Publications by authors named "Alex Kral"

147 Publications

Consumer discernment of fentanyl in illicit opioids confirmed by fentanyl test strips: Lessons from a syringe services program in North Carolina.

Int J Drug Policy 2021 Jan 22:103128. Epub 2021 Jan 22.

Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, United States.

Background: The United States (U.S.) continues to witness an unprecedented increase in opioid overdose deaths driven by precipitous growth in the supply and use of illicitly-manufactured fentanyls (IMF). Fentanyl's growing market share of the illicit opioid supply in the U.S. has led to seismic shifts in the composition of the country's heroin supply. The growth in fentanyl supply has transformed illicit opioid markets once offering heroin with fairly consistent purity and potency to a supply overpopulated with fentanyl(s) of inconsistent and unpredictable potency. In response, people who inject drugs (PWID) have developed a number of sensory strategies to detect fentanyl in illicit opioids. The current study examined the accuracy of sensory discernment strategies by measuring study participants' descriptions of the last opioid injected and checked with a fentanyl test strip (FTS) by that test's positive/negative result. The primary objective was to determine associations between FTS results and descriptions of the illicit opioid's physical appearance and physiological effects.

Methods: Between September-October 2017, a total of 129 PWID were recruited from a syringe services program in Greensboro, North Carolina and completed an online survey about their most recent use of FTS. Participants were instructed to describe the appearance and effects associated with the most recent opioid they injected and tested with FTS. We conducted bivariate and multivariate analyses to determine differences in positive vs negative FTS results and the physical characteristics and physiological experiences reported. An exploratory analysis was also conducted to describe the types and bodily locations of unusual sensations experienced by PWID reporting positive FTS results.

Results: For physical characteristics, 32% reported that the drug was white before adding water and 38% reported the solution was clear after adding water. For physiological effects compared to heroin, 42% reported a stronger rush, 30% a shorter high, 30% a shorter time to the onset of withdrawal symptoms, and 42% experienced unusual sensations. In the multivariable model adjusting for demographics and polydrug correlates, white color of drug before adding water, stronger rush, shorter time to withdrawal, and unusual sensations were significantly associated with a positive FTS result. The most common unusual sensations were pins and needles (51%), warming of the head and face (35%), and lightheadedness (30%), and the most common locations where sensations occurred were face and neck (61%), arms/legs (54%), and chest (37%).

Conclusion: We found positive FTS results were significantly associated with the physical characteristics and physiological effects described by PWID. Descriptions concerning physical appearance were consistent with law enforcement profiles of illicitly-manufactured fentanyl and physiological effects were concomitant with scientific and clinical medical literature on iatrogenic fentanyl use. Taken together, these findings suggest sensory strategies for detecting fentanyl in illicit opioids may be an effective risk reduction tool to help consumers navigate unpredictable markets more safely.
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http://dx.doi.org/10.1016/j.drugpo.2021.103128DOI Listing
January 2021

Impact of an unsanctioned safe consumption site on criminal activity, 2010-2019.

Drug Alcohol Depend 2021 Mar 11;220:108521. Epub 2021 Jan 11.

RTI International, 2150 Shattuck Avenue Suite 800, Berkeley, CA, 94704, United States.

Background: Health and social impacts of safe consumption sites (SCS) are well described in multiple countries. One argument used by those opposed to SCS in the US is that findings from other countries are not relevant to the US context. We examined whether an unsanctioned SCS operating in the US affected local crime rates.

Methods: Controlled interrupted time series (ITS) analysis of police incident reports for five years before and five years after SCS opening, comparing one intervention and two control areas in one city.

Results: Narcotic/drug incidents declined across the pre- and post-intervention periods in the intervention area and remained constant in both control areas, preventing an ITS analysis but suggesting no negative impact. On average, incident reports relating to assault, burglary, larceny theft, and robbery in the post-intervention period steadily decreased at a similar rate within both the Intervention area and Control area 1. However the change in rate of decline post-intervention was statistically significantly greater in the Intervention area compared to Control area 1 (difference in slope -0.007 SDs, 95 % CI: -0.013, -0.002; p = 0.01). The Intervention area had a statistically significant decline in crime over the post-intervention period compared to Control area 2 (difference in slope -0.023 SDs, 95 % CI: -0.03, -0.01; p < 0.001).

Conclusions: Documented criminal activity decreased rather than increased in the area around an unsanctioned SCS located in the US in the five years following SCS opening.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108521DOI Listing
March 2021

Correlates of Transactional Sex and Violent Victimization among Men Who Inject Drugs in Los Angeles and San Francisco, California.

