Asynchronous Video Directly Observed Therapy to Monitor Short-Course Latent Tuberculosis Infection Treatment: Results of a Randomized Controlled Trial.

Background: Observing medication ingestion through self-recorded videos (video directly observed therapy [VDOT]) has been shown to be a cost-effective alternative to in-person directly observed therapy (DOT) for monitoring adherence to treatment for tuberculosis disease. VDOT could be a useful tool to monitor short-course latent tuberculosis infection (LTBI) treatment. Methods: We conducted a prospective randomized controlled trial comparing VDOT (intervention) and clinic-based DOT (control) among patients newly diagnosed with LTBI who agreed to a once-weekly 3-month treatment regimen of isoniazid and rifapentine. Study outcomes were treatment completion and patient satisfaction. We also assessed costs. Pre- and posttreatment interviews were conducted. Results: Between March 2016 and December 2019, 130 participants were assigned to VDOT (n = 68) or DOT (n = 62). Treatment completion (73.5% vs 69.4%, P = .70) and satisfaction with treatment monitoring (92.1% vs 86.7%, P = .39) were slightly higher in the intervention group than the control group, but neither was statistically significant. VDOT cost less per patient (median, $230; range, $182-$393) vs DOT (median, $312; range, $246-$592) if participants used their own smartphone. Conclusions: While both groups reported high treatment satisfaction, VDOT was not associated with higher LTBI treatment completion. However, VDOT cost less than DOT. Volunteer bias might have reduced the observed effect since patients opposed to any treatment monitoring could have opted for alternative unobserved regimens. Given similar outcomes and lower cost, VDOT may be useful for treatment monitoring when in-person observation is prohibited or unavailable (eg, during a respiratory disease outbreak). The trial was registered at the National Institutes of Health (ClinicalTrials.gov NTC02641106). Clinical Trials Registration: ClinicalTrials.gov NTC02641106; registered 24 October 2016.

Impact of COVID-19 on tuberculosis detection and treatment in Baja California, México.

In 2020, Mexico reported the lowest tuberculosis (TB) incidence on record, and it is unclear to what extent COVID-19 has impacted TB surveillance, diagnosis, and treatment. It is important to understand COVID-19's impact in Baja California (BC), which has the highest TB burden in Mexico. With the increasing number of migrants and asylum seekers arriving in BC, limited resources and crowded living conditions increase the risk of TB transmission. The purpose of this study was to assess the impact of COVID-19 on TB diagnosis and treatment in BC. We were also interested in health disparities experienced by migrants in BC. We conducted a mixed methods analysis using quantitative surveillance data obtained from the Mexico National TB Program (NTP) and qualitative data collected through in-depth interviews and focus group discussions with TB program directors and personnel in BC's four provincial health jurisdictions. Compared to the year prior, surveillance data from March 2020 - February 2021 revealed that TB incidence in BC declined by 30.9% and favorable TB outcomes (TB cure or treatment completion) declined by 49.8%. Elucidating differences by migrant status was complicated by the lack of standardized collection of migrant status by the NTP. Qualitative analysis revealed that TB diagnostic and treatment supplies and services became limited and disproportionately accessible across jurisdictions since the pandemic began; however, favorable adaptations were also reported, such as increased telemedicine use and streamlined care referral processes. Participants shared that migrant status is susceptible to misclassification and that TB care is difficult due to the transitory nature of migrants. This study did not identify major differences in TB service delivery or access between migrants and non-migrants in BC; however, migrant status was frequently missing. COVID-19 has overwhelmed health systems worldwide, disrupting timely TB diagnostic and treatment services, and potentially caused underdiagnosis of TB in BC. TB programs in BC should quickly restore essential services that were disrupted by COVID-19 while identifying and preserving beneficial program adaptations, such as telemedicine and streamlined care referral processes. Improved methods for documenting migrant status of TB cases are also needed.

Prevalence and correlates of obstructive lung disease among people who inject drugs, San Diego, California.

