những chỉ số hành vi đó. Về kết quả, khách hàng tự tin vào khả năng phát triển các hành vi để duy trì việc tham gia ART, trong khi các nhà cung cấp nghi ngờ về kết quả của MI đối với những PWID trẻ tuổi hoặc những người có sự phụ thuộc nặng. Có một sự chấp nhận rộng rãi MI trong việc thúc đẩy sự tham gia cho cả hai bên. So với các nhà cung cấp, khách hàng có độ chấp nhận cao hơn về cơ chế của nó và có sự tự tin lớn hơn trong việc thực hiện các hành vi thúc đẩy cho việc tham gia ART. Cần có những đổi mới thiết kế để cải thiện khả năng chấp nhận MI cho cả hai bên.

Unsafe injection practices play a major role in elevated rates of morbidity and mortality among people who inject drugs (IDU). There is growing interest in the direct involvement of IDU in interventions that seek to address unsafe injecting. This study describes a drug user-led safer injecting education campaign, and explores facilitators’ experiences delivering educational workshops.

We conducted semi-structured qualitative interviews with 8 members of the Injection Support (IS) Team who developed and facilitated a series of safer injecting education workshops. Interviews explored facilitator’s perceptions of the workshops, experiences being a facilitator, and perspectives on the educational campaign. Interviews were transcribed verbatim and a thematic analysis was conducted.

IS Team facilitators described how the workshop’s structure and content enabled effective communication of information about safer injecting practices, while targeting the unsafe practices of workshop participants. Facilitators’ identity as IDU enhanced their ability to relate to workshop participants and communicate educational messages in language accessible to workshop participants. Facilitators reported gaining knowledge and skills from their involvement in the campaign, as well as positive feelings about themselves from the realization that they were helping people to protect their health. Overall, facilitators felt that this campaign provided IDU with valuable information, although facilitators also critiqued the campaign and suggested improvements for future efforts.

This study demonstrates the feasibility of involving IDU in educational initiatives targeting unsafe injecting. Findings illustrate how IDU involvement in prevention activities improves relevance and cultural appropriateness of interventions while providing individual, social, and professional benefits to those IDU delivering education.