J Urban Health 2021 Feb;98(1):70-82

Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Men who inject drugs (MWID) and engage in transactional sex (i.e., receive money or drugs in exchange for sex) are vulnerable to HIV and violence. However, MWID who engage in transactional sex have been less studied than women. We examine factors associated with transactional sex among MWID in Los Angeles and San Francisco and whether transactional sex is associated with violent victimization. MWID were recruited using targeted sampling methods in 2011-2013 and completed surveys that covered demographics, drug use, HIV risk, violence, transactional sex, and other items. Multivariable logistic regression was used to (1) determine factors independently associated with transactional sex and (2) determine if transactional sex was independently associated with violence victimization in the last 6 months among MWID. An interaction term between income source and sexual identity was included in the transactional sex model. Of the 572 male PWID in the sample, 47 (8%) reported transactional sex in the past 6 months. Self-reported HIV infection was 7% for MWID who did not report transactional sex, 17% for MWID who reported transactional sex, and 24% for MWID who reported transactional sex and reported gay or bisexual identity. In multivariable analysis, transactional sex was positively associated with gay or bisexual identity (GB without illegal income adjusted odds ratio [AOR] = 5.16; 95% confidence interval [CI] = 1.86-14.27; GB with illegal income AOR = 13.55, CI = 4.57-40.13), coerced sex in the last 12 months (AOR = 11.66, CI = 1.94-70.12), and violent victimization in the last 12 months (AOR = 2.31, CI = 1.13-4.75). Transactional sex was negatively associated with heroin injection (last 30 days) (AOR = 0.37; 95% CI = 0.18-0.78). Transactional sex was independently associated with violent victimization in the last 12 months (AOR = 2.04; 95% CI = 1.00-4.14) while controlling for confounders. MWID who engaged in transactional sex are at elevated risk for HIV and multiple forms of violent victimization. Interventions focused on this at-risk subpopulation are urgently needed and should include access to substance use disorder treatment, victimization services, and harm reduction services across the HIV care continuum.
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http://dx.doi.org/10.1007/s11524-020-00494-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873178PMC
February 2021

Factors associated with health-related cannabis use intentions among a community sample of people who inject drugs in Los Angeles and San Francisco, CA 2016 to 2018.

Drug Alcohol Depend 2021 Feb 23;219:108421. Epub 2020 Nov 23.

Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA.

Objective: Cannabis motivations have been studied extensively among patients of medicinal cannabis dispensaries, but less is known about motivations in community samples of opioid-using people who inject drugs. Our objective is to describe cannabis use motivations associated with self-treatment of physical pain, emotional issues, and as an opioid substitute.

Methods: Data come from 6-month follow-up interviews with people who inject drugs who participated in a study on the efficacy of an injection initiation prevention intervention in Los Angeles and San Francisco, California from 2016-18. The analytic sample consists of 387 people who inject drugs who reported past-month cannabis use. We developed multivariable logistic regression models by reported cannabis use motivations: physical pain relief, emotional problems, and opioid substitute.

Results: The most common cannabis use motivations reported by people who inject drugs was to "get high," relieve physical pain and emotional problems, and reduce opioid use. In separate multivariate models, using cannabis for physical pain relief was associated with higher odds of using cannabis as a substitute for opioids; cannabis for emotional problems was associated with being diagnosed with depression; and cannabis as a substitute for opioids was associated with non-prescribed, non-injection methadone use.

Conclusion: People who inject drugs reported using cannabis for health-related motivations. This motivation aligns with health needs and suggests the acceptability of cannabis use for health reasons in this population. Studies to determine the medical effectiveness of cannabis products for these common health and mental health needs among people who inject drugs are needed.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856255PMC
February 2021

Assisted injection provider practices and motivations in Los Angeles and San Francisco California 2016-18.

Int J Drug Policy 2020 Nov 27:103052. Epub 2020 Nov 27.

Department of Preventive Medicine, Health Behavior Research Division, Keck School of Medicine, University of Southern California, 2001 N Soto Street, Los Angeles, CA 90032, United States.

Background: Assisted injection is a high-risk and common practice among people who inject drugs (PWID) and occurs for diverse reasons according to qualitative research. To develop interventions for reducing assisted injection risks, it is important to understand the practices of PWID who provide injection assistance, including their motivations for providing assistance.

Methods: Using follow-up data from an efficacy trial among PWID recruited in Los Angeles and San Francisco, CA (n=601), we present descriptive statistics on motivations for providing injection assistance and use multivariable logistic regression modelling to examine factors associated with these motivations.

Results: PWID provided injection assistance most commonly to friends and acquaintances. A quarter provided assistance on a daily basis. The most common motivations for providing assistance were skill and injury prevention. PWID also provided assistance to stop pestering and for compensation in money or drugs. In separate models examining factors associated with the five main motivations, we found injury prevention to be associated with skill injecting others, neck injection, methamphetamine use, and recycling income. Pestering was associated with injury prevention, neck and hand injection, speedball use, and syringe selling. Skill was associated with injury prevention, neck and hand injection, being physically assaulted, and age. Providing assistance for money was associated with providing assistance for food or drugs, armpit injections, being female, and providing assistance more frequently. Providing assistance for drugs was associated with compensation in food or money, goofball injection, selling drugs, and panhandling.

Conclusion: Providing injection assistance is associated with injection needs of recipients and drug scene participation. We urgently need new interventions for reducing assisted injection risks. Since injection providers report being motivated by skill and to prevent injury, interventions such as training in safer injection techniques are likely to be met with enthusiasm.
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http://dx.doi.org/10.1016/j.drugpo.2020.103052DOI Listing
November 2020

A multi-ancestry sex stratified genome-wide association study of spontaneous clearance of hepatitis C virus.

J Infect Dis 2020 Oct 29. Epub 2020 Oct 29.

Johns Hopkins University, School of Medicine, Baltimore, MD. USA.

Background: Spontaneous clearance of acute hepatitis C virus (HCV) infection is more common in women than in men, independent of known risk factors.

Methods: To identify sex-specific genetic loci, we studied 4423 HCV-infected individuals (2903 males, 1520 females) of European, African and Hispanic ancestry. We performed autosomal, and X-chromosome sex-stratified and combined association analyses in each ancestry group.

Results: A male-specific region near ADP-ribosylation factor-like-5B gene was identified. Individuals with the C allele of rs76398191 were about 30% more likely to have a chronic HCV infection compared to individuals with the T allele (ORMales=0.69,P-valueMales=1.98x10-07) and this was not seen in females. The ARL5B gene encodes an interferon stimulated gene that inhibits immune response to dsRNA viruses. We also identified suggestive associations near Septin6 and Ribosomal Protein L39 genes on the X chromosome. In box sexes, allele G of rs12852885 was associated with a 40% increase in HCV clearance compared to the A allele (OR= 1.4, P-valueAll individuals=2.46 x 10-06). Septin6 facilitates HCV replication via interaction with the HCV NS5b protein and RPL39 acts as an HCV core interactor.