BACKGROUND: Pulmonary tissue damage leading to obstructive lung disease (OLD) could result from intravenous administration of insoluble particles found in illicit drugs. This study described the prevalence and identified correlates of OLD among people who inject drugs (PWID). METHODS: In 2012-2016, a community-based cohort of PWID who had injected within the past month were enrolled in a study to assess HIV, hepatitis C virus (HCV) andMycobacterium tuberculosis (Mtb) infections and their related risk factors. Data were obtained through face-to-face interviews, serological testing and spirometry. Baseline data were used for a cross-sectional analysis of the prevalence and correlates of OLD, defined as FEV1/FVC < 0.7. Univariate and multivariable logistic regression were used to identify factors associated with OLD. RESULTS: Among 516 participants who had complete spirometry and interview results, the mean age was 43.3 years, 73.6 % were male, 9.5 % were Black, 91.1 % smoked cigarettes and 18.2 % had OLD. Few (9.6 %) PWID with OLD reported a previous diagnosis of COPD although many (44.7 %) reported related symptoms. Black race (AOR = 2.66, 95 %CI: 1.37, 5.17), pack-years smoked (AOR = 1.06/5 years, 95 %CI: 1.01, 1.12), and duration of injection drug use (AOR = 1.13, 95 %CI: 1.01, 1.27) were independently associated with OLD after controlling for age. CONCLUSIONS: The prevalence of OLD was high in this cohort and associated with Black race and cigarette smoking-known risk factors. In addition, OLD prevalence increased with greater duration of injection drug use, suggesting a link between cumulative exposure to injected insoluble particles and OLD. Further examination of these adulterants and lung pathology are needed.

Requiring smartphone ownership for mHealth interventions: who could be left out?

BACKGROUND: Mobile health (mHealth) interventions have the potential to improve health through patient education and provider engagement while increasing efficiency and lowering costs. This raises the question of whether disparities in access to mobile technology could accentuate disparities in mHealth mediated care. This study addresses whether programs planning to implement mHealth interventions risk creating or perpetuating health disparities based on inequalities in smartphone ownership. METHODS: Video Directly Observed Therapy (VDOT) is an mHealth intervention for monitoring tuberculosis (TB) treatment adherence through videos sent by patients to their healthcare provider using smartphones. We conducted secondary analyses of data from a single-arm trial of VDOT for TB treatment monitoring by San Diego, San Francisco, and New York City health departments. Baseline and follow-up treatment interviews were used to assess participant smartphone ownership, sociodemographics and TB treatment perceptions. Univariate and multivariable logistic regression analyses were used to identify correlates of smartphone ownership. RESULTS: Of the 151 participants enrolled, mean age was 41 years (range: 18-87 years) and 41.1% were female. Participants mostly identified as Asian (45.0%) or Hispanic/Latino (29.8%); 57.8% had at most a high school education. At baseline, 30.4% did not own a smartphone, which was similar across sites. Older participants (adjusted odds ratio [AOR] = 1.09 per year, 95% confidence interval [CI]: 1.05-1.12), males (AOR = 2.86, 95% CI: 1.04-7.86), participants having at most a high school education (AOR = 4.48, 95% CI: 1.57-12.80), and those with an annual income below $10,000 (AOR = 3.06, 95% CI: 1.19, 7.89) had higher odds of not owning a smartphone. CONCLUSIONS: Approximately one-third of TB patients in three large United States of America (USA) cities lacked smartphones prior to the study. Patients who were older, male, less educated, or had lower annual income were less likely to own smartphones and could be denied access to mHealth interventions if personal smartphone ownership is required.

Association of Self-Reported Abscess With High-Risk Injection-Related Behaviors Among Young Persons Who Inject Drugs.

