Hepatitis C infection (HCV) continues to disproportionately affect Hispanics/Latinos in the United States. Hispanic/Latino intravenous drug users (IDUs), because of their risky injection and sexual behaviors, are prone to HCV infection and rapid transmission of the virus to others via several routes. With a prevalence rate of approximately 75% among IDUs, it is imperative that transmission of HCV be prevented in this population. This study aims to examine the associations between demographic, injection and sexual risk factors to HCV infection in a group Hispanic/Latino IDUs in Miami-Dade County, Florida. Preliminary unadjusted results in this sample reveal that age (OR=4.592, p=0.004), weekly injection (OR=5.171, p=0.000), daily injection frequency (OR=3.856, p=0.000) and use of a dirty needle (OR=2.320, p= 0.006) were all significantly associated with HCV infection. Being born outside the U.S. was significantly negatively associated with HCV infection (OR=0.349, p=0.004). Additionally, having two or more sex partners in the past three months (OR=0.472, p=0.014) was negatively associated with HCV infection. After adjusting for all other variables, older age (AOR=7.470, p=0.006), weekly injection (AOR=3.238, p=0.007) and daily injection frequency (AOR=2.625, p=0.010) were all significantly associated with HCV infection. Being born outside the U.S. (AOR=0.369, p=0.019) was a significant protective factor for HCV infection, along with having two or more sex partners in the past three months (AOR=0.481, p=0.037). When analyzing the significant variables in a backward regression model, having 2 or more sex partners in the past three months was not significant at the p

Background: Approximately 170 million persons are infected with the hepatitis C viral infection (HCV), globally. Of this number, 3.2 – 4 million persons in the U. S. are infected with HCV. Although previous research has indicated a decrease in the rates of Hepatitis C in the U.S. approximately 12,000 deaths occur annually from those who suffer from chronic liver disease, as a result of being chronic carriers of HCV. Being a recipient of blood transfusions prior to 1992, intravenous drug users (IDUs), or persons with multiple sex partners are associated with increased risk for HCV infection. IDUs constitute the largest cohort for those infected with HCV. Due to the few clinical manifestations HIV and HCV share and HIV patients living longer due to Highly Active Antiretroviral Therapy (HAART), Many individuals infected with HIV are discovering co-morbidities with HCV. Methods: Secondary Data from the State Electronic Notifiable Disease Surveillance System (SENDSS) were used to analyze all confirmed cases of hepatitis C in the state of Georgia for the year 2009. All subjects in this analysis were confirmed as Hepatitis C infected. Descriptive frequencies for all categorical data were tested and analyzed, which included: gender, race, geographic region, disease status, age distribution, risk factor data such as injection drug use, blood transfusion prior to 1992, long term hemodialysis, accidental needle stick, tattoo, sexual contacts, and incarceration. Binary logistic regression for univariate and multivariate analysis was used to test the associations between geographic region of all HCV cases and their demographic characteristics. Results: Descriptive analysis of the prevalence of HCV cases in Georgia in 2009 reveal higher rates of HCV in rural regions (GOA) of the state among White males of non-Hispanic origin. In this same region, these cases were more likely to report risk factors involving injection drug use, blood transfusions prior to 1992, incarceration, or tattoos. Prevalence of most cases of HCV in Georgia for the year 2009 are seen in those age 20 – 30 and those 40 – 60. A higher number of those reporting intravenous drug use in metropolitan Atlanta (MSA) are Black of non-Hispanic origin. Bivariate logistic regression reveals that White Non-Hispanics living in rural areas of Georgia (GOA) have a 3.48 higher odds of being infected with Hepatitis C than Black Non-Hispanics (OR = 3.48, p < 0.001, CI 2.54 – 4.77). Conclusion: Resources for prevention of Hepatitis C should be directed to marginalized communities within Georgia regions outside of the Atlanta Metropolitan Statistical Area. The primary focus of prevention should also be tailored to new initiates of intravenous drug use and those 20 – 30 and 40 – 60 years of age. Further knowledge and understanding of behaviors that put individuals at risk for acquiring Hepatitis C, such as intravenous drug use, in rural Georgia may warrant interventions tailored to benefit these communities from acquiring or spreading Hepatitis C.

