This dissertation explores the criminalization of hypodermic syringes as drug paraphernalia specifically in relation to the extent to which criminalization may impact individual’s connection with harm reduction services, implementation of harm reduction strategies, and healthcare. I utilize a critical criminological perspective to identify and explore the ways in which criminalization works to perpetuate and reinforce the marginalized status of and control and constrain the lives of people who inject drugs. I conducted secondary data analysis of interviews with twenty-five people who inject drugs in rural southern Illinois to explore the extent to which criminalization impacts accessibility and engagement with needed harm reduction and health services and identify the mechanisms through which this impact is enacted. Participants were asked to describe their knowledge of state laws and polices related to drug paraphernalia and calling emergency services in the event of witnessing an overdose. Lastly, this dissertation examined how people who inject drugs cope with their experiences with law enforcement. Findings illustrate that criminalization constricts accessibility and engagement with harm reduction and healthcare services among rural people who inject drugs through frequent violent encounters with law enforcement in which participants are routinely degraded, harassed, and abused. These encounters, coupled with pervasive community stigma, lock participants into a hyper-stigmatized master status further interrupting access and engagement with harm reduction and health services and diminishing networks of social support. Additionally, participants reported a lack of confidence in their understanding of state laws and policies related to paraphernalia and calling emergency services during overdose events; and, those who were most knowledgeable indicated that due to previous abusive encounters, they lacked trust in local law enforcement to uphold these protections. The local harm reduction agency served as a site of hope for participants as they leveraged services to restore a sense of control over their lives and drug use. Engagement with such services make it possible for participants to implement numerous harm reduction strategies in their daily lives and provided them with social support that was otherwise unavailable. Drug use associated stigma and violent encounters with police create significant barriers to accessing harm reduction services for rural people who inject drugs. As such, reducing drug use associated stigma is necessary to ensure that people who inject drugs can safely access needed harm reduction, health care, and treatment services.

Bakgrund Personer som injicerar droger uppsöker vården mindre frekvent än övriga befolkningen men löper ökad risk för ohälsa utifrån olika riskbeteenden såsom att dela injektionsmaterial och bruka olagliga substanser. Ohälsa som uppkommer kopplat till injicering av droger orsakar lidande hos individen samt stora kostnader för sjukvården. Förmåga att ta hand om egenvård påverkar möjligheten att bibehålla hälsa och inkluderas i samhället. Syfte Att utforska hur egenvård uppfattas av personer som injicerar droger samt vilket behov av vård dessa personer ger uttryck för. Metod Kvalitativ intervjustudie med explorativ ansats. Semistrukturerade intervjuer genomfördes med 12 personer som besökte sprututbytesmottagningen vid Karolinska universitetssjukhuset i Stockholm. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat Analysen resulterade i tre kategorier: Önskan om att bibehålla hälsa trots substansbrukssyndrom, Behov av specifik kompetens och personcentrerad vård och Behov av specifik vård och säkra miljöer. I kategorin Önskan om att bibehålla hälsa trots substansbrukssyndrom beskrivs att egenvård uppfattas som att använda droger säkert och att i övrigt upprätthålla en god fysik och psykisk hälsa. I kategorin Behov av specifik kompetens och personcentrerad vård framkom att specifik omvårdnadskompetens och kunskap om substansbrukssyndrom inom hälso- och sjukvården efterfrågas. I kategorin behov av Specifik vård och säkra miljöer beskrivs att personer som injicerar droger efterfrågar tillgång till vård anpassad efter de specifika behov och hälsorisker som droganvändning medför.  Slutsats Egenvård uppfattas som att bibehålla hälsa genom att injicera droger på ett säkert sätt, minska riskbeteende samt att undvika att exkluderas från samhället genom att ta hand om utseende, hygien och sträva mot en meningsfull vardag. Respondenterna uttrycker behov av personcentrerad vård, värdigt bemötande samt kompetens avseende droganvändande hos vårdpersonal. En personlig och kontinuerlig kontakt ses som essentiellt för att förbättra upplevelsen av vård hos denna målgrupp. / Background People who inject drugs are less able to access healthcare than the general population, but are at increased risk of illness related to risk behaviors such as sharing injection equipment and use of illegal substances. Illness caused by injection drug use is related to individual suffering as well as increased health care costs. The ability to perform self-care affects the ability to maintain health and being included in society. Aim The aim was to explore how self-care is percieved by people who inject drugs, as well as the needs of healthcare expressed by these individuals.  