Abscess is a common source of morbidity for people who inject drugs. We used data from the Study to Assess Hepatitis C Risk to measure prevalence of abscess and identify factors associated with the history of abscess. Of 541 participants, 388 (72%) were male and 149 (28%) were female. Almost half (n = 258, 48%) reported ever having an abscess. Persons who inject drugs with an abscess history were significantly more likely to have more injection partners (p = .01), inject heroin daily (p < .05), and share cookers (p = .001) and less likely to report using new syringes with each injection (p = .02). Most reported self-treating their last abscess and increasing drug use when having an abscess. High-risk injection-related activity was associated not only with infections such as HIV and hepatitis C virus but also with abscess. Nurses should screen patients presenting with abscess for high-risk practices and provide prevention education.

Change in Patient Comfort Using Mobile Phones Following the Use of an App to Monitor Tuberculosis Treatment Adherence: Longitudinal Study.

BACKGROUND: As mHealth apps proliferate, it is necessary for patients to feel capable and comfortable using devices that run them. However, limited research is available on changes in comfort level before and after the use of an mHealth app. OBJECTIVE: The objective of this study was to determine whether patients with tuberculosis who used an mHealth app called Video Directly Observed Therapy (VDOT) to monitor their antituberculosis treatment became more comfortable using mobile phones after the intervention and to identify factors associated with change in comfort. METHODS: We analyzed data from a longitudinal study assessing the feasibility and acceptability of the VDOT app among patients receiving antituberculosis treatment from public health departments in San Diego, San Francisco, and New York City. Comfort levels on six domains of mobile phone use (making phone calls, taking pictures, recording videos, text messaging, internet and email use on the phone) were measured on a 10-point scale (1=very uncomfortable; 10=very comfortable) at the start and end of treatment using VDOT via telephone interviews. The main outcomes were change in comfort level on each domain (recoded as binary measures) and an overall change score (sum of individual measures). Linear and logistic regression analyses were performed to assess whether sociodemographics, risk factors, and VDOT perceptions were associated with change of comfort measures. RESULTS: Among 120 participants with complete data, mean age was 39.8 years (SD 14.8, range 18-87 years), 46.7% (56/120) were female, and 76.7% (92/120) were foreign born. The combined comfort level at baseline was high overall (mean 48.8, SD 14.2, interquartile range 43.0-60.0) and the mean comfort score increased by 1.92 points at follow-up (P=.07). Statistically significant increases in comfort on individual domains included taking pictures (P=.02) and recording videos (P=.002). Females were more likely to have increased comfort in using the internet on the phone compared to males (odds ratio [OR] 3.03, 95% CI 1.08-8.52, P=.04). Participants who worked less hours per week were more likely to have increased comfort recording videos although this did not meet statistical significance (OR 1.03, 95% CI 1.00-1.05, P=.06). CONCLUSIONS: Findings suggest that, despite a high level of comfort using mobile phones at baseline, experience using the VDOT app was associated with increased comfort using mobile phone features. Additional research involving participants with lower baseline mobile phone experience is needed. An implication of these findings is that as patients begin to use mHealth apps for one health condition, they could acquire skills and confidence to more quickly adapt to using mHealth apps for other conditions.

Tuberculosis Treatment Monitoring by Video Directly Observed Therapy in 5 Health Districts, California, USA.

We assessed video directly observed therapy (VDOT) for monitoring tuberculosis treatment in 5 health districts in California, USA, to compare adherence between 174 patients using VDOT and 159 patients using in-person directly observed therapy (DOT). Multivariable linear regression analyses identified participant-reported sociodemographics, risk behaviors, and treatment experience associated with adherence. Median participant age was 44 (range 18-87) years; 61% of participants were male. Median fraction of expected doses observed (FEDO) among VDOT participants was higher (93.0% [interquartile range (IQR) 83.4%-97.1%]) than among patients receiving DOT (66.4% [IQR 55.1%-89.3%]). Most participants (96%) would recommend VDOT to others; 90% preferred VDOT over DOT. Lower FEDO was independently associated with US or Mexico birth, shorter VDOT duration, finding VDOT difficult, frequently taking medications while away from home, and having video-recording problems (p<0.05). VDOT cost 32% (range 6%-46%) less than DOT. VDOT was feasible, acceptable, and achieved high adherence at lower cost than DOT.