Conclusion: These novel gene associations support differential mechanisms of HCV clearance between sexes and provide biologic targets for treatment or vaccine development.
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http://dx.doi.org/10.1093/infdis/jiaa677DOI Listing
October 2020

Multi-ancestry fine mapping of interferon lambda and the outcome of acute hepatitis C virus infection.

Genes Immun 2020 11 28;21(5):348-359. Epub 2020 Oct 28.

Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.

Clearance of acute infection with hepatitis C virus (HCV) is associated with the chr19q13.13 region containing the rs368234815 (TT/ΔG) polymorphism. We fine-mapped this region to detect possible causal variants that may contribute to HCV clearance. First, we performed sequencing of IFNL1-IFNL4 region in 64 individuals sampled according to rs368234815 genotype: TT/clearance (N = 16) and ΔG/persistent (N = 15) (genotype-outcome concordant) or TT/persistent (N = 19) and ΔG/clearance (N = 14) (discordant). 25 SNPs had a difference in counts of alternative allele >5 between clearance and persistence individuals. Then, we evaluated those markers in an association analysis of HCV clearance conditioning on rs368234815 in two groups of European (692 clearance/1 025 persistence) and African ancestry (320 clearance/1 515 persistence) individuals. 10/25 variants were associated (P < 0.05) in the conditioned analysis leaded by rs4803221 (P value = 4.9 × 10) and rs8099917 (P value = 5.5 × 10). In the European ancestry group, individuals with the haplotype rs368234815ΔG/rs4803221C were 1.7× more likely to clear than those with the rs368234815ΔG/rs4803221G haplotype (P value = 3.6 × 10). For another nearby SNP, the haplotype of rs368234815ΔG/rs8099917T was associated with HCV clearance compared to rs368234815ΔG/rs8099917G (OR: 1.6, P value = 1.8 × 10). We identified four possible causal variants: rs368234815, rs12982533, rs10612351 and rs4803221. Our results suggest a main signal of association represented by rs368234815, with contributions from rs4803221, and/or nearby SNPs including rs8099917.
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http://dx.doi.org/10.1038/s41435-020-00115-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657970PMC
November 2020

HIV Pre-Exposure Prophylaxis Prevention Awareness, Willingness, and Perceived Barriers among People Who Inject Drugs in Los Angeles and San Francisco, CA, 2016-2018.

Subst Use Misuse 2020 23;55(14):2409-2419. Epub 2020 Sep 23.

Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months ( = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed.
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http://dx.doi.org/10.1080/10826084.2020.1823419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665852PMC
September 2020

Overdose Education and Naloxone Distribution Within Syringe Service Programs - United States, 2019.

MMWR Morb Mortal Wkly Rep 2020 Aug 21;69(33):1117-1121. Epub 2020 Aug 21.

Syringe service programs (SSPs), which provide access to sterile syringes and other injection equipment and their safe disposal after use,* represent a highly successful human immunodeficiency virus (HIV) prevention intervention. SSPs are associated with a 58% reduction in the incidence of HIV infection among persons who inject drugs (1). In addition, SSPs have led efforts to prevent opioid overdose deaths by integrating evidence-based opioid overdose education and naloxone distribution (OEND) programs (2-4). OEND programs train laypersons to respond during overdose events and provide access to naloxone and directions for drug delivery (2-4). SSPs are ideal places for OEND because they provide culturally relevant services designed to reach persons at high risk for experiencing or observing an opioid overdose. A 2013 survey found that only 55% of SSPs in the United States had implemented OEND (5). To characterize current implementation of OEND among SSPs, and to describe the current reach (i.e., the ratio of persons who received naloxone per opioid overdose death and the ratio of naloxone doses distributed per opioid overdose death) of SSP-based OEND programs by U.S. Census division, a survey of known U.S. SSPs was conducted in 2019, which found that 94% of SSPs had implemented OEND. In addition, the reach of SSP-based OEND programs varied by U.S. Census division. Scaling up of SSP-based OEND delivery programs could be a critical component for areas of the country with high opioid overdose death rates and low reach.
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http://dx.doi.org/10.15585/mmwr.mm6933a2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439981PMC
August 2020

Evaluation of an Unsanctioned Safe Consumption Site in the United States.

N Engl J Med 2020 08 8;383(6):589-590. Epub 2020 Jul 8.

University of California, San Diego, San Diego, CA.

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http://dx.doi.org/10.1056/NEJMc2015435DOI Listing
August 2020

Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs.

Drug Alcohol Depend 2020 06 18;211:107932. Epub 2020 Mar 18.

Behavioral Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, 94704 CA, United States of America.

Objective: Opioid withdrawal symptoms are widely understood to contribute to health risk but have rarely been measured in community samples of opioid using people who inject drugs (PWID).

Methods: Using targeted sampling methods, 814 PWID who reported regular opioid use (at least 12 uses in the last 30 days) were recruited and interviewed about demographics, drug use, health risk, and withdrawal symptoms, frequency, and pain. Multivariable regression models were developed to examine factors associated with any opioid withdrawal, withdrawal frequency, pain severity, and two important health risks (receptive syringe sharing and non-fatal overdose).