Method Qualitative interview study with explorative design. Semi structured interviews were conducted with 12 people visiting a needle exchange clinic at the Karolinska University Hospital in Stockholm, Sweden. The interviews were analyzed using content analysis. Results The analysis resulted in three categories: A wish to maintain good health despite substance use disorder, Need for specific competence and patient-centered care and Need for specific care and safe environments. The category A wish to maintain good health despite substance use disorder showed that self-care was perceived as using drugs in a safe way and to maintain a good physical and mental health overall. The category Need for specific competence and patient-centered care describes a wish for specific nursing skills and increased knowledge of substances use disorders within the health care system. The category Need for specific care and safe environments demonstrate that people who inject drugs are requesting access to healthcare adjusted to their specific needs and health risks. Conclusions The respondents perceive self-care as maintaining health by injecting drugs safely, reduce risk behavior and avoid being excluded from society by caring for appearance, hygiene and striving for a meaningful life. The respondents in this study express the need for person-centered care, dignified treatment and drug use expertise within the health care system. An individual and continuous contact at the needle exchange clinic is essential to improve the experience of health care for these individuals.

BACKGROUND: Although the total number of new documented HIV diagnoses annually decreased from 2008-2018, the rate of decrease started to slow in 2013, and substantial variation exists across at-risk groups. People who inject drugs (PWID) account for 9% of new diagnoses annually, with increasing incidence in this population starting in 2015. Among PWID, 34% of new HIV diagnoses occurred in individuals who were also classified as men who have sex with men (MSM), indicating that MSM-PWID have elevated HIV risk. Data on MSM-PWID are scarce, and programmatic and advocacy efforts in HIV prevention do not specifically target MSM-PWID, with no CDC-recommended interventions existing for this population. OBJECTIVE: We sought to characterize the complex, intersecting and unique HIV risks faced by MSM-PWID, including perceptions of HIV risk and attitudes toward antiretroviral pre-exposure prophylaxis (PrEP) among MSM-PWID in urban and non-urban areas of Massachusetts and Rhode Island. METHODS: We recruited PWID through community-based organizations (CBOs; e.g. syringe service programs) in 18 urban centers and smaller cities and towns across Massachusetts and Rhode Island. Participants completed semi-structured interviews exploring substance use behaviors and HIV prevention needs. This in-depth analysis focused on describing the experiences and HIV prevention needs and attitudes of nine participants in the sample who reported a sexual orientation other than “heterosexual.” RESULTS: Most participants identified as cisgender, bisexual men. However, the context of their sexual behaviors varied, with some participants only engaging in same-sex behavior during sex work. The relationship between identity and behavior is explored in the context of reported risk behavior. All participants engaged in at least one behavior that increased risk of HIV acquisition, including syringe sharing, inconsistent condom use, and sex work. Participants also described heightened risk when these behaviors overlapped, particularly within contexts of “sex parties” that some individuals described. At the same time, experiences of isolation and exclusion were common in the sample, indicating a potential vulnerability in this population. HIV risk perception varied among participants, but was not consistently aligned with the behaviors described. Many participants did not perceive needing HIV prevention services “yet,” indicating that they did not view their risk to be high enough to warrant prevention services. Alternatively, some described needing to prioritize daily survival and mental health over HIV prevention efforts. Although knowledge of PrEP was low, acceptability of PrEP was high in this sample, and several participants provided specific suggestions for improving the feasibility of PrEP. CONCLUSION: Data from this study illustrate the HIV risks and prevention needs of this at-risk population and highlight mechanisms to engage them in preventative care. Our main findings are (1) participants had low knowledge of PrEP, but were largely enthusiastic after learning about it from interviewers, (2) varying identity related to same-sex behavior among men who have sex with men and inject drugs may play a role in shaping HIV risk and prevention needs, (3) specific healthcare and prevention service needs of this population emerged, including reducing risk at sex parties and improving access to non-stigmatizing mental health services. An in-depth understanding of the ways in which sexual orientation and gender identity shape HIV risk and prevention needs remains crucial in providing treatment and prevention services to MSM-PWID.