Identification of a Syndemic of Blood-Borne Disease Transmission and Injection Drug Use Initiation at the US-Mexico Border.

BACKGROUND: Efforts to prevent injection drug use (IDU) are increasingly focused on the role that people who inject drugs (PWID) play in the assistance with injection initiation. We studied the association between recent (ie, past 6 months) injection-related HIV risk behaviors and injection initiation assistance into IDU among PWID in the US-Mexico border region. SETTING: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multicohort study assessing social and structural factors related to injection initiation assistance. This analysis included data collected since 2014 from 2 participating cohorts in San Diego and Tijuana. METHODS: Participants were 18 years and older and reported IDU within the month before study enrollment. Logistic regression analyses were conducted to assess the association between recent injection-related HIV risk behaviors (eg, distributive/receptive syringe sharing, dividing drugs in a syringe, and paraphernalia sharing) and recent injection initiation assistance. RESULTS: Among 892 participants, 41 (4.6%) reported recently providing injection initiation assistance. In multivariable analysis adjusting for potential confounders, reporting a higher number of injection-related risk behaviors was associated with an increased odds of recently assisting others with injection initiation (adjusted odds ratio per risk behavior: 1.3; 95% confidence interval: 1.0 to 1.6, P = 0.04). CONCLUSIONS: PWID who recently engaged in one or more injection-related HIV risk behavior were more likely to assist others in injection initiation. These results stress the syndemic of injection initiation and risk behaviors, which indicates that prevention of injection-related HIV risk behaviors might also reduce the incidence of injection initiation.

A fragmented code: The moral and structural context for providing assistance with injection drug use initiation in San Diego, USA.

BACKGROUND: Injection drug use initiation is shaped by social networks and structural contexts, with people who inject drugs often assisting in this process. We sought to explore the norms and contexts linked to assisting others to initiate injection drug use in San Diego, USA, to inform the development of structural interventions to prevent this phenomenon. METHODS: We undertook qualitative interviews with a purposive sample of people who inject drugs and had reported assisting others to initiate injection (n = 17) and a sub-sample of people who inject drugs (n = 4) who had not reported initiating others to triangulate accounts. We analyzed data thematically and abductively. RESULTS: Respondents' accounts of providing initiation assistance were consistent with themes and motives reported in other contexts: of seeking to reduce harm to the 'initiate', responding to requests for help, fostering pleasure, accessing resources, and claims that initiation assistance was unintentional. We developed analysis of these themes to explore initiation assistance as governed by a 'moral code'. We delineate a fragmented moral code which includes a range of meanings and social contexts that shape initiation assistance. We also show how assistance is happening within a structural context that limits discussion of injection drug use, reflecting a prevailing silence on drug use linked to stigma and criminalization. CONCLUSIONS: In San Diego, the assistance of others to initiate injection drug use is governed by a fragmented moral code situated within particular social norms and contexts. Interventions that address the social and structural conditions shaped by and shaping this code may be beneficial, in tandem with efforts to support safe injection and the reduction of injection-related harms.

History of medication-assisted treatment and its association with initiating others into injection drug use in San Diego, CA.