Results: Opioid withdrawal symptoms were reported by 85 % of participants in the last 6 months, with 29 % reporting at least monthly withdrawal symptoms and 35 % reporting at least weekly withdrawal symptoms. Very or extremely painful symptoms were reported by 57 %. In separate models, we found any opioid withdrawal (adjusted odds ratio [AOR] = 2.75, 95 % confidence interval [CI] = 1.52, 5.00) and weekly or more opioid withdrawal frequency (AOR = 1.94; 95 % CI = 1.26, 3.00) (as compared to less than monthly) to be independently associated with receptive syringe sharing while controlling for confounders. Any opioid withdrawal (AOR = 1.71; 95 % CI = 1.04, 2.81) was independently associated with nonfatal overdose while controlling for confounders. In a separate model, weekly or more withdrawal frequency (AOR = 1.69; 95 % CI = 1.12, 2.55) and extreme or very painful withdrawal symptoms (AOR = 1.53; 95 % CI = 1.08, 2.16) were associated with nonfatal overdose as well.

Conclusions: Withdrawal symptoms among PWID increase health risk. Treatment of withdrawal symptoms is urgently needed and should include buprenorphine dispensing.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.107932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259345PMC
June 2020

Reasons for assisting with injection initiation: Results from a large survey of people who inject drugs in Los Angeles and San Francisco, California.

Drug Alcohol Depend 2020 04 5;209:107885. Epub 2020 Feb 5.

Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA.

Injection drug initiation usually requires assistance by someone who already injects drugs. To develop interventions that prevent people from starting to inject drugs, it is imperative to understand why people who inject drugs (PWID) assist with injection initiation.

Methods: Injection initiation history and motives for initiating others were collected from 978 PWID in Los Angeles and San Francisco, CA, from 2016-17. This article documents motivations for providing injection initiation assistance and examines demographic, economic, and health-related factors associated with these motivations using multivariable logistic regression modeling.

Results: Among the 405 PWID who ever facilitated injection initiation, motivations for initiating were: injury prevention (66%), skilled at injecting others (65%), to avoid being pestered (41%), in exchange for drugs/money (45%), and for food/shelter/transportation (15%). High frequency initiation (>5 lifetime injection initiations) was associated with all motivations except for being pestered. Initiation to prevent injury was associated with being female. Initiation due to pestering was associated with recycling income and sex work. Being skilled was associated with age and HIV status, while initiation for money or drugs was associated with age, race, education, social security income, and substance use treatment. Lastly, initiation for food, shelter, or transportation was associated with age, sexual orientation and education level.

Conclusion: Diverse factors were associated with reported motivations for assisting someone to initiate injection for the first time. Our analysis underscores the need for prevention strategies focused on improving economic and housing conditions along with implementing drug consumption rooms to disrupt the social processes of injection initiation.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.107885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127951PMC
April 2020

Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms.

J Acquir Immune Defic Syndr 2019 12;82 Suppl 3:S322-S331

Department of Epidemiology, University of Washington, Seattle, WA.

Background: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement.

Methods: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV.

Results: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW.

Discussion: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.
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http://dx.doi.org/10.1097/QAI.0000000000002220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880809PMC
December 2019

Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs.

Int J Drug Policy 2019 12 13;74:299-304. Epub 2019 Nov 13.

RTI-International, San Francisco, CA, United States.

Background: Over the last several years, fentanyl has been introduced into the illicit drug supply in the United States. While the impact of fentanyl on overdose fatalities is clear, the increase in fentanyl use may also be affecting drug use practices with implications for infectious disease transmission. We conducted a cross-sectional survey to explore associations of perceived illicit fentanyl use with opioid use frequency, injection frequency and syringe sharing among people who inject drugs in two California cities.

Methods: People who inject drugs (PWID) were recruited from community settings in Los Angeles and San Francisco, CA from June 2017 to September 2018. Multivariable logistic regression was used to explore adjusted associations between perceived illicit fentanyl use and high frequency opioid use, high frequency injection and syringe sharing.

Results: Among the 395 study participants, the median age of participants was 44 years; 74% of participants were cisgender male; 73% reported to be homeless; 61% lived in San Francisco and 39% in Los Angeles. The prevalence of perceived illicit fentanyl use in the past six months was 50.4% (95% confidence interval (CI): 45.4%-55.3%) among PWID. Findings from our adjusted logistic regression models suggested that people reporting perceived illicit fentanyl use had a greater odds of high frequency opioid use (adjusted odds ratio (aOR) = 2.36; 95% CI: 1.43-3.91; p = 0.001), high frequency injection (aOR = 1.84; 95% CI: 1.08-3.13; p = 0.03) and receptive syringe sharing (aOR = 2.16; 95% CI: 1.06-4.36; p = 0.03), as compared to people using heroin and other street drugs but not fentanyl.

Conclusion: People reporting perceived illicit fentanyl use were at increased risk for injection-related infectious disease risks. Actions must be taken to reduce these risks, including improved access to syringe service programs and opioid treatment and consideration of innovative approaches, such as supervised consumption services.
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http://dx.doi.org/10.1016/j.drugpo.2019.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6949008PMC
December 2019

Overdose Education and Naloxone Distribution in the San Francisco County Jail.

J Correct Health Care 2019 10 31;25(4):394-404. Epub 2019 Oct 31.

RTI International, San Francisco, CA, USA.

People leaving incarceration are at high risk of opioid-related overdose. Overdose fatalities are preventable with administration of naloxone. In response to this risk, overdose education and naloxone distribution (OEND) programs have been implemented in a handful of jails and prisons in the United States. We document the history, structure, and data from the San Francisco County Jail OEND program. During 4 years of operation, 637 people participated; 67% received naloxone upon release, of whom only 3.5% had been previously trained in community-based OEND programs. Of those who received naloxone, 32% reported reversing an overdose and 44% received refills from community-based programs after reentry. This confirms that implementation of OEND in criminal justice settings is feasible and reaches people who have not previously been trained as well as those willing to act as overdose responders.
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http://dx.doi.org/10.1177/1078345819882771DOI Listing
October 2019

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California.