Hepatitis C virus (HCV) affects up to 45,000 people in Sweden today. Although it is a very treatable disease, the prevalence of HCV is extremely high within the population of people who inject drugs (PWID). This study examines the direct effect of needle exchange programs (NEPs) on HCV rates in Sweden. Previous research has shown that NEPs reduce the transmission of other blood-borne diseases among PWID. Using an interrupted time series (ITS) analysis, this study investigates if there are statistically significant differences between HCV rates in Swedish counties before and after the implementation of NEPs. The study also investigates via linear regression to see if there is a relationship between sterile injecting equipment (needles and syringes) dispensed and HCV rates in the counties where NEPs exist. While there has been a steady decrease in HCV rates across the country as a whole, the ITS analyses show no statistically significant differences in HCV rates due to the opening of NEPs. Because of the relatively recent introduction of NEPs in Sweden, more data points post-intervention may be needed before we can truly see the effect they have on regional HCV rates. There is also no relationship between the number of needles and syringes dispensed and county HCV rates. However, Sweden falls far short of the 300 syringes/needles per user per year recommendation of the World Health Organization at this time. Standardized data collection and further research can help answer these questions more clearly.

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.

Contexte: La crise des surdoses d’opioïdes qui sévit actuellement est un problème majeur de santé publique. Les personnes faisant usage de drogues par injection (PUDI) avec un trouble d’usage d’opioïdes (TUO) sont particulièrement vulnérables aux méfaits des opioïdes. Le traitement par agonistes opioïdes (TAO) est une intervention clé pour contrer l’épidémie de surdoses. L’engagement à long terme en traitement est un facteur important dans l’atteinte d’issues favorables. Nous avons examiné les facteurs individuels, contextuels et programmatiques qui sous-tendent la rétention en TAO dans une population de PUDI à Montréal, Canada. Méthodes: Nous avons mené une étude transversale basée sur les données provenant du questionnaire initial d’une cohorte longitudinale de PUDI à Montréal (HEPCO). Les participants recrutés avaient ≥ 18 ans et s’étaient injectés des drogues dans les derniers 6 mois. L’éligibilité au TAO était définie par l’utilisation d’opioïdes dans les 6 derniers mois et/ou l’engagement récent ou actuel en TAO. La rétention en TAO a été définie par la mesure auto-rapportée du temps passé en traitement au moment de l’entrevue, catégorisée en 4 groupes (non-engagé en TAO, <1 an, 1-3 ans, ≥3 ans). Des analyses par régression logistique multinomiale ont été menées pour identifier les facteurs associés à la rétention en traitement. Résultats: Parmi les 805 participants recrutés entre mars 2011 et janvier 2020, 546 (68%) étaient éligibles au TAO (78% hommes, âge moyen 37 ans), desquels 255 (47%) étaient engagés en TAO. Parmi ceux-ci, 29% l’étaient depuis <1 an, 21% entre 1-3 ans et 50% ≥3 ans. Dans les analyses multivariées, être une femme, l’âge, la stabilité de logement et l’infection chronique par le virus de l’hépatite C (VHC) étaient positivement associés avec une plus longue durée d’engagement en TAO (comparé aux non-engagés), alors que des associations négatives étaient observées pour la consommation régulière d’opioïdes, de cocaïne et de cannabis. Parmi les participants engagés en TAO, ceux recevant davantage de doses non-supervisées et ceux non soumis à des dépistages urinaires réguliers étaient davantage retenus en traitement. Une dose de méthadone ≥ 60 mg/jour était associée à une cote 3 fois plus élevée d’être engagé en traitement pour ≥1 an (vs <1 an), mais cette association n’était pas statistiquement significative pour la rétention ≥ 3 ans. Conclusion: La moitié des participants éligibles au TAO étaient engagés en traitement. Parmi les PUDI en TAO, une grande proportion était engagée en traitement pour ≥ 3 ans. En plus des facteurs sociodémographiques, nous avons identifié des facteurs programmatiques associés à une plus longue durée d’engagement en traitement. Des approches plus flexibles dans les programmes de TAO pourraient contribuer à une plus longue rétention en traitement. En raison du devis transversal employé, la causalité inverse ne peut être exclue; des analyses longitudinales sont nécessaires. / Background: The ongoing opioid overdose crisis is a major public health