The goal of this research is to analyze the stigmatization of opioid addiction within the framework of emergency care from an ethnographic perspective. Interviews with those who have been swept up in the current opioid epidemic indicate that stigma, or a shame or dishonor, and socioeconomic insecurity emerge often as common themes in their emergency care experiences. In many cases, socioeconomic insecurity most intensely translates into a lack of access to healthcare and emergency rooms across the country often function as primary care for uninsured populations. The central field site selected for this study was the emergency department of an urban trauma-level research hospital in an attempt to document the process of care for those in opioid crisis and the challenges healthcare providers face in facilitating this care. The aim of this research is to discover how stigma affects care in emergency room settings during an acute opioid crisis. This is a moment when patients may be most open to the idea of detoxification and sobriety. In this study, I argue that addiction can be shifted from being viewed as a disgraceful state to a medical condition, by uncovering what experiences overdose victims have while under emergency care, how patients experience stigma related to their opioid crisis, and what challenges healthcare providers describe while facilitating care during crisis. Findings suggest that stigma permeates the interactions drug-addicted patients have with healthcare professionals and that it may have a negative impact on their decision to seek further treatment. Application of results in the form of a community resource guide made available to patients and hospital staff indicate the potential for reducing stigma of intravenous/opioid-related addiction as healthcare providers are more able to discern gaps in care for addicted patients and facilitate greater follow-up care and access to resources. This thesis illustrates the potential for qualitative analysis of acute care to uncover vital next steps in reducing the stigma surrounding opioid addiction. Reducing stigma in the provision of care could foster more integrative approaches to treatment, help inform new protocols for caregivers, uncover resources to aid healthcare providers, and potentially provide a more substantial level of care and access to resources for the patient in crisis—one that may facilitate recovery in lieu of relapse.

There are two previous reports of Candida dubliniensis endophthalmitis in North America. Here, we report a third case of C. dubliniensis endogenous endophthalmitis in a 31-year-old male patient who complained of left-sided decreased visual acuity. He had an associated mitral and tricuspid valve endocarditis, in the setting of intravenous drug use. Blood and sputum cultures were positive for C. dubliniensis. Fundoscopic examination was consistent with a fungal endophthalmitis. He was treated with fluconazole followed by intravenous liposomal amphotericin B for 6 weeks. C. dubliniensis is an important but rare cause of endophthalmitis in intravenous drug abusers.

Background: Drug use is a public health problem associated with increased mortality, morbidity and lack of contact with healthcare. Stigmatization and discrimination surround drug use. Harm reduction aims to improve health without coercive measures to become drug-free in collaboration with people who inject drugs. Harm reduction is evidence-based, cost-effective and reduces the spread of infectious diseases. Needle exchanges provide information about drug-related risks and offer protection against this.  Aim: The aim was to describe experiences of harm reduction in needle exchanges in people who inject drugs.  Method: A qualitative literature study was carried out according to Polit and Beck's nine-step model. 11 articles were included and analyzed thematically according to the model of Braun and Clarke.  Results: The main finding is that people who inject drugs experience that needle exchanges offer knowledge and enable harm reduction. Needle exchanges are a place of health promotion for people who inject drugs.  Conclusion: How people who inject drugs experience the services and what makes them return is important knowledge for harm reduction to reach more people. Continued research is needed on how needle exchanges can reach more people who inject drugs. / Bakgrund: Drogbruk är ett folkhälsoproblem förenat med ökad dödlighet, sjuklighet och bristande kontakt med hälso- och sjukvård. Stigmatisering och diskriminering omgärdar drogbruk. Skadereduktion syftar till att förbättra hälsan utan tvingande åtgärder rörande drogfrihet. Skadereduktion är evidensbaserat, kostnadseffektivt och minskar spridningen av smittsamma sjukdomar. Sprututbyten ger information om drogrelaterade risker och erbjuder skydd mot dessa.  Syftet: Att beskriva erfarenheter av skadereduktion vid sprututbyten hos personer som injicerar droger. Metod: En kvalitativ litteraturstudie enligt Polit och Becks niostegsmodell. Elva artiklar inkluderades och analyserades tematiskt enligt modell av Braun och Clarke. Resultat: Huvudfynd är att personer som injicerar droger upplever att sprututbyten erbjuder kunskap och möjliggör skadereduktion. Sprututbyten är en plats för hälsopromotion för personer som injicerar droger.  Slutsats: Hur personer som injicerar droger upplever erbjuden skadereduktion vid sprututbyten och vad som får dem att återkomma är betydelsefull kunskap för att skadereduktion ska nå fler. Fortsatt forskning behövs om hur sprututbyten kan nå fler personer som injicerar droger.