BACKGROUND: Medication-assisted treatment (MAT) remains the gold standard for the treatment of opioid use disorder. MAT also reduces the frequency of injecting among people who inject drugs (PWID). Relatedly, data suggest that PWID play a key role in the initiation of others into drug injecting by exposing injecting practices to injection-naïve drug users. Our primary objective was to test whether a history of MAT enrollment is associated with a reduced odds of PWID providing injection initiation assistance. METHODS: Preventing Injecting by Modifying Existing Responses (PRIMER; NIDA DP2-DA040256-01), is a multi-site cohort study assessing the impact of socio-structural factors on the risk that PWID provide injection initiation assistance. Data were drawn from a participating cohort of PWID in San Diego, CA. The primary outcome was reporting ever providing injection initiation assistance; the primary predictor was reporting ever being enrolled in MAT. Logistic regression was used to model associations between MAT enrollment and ever initiating others into injecting while adjusting for potential confounders. RESULTS: Participants (n = 354) were predominantly male (n = 249, 70%). Thirty-eight percent (n = 135) of participants reported ever initiating others into injection drug use. In multivariate analysis, participants who reported a history of MAT enrollment had significantly decreased odds of ever providing injection initiation assistance (Adjusted Odds Ratio [AOR]: 0.62, 95% Confidence Interval [CI]: 0.39-0.99). CONCLUSIONS: These preliminary findings suggest an association between MAT enrollment and a lower odds that male PWID report providing injection initiation assistance to injection-naïve drug users. Further research is needed to identify the pathways by which MAT enrollment may impact the risk that PWID initiate others into drug injecting.

Cross-border injection drug use and HIV and hepatitis C virus seropositivity among people who inject drugs in San Diego, California.

BACKGROUND: The prevalence of HIV and Hepatitis C Virus (HCV) are significantly lower among people who inject drugs (PWID) in San Diego, CA, USA compared with PWID in Tijuana, Mexico, located directly across the border. We investigated associations between cross-border injection drug use (IDU), HIV and HCV seroprevalence and engagement in injecting risk behaviours while on each side of the border. METHODS: Using baseline interviews and serologic testing data from STAHR II, a longitudinal cohort study of PWID in San Diego, bivariate and multivariable logistic regression analyses examined associations between recent (past six months) cross-border IDU and HIV and HCV antibody seropositivity, socio-demographics, drug use characteristics, and participants' connections to, and perceptions about Mexico. Chi-squared tests and McNemar tests examined associations between cross-border IDU and injecting risk behaviours. RESULTS: Of the 567 participants (93% U.S.-born, 73% male, median age 45 years), 86 (15%) reported recent cross-border IDU. Cross-border IDU was not associated with HIV (OR: 0.85, 95% CI: 0.37-1.95) or HCV seropositivity (OR: 1.01, 95% CI: 0.62-1.65). Age, identifying as Hispanic or Latino/a, and being concerned about risk of violence when travelling to Mexico were independently associated with decreased odds of recent cross-border IDU. Injecting cocaine at least weekly, having ever lived in Mexico and knowing PWID who reside in Mexico were associated with increased odds of recent cross-border IDU. PWID who reported cross-border IDU were significantly less likely to engage in receptive needle sharing, equipment sharing, and public injection while in Mexico compared with in San Diego (all p<0.001). CONCLUSION: Prevalence of HIV and HCV infection was similar among PWID who had and had not injected in Mexico, possibly due to practising safer injecting while in Mexico. Research is needed to elucidate contextual factors enabling U.S. PWID to inject safely while in Mexico.

Cold Preparation of Heroin in a Black Tar Market.

BACKGROUND: Black tar heroin is typically prepared for injection with heat which decreases the risk of HIV transmission by inactivating the virus. We received reports that persons who inject drugs (PWID) in Tijuana, Baja California, Mexico, a black tar heroin market, were using only water to dissolve heroin. OBJECTIVES: Because Tijuana abuts San Diego County, CA, United States, we undertook the present analyses to determine the prevalence of this practice among PWID in San Diego, California. METHODS: PWID completed quarterly behavioral assessments and serological testing for blood-borne viruses. Bivariate and multivariable logistic regression models were constructed to assess for individual, social, and structural correlates of preparing heroin without heat within the preceding 6 months. RESULTS: Nearly half of black tar heroin users (149/305) reported they had prepared heroin without heat within 6 months. In multivariable analysis, cold preparation was independently associated with younger age (10 year decrease; AOR = 1.25; 95% CI 1.03, 1.53), more drug injecting acquaintances (per 5 acquaintance increase; AOR = 1.05; 95% CI 1.01, 1.09) and prefilled syringe use (injecting drugs from syringes that are already filled with drugs before purchase; AOR = 1.86; 95% CI 1.14, 3.02). Conclusions/Importance: To our knowledge, this is the first paper to report that PWID living in a black tar heroin market are preparing heroin without heat. Additional research is needed to determine whether this is an endemic practice or PWID are engaging in new forms of drug preparation in response to changes in the environment.