issue. People who inject drugs (PWID) with opioid use disorder (OUD) are the most vulnerable to opioid-related harms. Opioid agonist therapy (OAT) is a safe and efficient treatment for OUD and is a key intervention to curb the epidemic. Longer-term engagement in OAT has been associated with better health and social outcomes. Retention in treatment is paramount. We sought to identify individual, contextual and treatment factors associated with retention in OAT in Montréal, Canada. Methods: We conducted a cross-sectional analysis of baseline data collected within a longitudinal cohort study of PWID in Montreal (HEPCO). Eligible participants were aged ≥18 years and had injected drugs in the previous 6 months. We restricted the analysis to those eligible for OAT, inferred from self-reported illicit opioid use or OAT receipt in the past-six months. The outcome variable, retention in OAT, was defined as self-reported time spent in treatment at baseline, categorized as not on OAT, < 1 year, 1-3 years, ≥3 years. Multinomial logistic regression analyses were conducted to identify factors associated with retention. Results: Of 805 cohort participants enrolled between March 2011 and January 2020, 546 (68%) were considered eligible for OAT (mean age: 37; 78% male) and included in analyses. Of those, 255 (47%) were currently enrolled in OAT (29% in treatment for <1 year, 21% for 1-3 years and 50% for ≥ 3 years). In multivariable analyses, female gender, older age, stable housing, and chronic hepatitis C infection were positively associated with longer stay in OAT (compared to not on OAT), whereas negative associations were noted for regular opioid, cocaine and cannabis use. Among PWID enrolled in OAT, those receiving take-home doses and those who did not have regular urine drug screening were more likely to have a longer stay in treatment. Methadone dose ≥ 60 mg/day was associated with over 3-fold odds of retention ≥ 1 year (vs < 1 year), but the association was not statistically significative for ≥ 3 years retention. Conclusion: Half of participants likely to be eligible for OAT were enrolled in treatment. Among active PWID receiving OAT, high prevalence of long-term engagement in treatment was observed. In addition to sociodemographic factors, we identified treatment-related factors associated with greater treatment duration, suggesting the need for flexible implementation approaches in OAT programmes. Due to our cross-sectional design, however, reverse causation cannot be excluded; findings should be confirmed in longitudinal samples.

La majorité des personnes utilisatrices de drogues par injection (PUDI) contracteront le virus de l’hépatite C (VHC), les mettant à risque accru de complications hépatiques graves et parfois mortelles. Les comportements les plus risqués pour l’acquisition du VHC incluent le partage de matériel d’injection et l’injection à haute fréquence. Un facteur jusqu’ici négligé dans l’évaluation du risque de VHC est l’aspect dynamique de l’injection, c.-à-d. la manière dont elle varie dans le temps, incluant l’effet des périodes sans injection et celui des changements dans la fréquence d’injection. On reconnaît également l’effet délétère que l’instabilité résidentielle peut avoir sur le risque de VHC, bien que les mécanismes sous-jacents soient mal compris. Cette thèse s’intéresse à l’effet des variations temporelles de l’injection sur le risque de VHC, et à la manière dont la fréquence d’injection évolue en concomitance avec les conditions résidentielles dans le temps, afin d’aider au développement de nouvelles stratégies de prévention du VHC. Les données ont été recueillies entre mars 2011 et juin 2016 dans la Hepatitis Cohort, une cohorte de PUDI suivies trimestriellement à Montréal, au Québec. Une première analyse a évalué l’effet des périodes sans injection de trois mois ou moins sur le risque de VHC sur 916 personnes-années de suivi, par régression de Cox (N=372). Celle-ci suggère que les PUDI présentant des périodes sans injection courtes (3/3 mois sans injection) et sporadiques (1/3 ou 2/3 mois sans injection) sont respectivement 76% et 44% moins à risque de VHC que celles s’injectant de manière persistante (0/3 mois sans injection). Une deuxième analyse a utilisé la modélisation de trajectoires fondée sur le groupement pour identifier cinq types distincts de trajectoires de fréquence d’injection suivies sur une année, lesquels ont ensuite été comparés en termes d’incidence du VHC sur des périodes de suivi allant de 71 à 355 personnes-années (N=386). Les résultats suggèrent que les PUDI dont la fréquence reste élevée (injection