Subst Use Misuse 2020 14;55(3):377-386. Epub 2019 Oct 14.

Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). : This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. A cross-sectional sample of PWID ( = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.
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http://dx.doi.org/10.1080/10826084.2019.1673420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002277PMC
October 2019

Initiating Persons into Injection Drug Use in Rural West Virginia, USA.

Subst Use Misuse 2020 8;55(2):337-344. Epub 2019 Oct 8.

Department of Health, Behavior, Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

: While prior research has explored factors associated with people who inject drugs (PWID) initiating others into drug injection in urban settings, very little work has been done to understand this behavior among rural PWID in Appalachia. : We aim to identify factors associated with PWID initiating injection-naïve individuals into drug injection in a rural community in West Virginia (WV). : Data were derived from a cross-sectional survey of 420 rural PWID (163 women) in Cabell County, WV in June-July 2018 who indicated recent (past 6 months) injection drug use. Individuals completed a survey that included measures on socio-demographics and injection socialization behaviors. We used logistic regression to identify factors associated with PWID recently initiating someone for their first injection. : A minority (17%) reported recently initiating someone for their first injection. In multivariable regression, recent injection initiation was independently associated with number of injections per day (adjusted odds ratio [aOR] 1.16; 95% confidence interval [CI]:1.07,1.25), recent injection in front of an injection-naïve person (aOR 2.75; 95% CI: 1.25,6.04), recent describing how to inject drugs to an injection-naïve person (aOR 5.83; 95% CI: 2.71,12.57), and recent encouragement of an injection-naïve person to inject (aOR 7.13; 95% CI: 2.31,21.87). : Injection initiation was independently associated with several injection socialization behaviors involving injection-naïve individuals. PWID who recently initiated injection-naïve individuals had higher odds of frequent injection. Educating rural PWID about how their behaviors can influence others and the importance of engaging in safe injection practices could carry significant public health utility.
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http://dx.doi.org/10.1080/10826084.2019.1669660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980648PMC
October 2020

Measures of harm reduction service provision for people who inject drugs.

Bull World Health Organ 2019 Sep 20;97(9):605-611. Epub 2019 Jun 20.

Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, 3004, Australia.

Coverage is an important dimension in measuring the effectiveness of needle and syringe programmes in providing sterile injecting equipment for people who inject drugs. The World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) currently recommend methods for measuring coverage at the population level, that is, across an estimated population of people who inject drugs within a given geographical area. However, population-level measures of coverage rely on highly uncertain population estimates and cannot capture the different levels of syringe acquisition and injecting episodes among individual users. Consequently, such measures only broadly evaluate the extent of programme service delivery, rather than describe how people who inject drugs as individuals and sub-groups interact with needle and syringe programmes. In response to these limitations, several researchers have proposed measuring coverage at the individual level, by the percentage of injecting episodes in relation to the number of sterile needles and syringes acquired. These measures evaluate coverage according to each individual's needs. Such measures provide enhanced information for planning and monitoring of harm reduction programmes and have now been used in multiple international research studies. We advise that WHO, UNODC and UNAIDS add individual-level coverage measurement methods to their international monitoring guidelines for harm reduction programmes. By doing this, more responsive and effective programmes can be created to better reduce injecting risk behaviours and blood-borne virus transmission among people who inject drugs.
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http://dx.doi.org/10.2471/BLT.18.224089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705510PMC
September 2019

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs.

Addiction 2019 12 2;114(12):2267-2278. Epub 2019 Aug 2.

University of Bristol, Bristol, UK.

Aims: To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States.

Design: HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective.

Setting: Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings.

Participants: PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies.

Interventions And Comparator: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID.

Measurements: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs).

Findings: For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis.

Conclusions: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.
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http://dx.doi.org/10.1111/add.14731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751348PMC
December 2019

Syringe disposal among people who inject drugs before and after the implementation of a syringe services program.

Drug Alcohol Depend 2019 09 29;202:13-17. Epub 2019 Jun 29.

Department of Medicine, University of Miami, 1120 NW 14thSt., Miami, FL, 33136, USA. Electronic address:

Introduction: Due to the increase in people who use opioids in the US, there has been a steady increase in injection drug use. Without access to safe syringe disposal locations, people who inject drugs (PWID) have few options other than improper disposal, including in public places. In 2016, Florida's first legal Syringe Services Program (SSP) was established in Miami. This study aims to compare syringe disposal practices among PWID before and after the implementation of an SSP.

Methods: Visual inspection walkthroughs of randomly selected census blocks in the neighborhoods in the top quartile of narcotics-related arrests were conducted to assess improperly discarded syringes. Syringe location was geocoded in ArcGIS. Adult PWID pre-SSP (n = 448) and post-SSP (n = 482) implementation were recruited for a survey using respondent-driven sampling in Miami. A Poisson regression model was used to determine the adjusted relative risk (aRR) of improper syringe disposal pre- and post-SSP.

Results: A total of 191 syringes/1000 blocks were found post-implementation versus 371/1000 blocks pre-implementation, representing a 49% decrease after SSP implementation. In the surveys, 70% reported any improper syringe disposal post-SSP implementation versus 97% pre-SSP implementation. PWID in the post-implementation survey had 39% lower adjusted relative risk (aRR = 0.613; 95% CI = 0.546, 0.689) of improper syringe disposal as compared to pre-implementation.