Comparison of Three Popular Methods for Recruiting Young Persons Who Inject Drugs for Interventional Studies.

Persons who inject drugs (PWID) are at risk for adverse health outcomes as a result of their drug use, and the resulting social stigma makes this a difficult population to reach for interventions aimed at reducing morbidity and mortality. During our study of adult PWID aged ≤40 years living in San Diego during 2009 and 2010, we compared three different sampling methods: respondent-driven sampling (RDS), venue-based sampling at one syringe exchange program (SEP), and street-based outreach. We compared demographic, socioeconomic, health, and behavioral factors and tested participants for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) and compared across the three methods. Overall, 561 (74.8%) of the targeted 750 PWID were enrolled. Venue-based convenience sampling enrolled 96% (242/250) of the targeted participants, followed closely by street-based outreach with 92% (232/250) recruited. While RDS yielded the fewest recruits, producing only 35% (87/250) of the expected participants, those recruited through RDS were more likely to be female, more racially diverse, and younger.

Differential experiences of Mexican policing by people who inject drugs residing in Tijuana and San Diego.

BACKGROUND: Research among people who inject drugs (PWIDs) in the USA and Mexico has identified a range of adverse health impacts associated with policing of PWIDs. We employed a mixed methods design to investigate how PWIDs from San Diego and Mexico experienced policing in Tijuana, and how these interactions affect PWIDs behavior, stratifying by country of origin. METHODS: In 2012-2014, 575 PWIDs in San Diego, 102 of whom had used drugs in Mexico in the past six months, were enrolled in the STAHR-II study, with qualitative interviews conducted with a subsample of 20 who had recently injected drugs in Mexico. During this period, 735 PWIDs in Tijuana were also enrolled in the El Cuete-IV study, with qualitative interviews conducted with a subsample of 20 recently stopped by police. We calculated descriptive statistics for quantitative variables and conducted thematic analysis of qualitative transcripts. Integration of these data involved comparing frequencies across cohorts and using qualitative themes to explain and explore findings. RESULTS: Sixty-one percent of San Diego-based participants had been recently stopped by law enforcement officers (LEOs) in Mexico; 53% reported it was somewhat or very likely that they would be arrested while in Mexico because they look like a drug user. Ninety percent of Tijuana-based participants had been recently stopped by LEOs; 84% reported it was somewhat or very likely they could get arrested because they look like a drug user. Participants in both cohorts described bribery and targeting by LEOs in Mexico. However, most San Diego-based participants described compliance with bribery as a safeguard against arrest and detention, with mistreatment being rare. Tijuana-based participants described being routinely targeted by LEOs, were frequently detained, and reported instances of sexual and physical violence. Tijuana-based participants described modifying how, where, and with whom they injected drugs in response; and experienced feelings of stress, anxiety, and powerlessness. This was less common among San Diego-based participants, who mostly attempted to avoid contact with LEOs in Mexico while engaging in risky injection behavior. CONCLUSION: Experiences of discrimination and stigma were reported by a larger proportion of PWIDs living in Mexico, suggesting that they may be subject to greater health harms related to policing practices compared with those residing in the USA. Our findings reinforce the importance of efforts to curb abuse and align policing practices with public health goals in both the US and Mexico.

Factors associated with patterns of mobile technology use among persons who inject drugs.

