Hepatitis C Virus (HCV) is an infection that can have grave consequences when left untreated. Hepatitis C can be easily eradicated with direct acting antiviral therapy. People who inject drugs (PWID) and inmates are among those with the highest incidence of HCV. However, cure rates among this population remains low. This is, in part, related to an interruption in the HCV care cascade such that only 30% of PWID are linked to care and only 8% of those receive treatment. Inadequate screening and failure to be linked to HCV care remain the largest impediments to treatment success. There is limited research on barriers and facilitators to primary care, where screening may take place, and linkage to HCV care among PWID. Few studies have evaluated vulnerable populations such as those living in rural communities or inmates. The purpose of this dissertation was to develop a broader understanding of barriers and facilitators to healthcare utilization among PWID at the primary care and specialist levels (linkage to care). Three manuscripts addressed important gaps in knowledge. The first was a review of the literature to describe the state of science on linkage to care among PWID. All but one reviewed study recruited from countries with universal healthcare, urban areas, and opioid substitution facilities. The review of the literature revealed that little is known about the barriers/facilitators to linkage to HCV care faced by rural-dwelling PWID from countries without universal healthcare. The second manuscript is a study to determine whether predictors of linkage to care identified in urban-dwelling PWID from countries with universal healthcare predicted seeking HCV care among PWID living in rural Appalachia. Data were obtained from a subsample of 63 HCV positive PWID who recently used opioids, were between the ages of 18-35 years, and lived in one of five rural counties in Kentucky. Logistic regression revealed that recent injection drug use was the only predictor of seeking HCV care. However, remote use of opioid substitution therapy and no transportation issues approached clinical significance. Although not evaluated in our second manuscript, seeing a primary care provider (PCP) is associated with an increased likelihood of being linked to care and higher rates of screening/diagnosis. Among rural dwelling PWID, there are subpopulations that may face unique barriers to linkage to care. One sub-population that may be particularly vulnerable are female PWID who are incarcerated. Therefore, the purpose of the third study was to determine predictors of primary care use using data from 302 female inmates from rural Appalachia with a history of injecting drugs. Age, insurance issues, and health problems that interfere with responsibilities were predictors of PCP use. In this dissertation, I have addressed important gaps in the literature by determining barriers and facilitators to seeking HCV care and primary care use among PWID from rural Kentucky. Additional studies are needed using a larger sample of rural PWID to confirm our findings. In addition, further studies should evaluate system and provider level barriers to linkage to care and PCP use among rural PWID.

The purpose of this thesis is to scope the literature to understand how people who use injection drug (PWIDs) experience access to hepatitis C (HCV) testing and diagnosis. The design was a scoping review methodology, guided by Arksey and O’Malley, JBI, and PRISMA-ScR guidelines. A search was conducted through seven electronic databases using a peer-reviewed search strategy. Five studies were yielded through two-level screenings. The extracted data were synthesized using conventional data analysis and reported using tables and narrative summaries. Four categories were found: Awareness and Knowledge, Stigma, Healthcare Service, and Psychological Responses. The studies were conducted in Australia, UK, and US published between 2014 to 2018. A total of 19 participant characteristics were extracted to contextualize their experiences. The World Health Organization’s definition of accessibility should be defined through the guidance of the constructed truths of the individuals in the current context. The lack of demographic data and connection to client quotes further exacerbates the inequities among the population through overlooking their intragroup identities.

The current opioid epidemic has had grave financial and mortal costs for our nation, and the numbers continue to climb despite our best efforts. In spite of attempts to limit the prescription of opioids and implementation of harm reduction strategies, it is clear that we are not doing enough for people struggling with drug addiction. There are many voices present in the war on drugs, however one that is noticeably absent from the conversation is that of people who inject drugs. It is clearly time to try something new which requires a fresh approach and a new point of view. Confronting the current crisis using a public health approach addresses the associated moral challenges faced in the past and provides a new lens to view potential challenges and solutions. With this new approach arises the need for a public health ethical framework to make ethically informed, community engaging, evidence based decisions on a societal, public health, and everyday level. In addition to this new public health ethics framework, the engagement of the community of people who inject drugs is no longer negotiable in order to develop more effective harm reduction interventions and policies. / Urban Bioethics