Conclusions: There was a significant decrease in the number of improperly discarded syringes in public in Miami after the implementation of an SSP. Providing PWID with proper disposal venues such as an SSP could decrease public disposal in other communities.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.04.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854527PMC
September 2019

Overdose Prevention Site Acceptability among Residents and Businesses Surrounding a Proposed Site in Philadelphia, USA.

J Urban Health 2019 06;96(3):341-352

Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market Street, Room 435, Philadelphia, PA, 19104, USA.

Overdose prevention sites (OPS) are places where people use previously obtained drugs under the supervision of a health professional. They have been proposed in six United States (US) cities, including Philadelphia, to help reduce opioid-related overdose deaths and public injection. Philadelphia has the highest overdose rate among large cities in the US, which has led a local community-based organization to plan the implementation of OPS. Kensington, a neighborhood with the highest drug mortality overdose rates in the city, is a likely site for the proposed OPS. Given the dearth of research systematically assessing public opinion towards OPS prior to implementation, we enrolled 360 residents and 79 business owners/staff in the Kensington neighborhood in a cross-sectional acceptability study. Face-to-face surveys assessed participant characteristics, experiences with drug-related social problems, and OPS acceptability. Using descriptive statistics, we estimated factors associated with favorability towards opening an OPS in the Kensington neighborhood. Ninety percent of residents were in favor of an OPS opening in Kensington. Support was significantly higher among unstably housed individuals and persons who currently use opioids. In the business sample, 63% of owners/staff were in favor of opening an OPS in Kensington. A greater proportion of Asian/Pacific Islanders, Hispanic/Latinx respondents, and non-Hispanic/Latinx Black respondents were in favor of an OPS opening in Kensington compared with white respondents (p < 0.04). While details about implementation are still being considered, results indicate general acceptability among Kensington residents and businesses for an OPS, especially if it can deliver benefits that curb drug-related social problems. Should an OPS be implemented in Philadelphia, it would be important to monitor changes in drug-related social problems and acceptability post implementation.
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http://dx.doi.org/10.1007/s11524-019-00364-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565835PMC
June 2019

Scaling Up Hepatitis C Prevention and Treatment Interventions for Achieving Elimination in the United States: A Rural and Urban Comparison.

Am J Epidemiol 2019 08;188(8):1539-1551

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.

In the United States, hepatitis C virus (HCV) transmission is rising among people who inject drugs (PWID). Many regions have insufficient prevention intervention coverage. Using modeling, we investigated the impact of scaling up prevention and treatment interventions on HCV transmission among PWID in Perry County, Kentucky, and San Francisco, California, where HCV seroprevalence among PWID is >50%. A greater proportion of PWID access medication-assisted treatment (MAT) or syringe service programs (SSP) in urban San Francisco (established community) than in rural Perry County (young, expanding community). We modeled the proportion of HCV-infected PWID needing HCV treatment annually to reduce HCV incidence by 90% by 2030, with and without MAT scale-up (50% coverage, both settings) and SSP scale-up (Perry County only) from 2017. With current MAT and SSP coverage during 2017-2030, HCV incidence would increase in Perry County (from 21.3 to 22.6 per 100 person-years) and decrease in San Francisco (from 12.9 to 11.9 per 100 person-years). With concurrent MAT and SSP scale-up, 5% per year of HCV-infected PWID would need HCV treatment in Perry County to achieve incidence targets-13% per year without MAT and SSP scale-up. In San Francisco, a similar proportion would need HCV treatment (10% per year) irrespective of MAT scale-up. Reaching the same impact by 2025 would require increases in treatment rates of 45%-82%. Achievable provision of HCV treatment, alongside MAT and SSP scale-up (Perry County) and MAT scale-up (San Francisco), could reduce HCV incidence.
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http://dx.doi.org/10.1093/aje/kwz097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415256PMC
August 2019

Factors Associated with Frequency of Recent Initiation of Others into Injection Drug Use Among People Who Inject Drugs in Los Angeles and San Francisco, CA, USA, 2016-17.

Subst Use Misuse 2019 3;54(10):1715-1724. Epub 2019 May 3.

d Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine , University of Southern California , Los Angeles , California , USA.

Drug injection initiation is often assisted by a person who injects drugs (PWID). How often PWID provide this assistance has not been examined. We examine frequency of injection initiation assistance and factors associated with high (4+) and low frequency (1-3) initiation assistance as compared to no initiation assistance among PWID. Participants were 979 Californian PWID. PWID were interviewed about providing injection initiation assistance in the last 6 months among other items. Multinomial regression analysis was used to examine factors associated with levels of frequency of injection initiation assistance. Among participants, 132 (14%) had initiated 784 people into injection (mean = 5.94 [standard deviation = 20.13]; median = 2, interquartile range = 1,4) in the last 6 months. PWID engaged in high frequency initiation (26% of sample) assisted 662 new initiates (84% of total). Using multinomial regression analysis with no initiating as the referent group, we found that high frequency initiating was statistically associated with higher injection frequency, having a paying sex partner, taking someone to a shooting gallery, and providing injection assistance. Lower frequency initiation was statistically associated with having a paying sex partner, illegal income source, and providing injection assistance. Differences between high and low frequency initiators were not found. Sex work and assisting with drug injection were linked to initiating others. Individual-level interventions that reduce this behavior among PWID and structural interventions such as safe consumption sites and opioid medication treatments that interrupt the social process of injection initiation should be considered as ways to reduce injection initiations.
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http://dx.doi.org/10.1080/10826084.2019.1608252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863088PMC
May 2020

Sexual Risk and Criminal Justice Involvement Among Women Who Use Drugs.