Since the onset of the AIDS (Acquired Immunodeficiency Syndrome) crisis in 1982, Aboriginal women have been contracting HIV (Human Immunodeficiency Virus) and Hepatitis C in increasing numbers. A new Aboriginal HIV/AIDS research agenda is imperative. This research was conducted in an attempt to understand why Aboriginal women in Saskatchewan remain marginalized in their continuing struggle against HIV/AIDS and Hepatitis C. Through the use of in-depth ethnographic profiles and personal histories, twenty-two Aboriginal women from Saskatchewan candidly shared their life histories. The women were asked a range of questions, including their knowledge about HIV/AIDS and Hepatitis C, and their attitudes and behaviours concerning sexual activities, alcohol and drug use, education, health, and lifestyle. The key issues for Aboriginal women with HIV/AIDS and/or Hepatitis C focus on the fact that they sustain triple jeopardy, in that they are discriminated against for having HIV/AIDS and/or Hepatitis C, for being a minority population by virtue of their Aboriginal ancestry, and for being women. Any analyses of what makes Aboriginal women vulnerable to HIV and Hepatitis C infection must take into account the role of poverty, independent of any risk factors, in leading to infection, illness, and in some instances, death. The majority of the respondents were found to be prostitutes who continued to be involved in street prostitution, even after they had been diagnosed with HIV and/or Hepatitis C. Twenty percent of the respondents were infected through unprotected sexual activity, 20% through intravenous drug use, and 60% were infected through both unsafe sex and intravenous drug use. The results of this research the incidence of both HIV and Hepatitis C is high in Aboriginal communities in Saskatchewan, due largely to low condom use, high rates of STDs (sexually transmitted diseases), low self-esteem, a lack of self-identity, increasing intravenous drug use, violence, sexual abuse, and high representation in street prostitution. Research to date is inadequate to the task of preventing the further spread of HIV and/or Hepatitis C, and providing effective and culturally appropriate treatment to Aboriginal women in Saskatchewan. This thesis serves to fill some of the research gap in knowledge about the relationship between race, gender, social class, sexual behavior and HIV/AIDS and/or Hepatitis C infection.

Since the onset of the AIDS (Acquired Immunodeficiency Syndrome) crisis in 1982, Aboriginal women have been contracting HIV (Human Immunodeficiency Virus) and Hepatitis C in increasing numbers. A new Aboriginal HIV/AIDS research agenda is imperative. This research was conducted in an attempt to understand why Aboriginal women in Saskatchewan remain marginalized in their continuing struggle against HIV/AIDS and Hepatitis C. Through the use of in-depth ethnographic profiles and personal histories, twenty-two Aboriginal women from Saskatchewan candidly shared their life histories. The women were asked a range of questions, including their knowledge about HIV/AIDS and Hepatitis C, and their attitudes and behaviours concerning sexual activities, alcohol and drug use, education, health, and lifestyle. The key issues for Aboriginal women with HIV/AIDS and/or Hepatitis C focus on the fact that they sustain triple jeopardy, in that they are discriminated against for having HIV/AIDS and/or Hepatitis C, for being a minority population by virtue of their Aboriginal ancestry, and for being women. Any analyses of what makes Aboriginal women vulnerable to HIV and Hepatitis C infection must take into account the role of poverty, independent of any risk factors, in leading to infection, illness, and in some instances, death. The majority of the respondents were found to be prostitutes who continued to be involved in street prostitution, even after they had been diagnosed with HIV and/or Hepatitis C. Twenty percent of the respondents were infected through unprotected sexual activity, 20% through intravenous drug use, and 60% were infected through both unsafe sex and intravenous drug use. The results of this research the incidence of both HIV and Hepatitis C is high in Aboriginal communities in Saskatchewan, due largely to low condom use, high rates of STDs (sexually transmitted diseases), low self-esteem, a lack of self-identity, increasing intravenous drug use, violence, sexual abuse, and high representation in street prostitution. Research to date is inadequate to the task of preventing the further spread of HIV and/or Hepatitis C, and providing effective and culturally appropriate treatment to Aboriginal women in Saskatchewan. This thesis serves to fill some of the research gap in knowledge about the relationship between race, gender, social class, sexual behavior and HIV/AIDS and/or Hepatitis C infection.

People who inject drugs, particularly opioids, are a growing population, especially in North Philadelphia. This population is at high risk for medical complications that require hospitalization. While hospitalized, this population poses unique challenges to the healthcare system, including high costs and readmission rates, as well as stress and burnout among providers and staff. These patients are at high risk of discharges against medical advice because of complicated social factors as well as inadequate recognition of pain and withdrawal. As the opioid epidemic evolves, previous strategies for managing these patients, which traditionally relied on referral to psychiatry or social work in addition to symptomatic treatment, need to be re-evaluated. Ethically, the decision-making capacity of these patients is frequently called into question, and there is a difficult-to-strike balance between respecting their autonomy and acting with beneficence to provide the best care. There are also public health concerns that come into play. Better acknowledgment of the issues that this population faces, and better management of pain and withdrawal, may improve their outcomes, as well as reduce provider stress and burnout. / Urban Bioethics