fréquente) ou change dans le temps (croissante, décroissante) sont à plus haut risque de VHC que celles s’injectant à basse fréquence (sporadique, peu fréquente). Une dernière analyse a identifié trois types de trajectoires de stabilité résidentielle suivies sur un an (persistance, déclin, amélioration; N=386), lesquels ont été évalués en association avec les trajectoires de fréquence d’injection suivies simultanément. Les résultats suggèrent qu’il existe un lien entre l’amélioration des conditions résidentielles et la diminution de la fréquence d’injection, mais aussi que la probabilité d’injection à fréquence croissante est plus élevée chez les PUDI maintenant des conditions résidentielles stables que celles chez qui elles s’améliorent. Collectivement, les résultats ont de nombreuses implications en termes de prévention du VHC. Cliniquement, l’instabilité de la fréquence d’injection semble être un facteur de risque à monitorer régulièrement. En termes de santé publique, les interventions favorisant l’engagement dans des périodes sans injection ou le maintien d’une basse fréquence d’injection pourraient être prometteuses. Enfin, les stratégies visant l’amélioration des conditions résidentielles pourraient éventuellement aider les PUDI à réduire leur fréquence d’injection, mais être insuffisantes pour maintenir celle-ci à basse fréquence une fois la stabilité atteinte. / The majority of people who inject drugs (PWID) will become infected with hepatitis C virus (HCV), placing them at risk of serious and sometimes fatal liver complications. Injecting behaviours with higher risk of HCV transmission include injecting equipment sharing and high frequency injecting. One factor that has been overlooked when assessing HCV acquisition risk is the dynamic aspect of drug injecting, i.e., how drug injecting varies over time, including the role of injecting cessation episodes and that of changes in injecting frequency. Moreover, there is growing recognition of the deleterious effect unstable housing can have on HCV acquisition risk, although the underlying mechanisms are not yet fully understood. This thesis examines how temporal variations in drug injecting relate to HCV acquisition risk and further explores how housing conditions and injecting frequency evolve together over time, for the purposes of contributing to the development of novel HCV prevention strategies. Data were collected between March 2011 and June 2016 in the Hepatitis Cohort, a prospective cohort study of PWID interviewed and tested for HCV infection at three-monthly intervals in Montréal, Québec. A first analysis examined the effect of injecting cessation episodes of three months or less on the risk of contracting HCV during 916 person-years of follow-up, using Cox regression (N=372). Results suggest that PWID with short injecting cessation episodes (3/3 months without injecting) or sporadic injecting cessation episodes (1/3 or 2/3 months without injecting) are 76% and 44% less at risk of contracting HCV than those with persistent injecting (0/3 months without injecting), respectively. A second analysis used group-based trajectory modeling to identify five distinct types of one-year injecting frequency trajectories and compared these in terms of HCV incidence over follow-up periods ranging from 71 to 355 person-years (N=386). Findings suggest that PWID injecting with consistently high frequencies (frequent) or time-varying frequencies (increasing, decreasing) are at greater HCV acquisition risk compared with those maintaining low injecting frequencies (sporadic, infrequent). Finally, a third analysis identified three types of one-year housing stability trajectories (sustained, declining, improving) and examined their associations with concomitant injecting frequency trajectories (N=386). Findings suggest an association between improving housing stability and decreasing injecting frequency, but also a higher probability of increasing injecting frequency among PWID who maintain housing stability compared to those that improve it. Collectively, these findings have numerous implications for HCV prevention. Clinically, instability in injecting frequency appears to be a risk factor that should be monitored regularly. From a public health perspective, interventions that promote engagement in injecting cessation episodes or maintenance of low injecting frequency may be promising. Finally, strategies aimed to improve housing stability may help PWID to decrease their injecting frequency but may not be sufficient to help them maintain low injecting frequencies once housing stability is achieved.