AIDS Behav 2019 Dec;23(12):3366-3374

Community Health and Implementation Research Program, RTI International, San Francisco, CA, USA.

Criminal justice system involvement among US women is associated with increased risk for HIV/sexually transmitted infections, yet effects of different forms of criminal justice involvement on intimate relationships are not well understood. This study examined associations between arrest, probation, and jail incarceration on the number of sexual partners, sexual concurrency, and consistent condom use for drug-using women (n = 631) in Oakland, California. We used logistic and negative binomial regression and adjusted for demographics, sex exchange and drug use. Probation was associated with higher rates of sexual partnership and concurrency (IRR 1.87, 95% CI [1.11, 3.15]; OR 3.64, 95% CI [1.08, 12.20]). Incarceration lasting over 12 weeks was associated with higher rates of sexual partnership (IRR 2.23, 95% CI [1.41, 3.51]). Women incarcerated once in the past year had higher odds of concurrency (OR 2.15, 95% CI [1.01, 4.57]). Our results reinforce the need for risk-reduction interventions and criminal justice diversion for women who use drugs.
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http://dx.doi.org/10.1007/s10461-019-02447-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739179PMC
December 2019

Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward.

Psychiatr Serv 2019 04 13;70(4):294-301. Epub 2019 Feb 13.

Department of Health Policy and Management (Kennedy-Hendricks, Bluestein, Barry), Center for Mental Health and Addiction Policy Research (Kennedy-Hendricks, Bluestein, Barry, Sherman), and Department of Health Behavior and Society (Sherman), all at Johns Hopkins Bloomberg School of Public Health, Baltimore; Behavioral Health and Criminal Justice Division, RTI International, San Francisco (Kral).

Objective: Safe consumption sites enable use of preobtained drugs in hygienic settings where trained staff are available to respond to overdoses and connect individuals with health and social services. This study examined efforts to advance policies to establish safe consumption sites in the United States, where no sanctioned sites exist.

Methods: Between April and July 2018, the authors conducted 25 telephone interviews with a purposive sample of key informants in five communities considering safe consumption site implementation. Participants included organizers and advocates, government officials, and personnel with social service and health organizations. Interview notes were analyzed by using hybrid inductive-deductive coding.

Results: Key strategies for organizing support for safe consumption sites included involving people who use drugs, engaging diverse partners, supporting allies in related causes, and using various tactics to garner support from policy makers. Major barriers to adoption included identifying the right locations, uncertainty about the federal response, mistrust arising from racial injustice in drug policy, and financing. Participants identified facilitators of progress toward safe consumption site adoption, such as building on existing harm reduction programs, securing political champions, and exposing community officials to programs operating internationally.

Conclusions: A window of opportunity may be opening to advance policy related to safe consumption sites; whether sanctioned sites become part of the broader policy strategy for addressing drug use and overdose in the United States will depend on the experiences of the first sites. Organizing around this issue may facilitate engagement among people who use drugs in broader conversations about drug policy.
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http://dx.doi.org/10.1176/appi.ps.201800398DOI Listing
April 2019

Multi-Ancestry Genome-Wide Association Study of Spontaneous Clearance of Hepatitis C Virus.

Gastroenterology 2019 Apr 26;156(5):1496-1507.e7. Epub 2018 Dec 26.

Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland. Electronic address:

Background & Aims: Spontaneous clearance of hepatitis C virus (HCV) occurs in approximately 30% of infected persons and less often in populations of African ancestry. Variants in major histocompatibility complex (MHC) and in interferon lambda genes are associated with spontaneous HCV clearance, but there have been few studies of these variants in persons of African ancestry. We performed a dense multi-ancestry genome-wide association study of spontaneous clearance of HCV, focusing on individuals of African ancestry.

Methods: We performed genotype analyses of 4423 people from 3 ancestry groups: 2201 persons of African ancestry (445 with HCV clearance and 1756 with HCV persistence), 1739 persons of European ancestry (701 with HCV clearance and 1036 with HCV persistence), and 486 multi-ancestry Hispanic persons (173 with HCV clearance and 313 with HCV persistence). Samples were genotyped using Illumina (San Diego, CA) arrays and statistically imputed to the 1000 Genomes Project. For each ancestry group, the association of single-nucleotide polymorphisms with HCV clearance was tested by log-additive analysis, and then a meta-analysis was performed.

Results: In the meta-analysis, significant associations with HCV clearance were confirmed at the interferon lambda gene locus IFNL4-IFNL3 (19q13.2) (P = 5.99 × 10) and the MHC locus 6p21.32 (P = 1.15 × 10). We also associated HCV clearance with polymorphisms in the G-protein-coupled receptor 158 gene (GPR158) at 10p12.1 (P = 1.80 × 10). These 3 loci had independent, additive effects of HCV clearance, and account for 6.8% and 5.9% of the variance of HCV clearance in persons of European and African ancestry, respectively. Persons of African or European ancestry carrying all 6 variants were 24-fold and 11-fold, respectively, more likely to clear HCV infection compared with individuals carrying none or 1 of the clearance-associated variants.

Conclusions: In a meta-analysis of data from 3 studies, we found variants in MHC genes, IFNL4-IFNL3, and GPR158 to increase odds of HCV clearance in patients of European and African ancestry. These findings could increase our understanding of immune response to and clearance of HCV infection.
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http://dx.doi.org/10.1053/j.gastro.2018.12.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788806PMC
April 2019

Peer-to-peer injection: Demographic, drug use, and injection-related risk factors.

Int J Drug Policy 2018 11 31;61:44-51. Epub 2018 Oct 31.

Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, 2001 N Soto St, 3rd floor, Los Angeles, CA 90033, United States. Electronic address:

Background: Peer-to-peer injection (either providing or receiving an injection to/from a person who injects drugs [PWID]) is common (19%-50%) among PWID. Most studies of peer-to-peer injection have focused on receiving injection assistance, with fewer examining providing injection assistance and none considering characteristics of PWID who do both. We examined characteristics of PWID by peer-to-peer injection categories (receiving, providing, both, and neither) and determined if these behaviors were associated with receptive and distributive syringe sharing.

Methods: Los Angeles and San Francisco PWID (N = 777) were recruited using targeted sampling methods and interviewed during 2011-2013. Multinomial logistic regression was used to determine characteristics associated with peer-to-peer injection categories and logistic regression was used to examine if peer-to-peer categories were independently associated with distributive and receptive syringe sharing.

Results: Recent peer-to-peer injection was reported by 42% of PWID (18% provider; 14% recipient; 10% both). In multinomial regression analysis, PWID reporting any peer-to-peer injection were more likely to inject with others than those who did neither. Injection providers and those who did both were associated with more frequent injection, illegal income source, and methamphetamine injection while injection recipients were associated with fewer years of injection. Injection providers were younger, had more years of injecting, and were more likely to inject heroin than PWID who did neither. In multivariate analyses, we found that providers and PWID who did both were significantly more likely to report receptive and distributive syringe sharing than PWID who did neither.

Conclusion: Peer-to-peer injection is associated with HIV/HCV risk. Current prevention strategies may not sufficiently address these behaviors. Modification of existing interventions and development of new interventions to better respond to peer-to-peer injection is urgently needed.
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http://dx.doi.org/10.1016/j.drugpo.2018.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7285620PMC
November 2018

Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States.

Int J Drug Policy 2019 01 3;63:122-128. Epub 2018 Oct 3.

Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States. Electronic address:

Background: In 2016, the number of overdose deaths involving illicitly-manufactured fentanyl (IMF) surpassed heroin and prescription opioid deaths in the United States for the first time, with IMF-involved overdose deaths increasing more than 500% across 10 states from 2013 to 2016. IMF is an extremely potent synthetic opioid that is regularly mixed with heroin and often sold to unwitting consumers. Community-based organizations have started to distribute fentanyl test strips (FTS) as a strategy to identify IMF in street purchased products. We investigated the association between FTS use and changes in drug use behavior and perceived overdose safety among a community-based sample of people who inject drugs (PWID) in the United States.

Methods: Between September-October 2017, a total of 125 PWID completed an online survey about their most recent FTS use in Greensboro, North Carolina. Our first outcome of interest included whether PWID engaged in any of the following changes in drug use behavior after using FTS: used less than usual, administered tester shot, pushed syringe plunger slower than usual, and snorted instead of injected. Our second outcome of interest was whether PWID felt that FTS use made them feel better able to protect themselves from overdose. We conducted bivariate and multivariate analyses to determine the association between FTS use and these two outcomes.

Results: Overall, 63% of the sample reported a positive FTS test result and 81% reported using FTS prior to consuming their drugs. For the outcomes, 43% reported a change in drug use behavior and 77% indicated increased perceived overdose safety by using FTS. In multivariable models adjusting for demographic and FTS correlates, PWID with a positive FTS test result had five times the odds of reporting changes in drug use behavior compared to those with a negative result. PWID who used the FTS after drug consumption were 70% less likely to report behavioral changes at subsequent drug consumption compared to those who used it before consumption. PWID who were not existing clients of the syringe services program had four times higher odds than existing clients to report increased overdose safety from using FTS.

Conclusions: We found that using FTS and receiving a positive test result was associated with changes in drug use behavior and perceptions of overdose safety. FTS may represent an effective addition to current overdose prevention efforts when included with other evidence-based strategies to prevent opioid overdose and related harm.
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http://dx.doi.org/10.1016/j.drugpo.2018.08.007DOI Listing
January 2019

Accumulation of Jail Incarceration and Hardship, Health Status, and Unmet Health Care Need Among Women Who Use Drugs.

Womens Health Issues 2018 Sep - Oct;28(5):470-475. Epub 2018 Jul 27.

RTI-International, San Francisco, California.

Background: Jail is frequently described as a "revolving door," which can be profoundly destabilizing to people moving in and out of the system. However, there is a dearth of research attempting to understand the impacts of the accumulation of incarceration events on women who use drugs. We examined the association of the frequency of jail incarceration with hardship, perceived health status, and unmet health care need among women who use drugs.

Methods: Our community-based sample included women who use heroin, methamphetamine, crack cocaine, and/or powder cocaine (N = 624) in Oakland, California, from 2012 to 2014. Poisson regression models with robust variances were built to estimate adjusted prevalence ratios between the frequency of jail incarcerations and measures of hardship, perceived health, and unmet health care need, adjusting for a set of a priori specified covariates.

Results: We observed associations between high levels of jail frequency and higher levels of homelessness (p = .024), feeling unsafe in their living situation (p = .011), stress (p = .047), fair to poor mental health (p = .034), unmet mental health care need (p = .037), and unmet physical health care need (p = .041). We did not observe an association between jail frequency and unmet subsistence needs score or fair to poor physical health.

Conclusions: We observed associations between higher levels of jail frequency and a higher prevalence of hardship, poor mental health, and unmet health care need. Our findings suggest areas for additional research to untangle the impacts of frequent incarceration on women's health and well-being.
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http://dx.doi.org/10.1016/j.whi.2018.05.005DOI Listing
November 2018