BACKGROUND: New and innovative methods of delivering interventions are needed to further reduce risky behaviors and increase overall health among persons who inject drugs (PWID). Mobile health (mHealth) interventions have potential for reaching PWID; however, little is known about mobile technology use (MTU) in this population. In this study, the authors identify patterns of MTU and identified factors associated with MTU among a cohort of PWID. METHODS: Data were collected through a longitudinal cohort study examining drug use, risk behaviors, and health status among PWID in San Diego, California. Latent class analysis (LCA) was used to define patterns of MTU (i.e., making voice calls, text messaging, and mobile Internet access). Multinomial logistic regression was then used to identify demographic characteristics, risk behaviors, and health indicators associated with mobile technology use class. RESULTS: In LCA, a 4-class solution fit the data best. Class 1 was defined by low MTU (22%, n = 100); class 2, by PWID who accessed the Internet using a mobile device but did not use voice or text messaging (20%, n = 95); class 3, by primarily voice, text, and connected Internet use (17%, n = 91); and class 4, by high MTU (41%, n = 175). Compared with low MTU, high MTU class members were more likely to be younger, have higher socioeconomic status, sell drugs, and inject methamphetamine daily. CONCLUSION: The majority of PWID in San Diego use mobile technology for voice, text, and/or Internet access, indicating that rapid uptake of mHealth interventions may be possible in this population. However, low ownership and use of mobile technology among older and/or homeless individuals will need to be considered when implementing mHealth interventions among PWID.

Prevalence and Correlates of the Use of Prefilled Syringes Among Persons Who Inject Drugs in San Diego, CA.

Persons who inject drugs (PWID) are at increased risk for blood-borne virus (BBV) infections and overdose resulting from high-risk injecting practices. Studies of prefilled syringe use ([PFSU] using a syringe that already contained drug solution when it was obtained by the user), an injection practice previously described in Eastern Europe, suggest that it increases susceptibility to BBV. However, little is known about this practice in the USA. Data were obtained from an ongoing cohort study of PWID to determine the prevalence and assess correlates of PFSU in San Diego, CA. Baseline interviews assessed socio-demographics and drug use behaviors. Logistic regression was used to identify factors independently associated with ever using a prefilled syringe (yes/no). Participants (n = 574) were predominately males (73.9%) and white (50.9%) with a mean age of 43.4 years (range 18-80); 33.3% reported ever using prefilled syringes, although only 4.9% reported use in the past 6 months. In multivariable analyses, PFSU was independently associated with ever having a rushed injection due to police presence [adjusted odds ratio (AOR) = 2.51, 95% CI 1.66, 3.79], ever being in prison (AOR = 1.80, 95% CI 1.23, 2.63), injecting most often in public versus private places in the past 6 months (AOR = 1.66, 95% CI 1.11, 2.48), and injecting drugs in Mexico (AOR = 1.70, 95% CI 1.16, 2.49). Results indicate that a history of PFSU is common and associated with environmental factors that may also increase risk for adverse health outcomes. Studies are needed to better understand PFSU in order to develop interventions to prevent adverse outcomes associated with their use.

Effect of legal status of pharmacy syringe sales on syringe purchases by persons who inject drugs in San Francisco and San Diego, CA.

BACKGROUND: Sharing blood-contaminated syringes is the main risk factor for acquiring and transmitting blood-borne infections among persons who inject drugs (PWID). To reduce this risk, in 2005, California enacted legislation allowing local health jurisdictions to legalize non-prescription syringe sales after approving a disease prevention demonstration project (DPDP). With San Francisco approving a DPDP immediately and San Diego never approving one, we compared PWID across cities for their use of pharmacies PWID to obtain syringes. METHODS: PWID age 18-30 years old were recruited into separate studies in San Francisco (n=243) and San Diego (n=338) between 2008 and 2011. We used multivariable logistic regression to compare the proportions of PWID who obtained syringes from pharmacies by city while controlling for sociodemographics, injection practices and other risk behaviors. RESULTS: Overall, most PWID were White (71%), male (63%), and between the ages of 18-25 years (55%). Compared to San Francisco, a smaller proportion of PWID in San Diego had bought syringes from pharmacies in the prior three months (16.9% vs. 49.8%; p<0.001), which remained statistically significant after adjusting for sociodemographic and behavioral factors (adjusted odds ratio=4.45, 95% confidence interval: 2.98, 6.65). CONCLUSIONS: Use of pharmacies to obtain syringes was greater where it was legal to do so. Public health policy can influence HIV and hepatitis C associated risk among PWID; however, implementation of these policies is crucial for the benefits to be realized.

Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention.

BACKGROUND: Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs. METHODS: 573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues - the health care and criminal justice systems - that could serve as potential venues for OEND programs. RESULTS: Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07, 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37, 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months. CONCLUSIONS: Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.

Hepatitis A and B among young persons who inject drugs--vaccination, past, and present infection.

BACKGROUND: Our study aims were to assess hepatitis A virus (HAV) and hepatitis B virus (HBV) susceptibility and infection among young persons who inject drugs (PWID) who may have been vaccinated as children and to evaluate self-report of HAV and HBV vaccination. METHODS: We recruited PWID aged 18-40 years-old in San Diego during 2009 and 2010 and collected demographic, socioeconomic, health, and behavioral factors. Participants were asked if they had been vaccinated against HAV and HBV, and serum samples were collected for HAV and HBV serologic testing. RESULTS: Of 519 participants, 365 (72%) were male, 252 (49%) were white non-Hispanic, 38 (7%) were Black non-Hispanic, 138 (27%) were White Hispanic, and 22 (4%) were born outside the U. S. Of the total participants, 245 (47%) had surface hepatitis B antibody (anti-HBs) titers <10mIU/ml (i.e., HBV susceptible) and 325 (63%) had no detectable HAV antibodies (HAV susceptible). Hepatitis B surface antigen was detected in 7 (1%) of total participants; and 135 (26%) were anti-HCV-antibody positive. Compared to serologic findings, self-report of HBV and HAV vaccination was 71% and 41% sensitive, and 58% and 73% specific, respectively. CONCLUSION: HAV and HBV antibodies in half or more of this young PWID population did not have levels indicative of protection, and about a quarter had HCV infection, putting them at risk for complications resulting from co-infection with HAV or HBV. Programs serving this population should vaccinate PWIDs against HAV and HBV and not rely on self-report of vaccination.

Patterns of drug use, risky behavior, and health status among persons who inject drugs living in San Diego, California: a latent class analysis.

BACKGROUND: Among persons who inject drugs (PWID), polydrug use (the practice of mixing multiple drugs/alcohol sequentially or simultaneously) increases risk for HIV transmission and unintentional overdose deaths. Research has shown local drug markets influence drug use practices. However, little is known about the impact of drug mixing in markets dominated by black tar heroin and methamphetamine, such as the western United States. METHODS: Data were collected through an ongoing longitudinal study examining drug use, risk behavior, and health status among PWID. Latent class analysis (LCA) was used to identify patterns of substance use (heroin, methamphetamine, prescription drugs, alcohol, and marijuana) via multiple administration routes (injecting, smoking, and swallowing). Logistic regression was used to identify behaviors and health indicators associated with drug use class. RESULTS: The sample included 511 mostly white (51.5%) males (73.8%), with mean age of 43.5 years. Two distinct classes of drug users predominated: methamphetamine by multiple routes (51%) and heroin by injection (49%). In multivariable logistic regression, class membership was associated with age, race, and housing status. PWID who were HIV-seropositive and reported prior sexually transmitted infections had increased odds of belonging to the methamphetamine class. Those who were HCV positive and reported previous opioid overdose had an increased odds of being in the primarily heroin injection class (all P-values < .05). CONCLUSION: Risk behaviors and health outcomes differed between PWID who primarily inject heroin vs. those who use methamphetamine. The findings suggest that in a region where PWID mainly use black tar heroin or methamphetamine, interventions tailored to sub-populations of PWID could improve effectiveness.