The thesis explores chronic leg ulceration experienced by young people who inject drugs (PWID). The applied health research study, in two phases, used a sequential explanatory mixed methods design. Phase 1 involved a survey of 200 people who injected drugs to investigate the prevalence of skin problems and leg ulceration, together with the identification of risk factors for ulceration. Phase 2 involved a series of fifteen qualitative semi-structured interviews that explored the results relating to risk factors with a sample of PWID who had experienced leg ulceration, and investigated participants’ perceptions of appropriate harm reduction methods. Main findings There were three research questions in this study: 1) What is the extent of skin problems and chronic leg ulceration in young people who inject drugs? The study identified a high prevalence of leg ulceration as 15%. 60% of the sample had experienced a skin problem. Each reported skin complication is clearly defined. 2) What causes chronic leg ulceration in young people who inject drugs? Leg ulceration experienced by PWID in this study was directly linked to deep vein thrombosis (DVT), as well as injecting in the groin and the leg. DVT was strongly associated with groin and leg injecting. The acceptance amongst injectors of the groin and leg as a site of choice has occurred with a lack of awareness of the long-term consequences of damage to the limb. 3) What are appropriate harm reduction measures in young people who inject drugs? Harm reduction methods related to the development of leg ulceration have been absent across schools and drug services. Training for healthcare workers which enables them to identify risk factors should be developed, and harm reduction information related to leg ulceration should be included in drug education within schools, and instigated within drugs services. This applied health research has led to a number of practice-focused recommendations surrounding clinical care including early detection of venous insufficiency and accessible services to prevent, assess, and treat venous disease in PWID. The original contribution to knowledge is three-fold: 1. Leg ulcers have been found to be highly prevalent in young people who inject drugs. 2. Ulceration is predominantly caused by venous thrombosis due to injecting in the legs or groin. 3. Harm reduction related to the development of venous disease has lacked impact and effect.

The aim of this thesis is to describe the users visiting the syringe exchange clinic in Malmö with respect to what characterises the group, how they utilize the services of the clinic and how their patterns of participation relate to risk behaviour, physical and mental health and social development. The heterogeneity of the group has been captured by the use of Stimsons dimensions “integration in majority society” and “involvement in sub-culture”, yielding four different groups of syringe exchangers: “stables”, “loners”, “two-worlders” and “junkies”. The study rests on two sources of data: a register from the clinic including all syringe exchangers that have visited the clinic between 1989 and 2003, altogether 3660 individuals, and an interview of visitors at the clinic during 1995, including 496 persons. The results show that syringe exchangers, compared to other persons with severe addiction in Malmö, to a larger extent use amphetamine as their drug-of-choice, are older and inject more irregularly. The population visiting the clinic is heterogeneous with respect to integration in society and involvement in sub-cultures. The group classified as junkies do, as expected, display the highest inclination to share syringes and needles with other and hence have the most advanced risk behaviours. As to utilization of the programme, the results show that the longer the syringe exchangers stay in the programme, the more frequent they visit it. Also with respect to utilization-patterns, we find substantial variations within the studied group. Five categories are discernible: drop-in visitors with only one or two visits, sporadic visitors who in spite of contacts over a number of years never really establish a regular contact, intermittent visitors who have had contact over several years but display a very irregular visiting pattern, regular visitors who relatively fast establish a consistent contact with visits between uniform time intervals and frequent visitors who tend to stay longer than others and visit the clinic more often. Another aspect of utilization is to what extent the distribution of needles and syringes cover the needs of the visitors. With a strict definition of need, only a minority manages to cover their needs, but if we accept a more extensive individual re-use, around 90 percent of the average need is covered. Data also reveals that a very high proportion of the users on at least one occasion have visited the programme without syringe exchange taking place or any complementary service delivered. Basically these visits seem to be of a more social nature, reinforcing the contacts between the staff and the visitors. Data do not give any clear support for the basic assumption that syringe exchange reduce the incidence of HIV or hepatitis. Recent sharing of utensils or low coverage of syringe need through the programme do not predict a higher infection risk. Instead we find that the social contacts with the staff (without syringe exchange) function as a predictor of lower incidence. This indicates that the mechanisms may be more complex than just related to the provision of clean needles and syringes. The result shows that integration increase over time while sub-cultural involvement decreases. However, the patterns for different groups are very diverse and we find no evidence that more frequent contacts as such are related to increased integration. There is however, some evidence that social visits are positively related to increased integration. No support could be found for the assumption that the programme increases the number of severe addicts.