Bakgrund: Personer som injicerar droger har i tidigare studier visat sig ha en lägre livskvalitet än andra populationer och många lider av psykisk ohälsa. Spridning av blodsmittor som hiv och hepatiter och andra blodburna infektioner kan vara en risk vid injicering. Tillgång till sterila sprutor och kanyler genom sprututbyte är en åtgärd för att minska spridning av infektionssjukdomar. Centralt för psykiatrisk omvårdnad, i likhet med harm reduction, är att värna mänskliga rättigheter, att erbjuda vård på lika villkor och stärka förmågan till egenvård. Syfte: Syftet med denna studie var att undersöka om livskvalitet hos personer som injicerar droger förbättras över tid efter inskrivning på Stockholms sprututbyte samt om det fanns någon skillnad mellan könen. Metod: Denna studie genomfördes som en prospektiv icke-experimentell longitudinell kvantitativ studie. Urvalet bestod av besökare på Stockholms sprututbyte som valde att delta. Studiedeltagarna svarade på livskvalitetsenkäten EQ-5D vid tre mättillfällen. EQ-5D mäter graden av tillfredsställelse i fem dimensioner (indexpoäng) samt innehåller en global skattning av nuvarande hälsotillstånd (EQ VAS). Förändring över tid analyserades med hjälp av ANOVA för upprepade mätningar. Resultat: Resultatet visade på en signifikant förbättring av livskvalitet över tid avseende EQ VAS för hela gruppen. Resultatet visade vidare att kvinnor skattade sitt nuvarande hälsotillstånd EQ VAS signifikant lägre än män. Slutsats: Deltagande i sprututbyte verkar ha betydelse och inverka positivt på hälsorelaterad livskvalitet hos personer som injicerar droger men mer behöver studeras för att få en bredare kunskap om vad det är som gör att det förhåller sig så. / Background: People who inject drugs have shown in previous studies to have a lower quality of life than other populations and many suffer from mental illness. The spread of blood infections such as hiv and hepatitis and other blood borne infections can be a risk when injecting. Access to sterile syringes and needles through syringe exchange is a measure to reduce the spread of infectious diseases. Central to psychiatric care, like harm reduction, is to protect human rights, to offer care on equal terms and to strengthen the capacity for self-care. Aim: The purpose of this study was to investigate whether the quality of life of people who inject drugs improves over time after enrollment in Stockholm needle and syringe exchange program and if there were any gender differences. Method: This study was conducted as a prospective non-experimental longitudinal quantitative study. The selection consisted of visitors at the Stockholm exchange who chose to participate. The study participants answered the quality of life questionnaire EQ-5D on three occasions. EQ-5D measures the degree of satisfaction in five dimensions (index points) and contains a global estimate of the current state of health (EQ VAS). Change over time was analyzed using ANOVA for repeated measurements. Results: The results showed a significant improvement in quality of life over time with regard to EQ VAS for the entire group. The results further showed that women estimated their current state of health EQ VAS significantly lower than men. Conclusions: Participation in needle and syringe exchange programs appears to have significance and a positive impact on health-related quality of life but further studies needs to gain a broader knowledge of what it is that makes it so.

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.

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.

Background: Understanding concentrated areas with high rates of opioid use disorder (OUD) allows for improved placement of Narcan access points through syringe services programs (SSPs). People Who Inject Drugs (PWID) have lower risk of contracting infectious diseases the closer they are to SSPs. Tennessee law prohibits SSPs within 2000ft of a school or park, impacting the placement of SSPs in non-urban areas. Testing factors related to SSP siting placement within a system dynamic model can better determine the relationship between PWID risk environment and SSP access and utility. Methods: We identified areas of greatest need for harm reduction interventions within a non-urban Tennessee county with Emergency Medical Services (EMS) Narcan administrations data (Aim 1). We then created a Google map to determine a theoretical ideal location for an SSP. We then applied the current legal restrictions to SSP placement to find the next-closest legal location (Aim 2). We then developed a theoretical system dynamic model of SSP access and utility and Risk Environment (Aim 3). Results: We determined “EMS Zone 1” has a higher rate of EMS Narcan administrations than most EMS zones in the county and a higher rate compared to the whole county (Aim 1). We located a theoretical SSP location with shorter walk, drive, and public transportation times compared to the existing location. The closest legal SPP location still had an improvement in travel times but lacked other utility factors (Aim 2). Our theoretical model indicates that laws limiting SSP placement increase the distance PWID travel to SSPs. The distance of support services to SSP sites has a negative relationship with risk environment and to accessibility and utility of SSPs (Aim 3). Conclusion: County-level geographic data is too crude to determine true “hot spots” of OUD. This new method using EMS data can provide entities a process for determining the best location for SSPs. Identifying measures of utility/accessibility for PWID can identify improved locations for SSPs but legal restrictions may lower utility/accessibility of SSPs especially for non-urban PWID. Current “Policy” or “Structural” level factors as described by the Social Ecological Model negatively impact PWID risk environment. Structural” or “Policy” and “Community” level interventions among state, city, and county governments have the highest potential to positively impact PWID risk environment.

Bakgrund: Hepatit C (HCV) är en virussjukdom som smittar via blodet. Personer sominjicerar droger (PSID) riskerar att drabbas av HCV till följd av injektionsrelateraderiskbeteenden. Idag finns det effektiv behandling mot HCV men det kräver viss följsamhet avden som behandlas. Syfte: Syftet var att undersöka sjuksköterskors upplevelser av följsamhet till behandling avhepatit C hos personer som injicerar droger. Metod: En kvalitativ intervjustudie genomfördes. Totalt intervjuades åtta sjuksköterskor frånfyra mottagningar. Datan analyserades sedan enligt Lundberg och Graneheims modell förkvalitativ innehållsanalys. Resultat: Resultatet sammanfattades under fyra huvudkategorier: Livssituation, Samverkan,Behandlingsrelaterade aspekter och Stigma. Totalt identifierades tretton subkategorier. Slutsats: Sjuksköterskor upplevde stora variationer i följsamhet till behandling hos PSID. Detupplevdes som positivt för följsamheten om PSID fick förutsättningar såsom en stabil tillvarooch regelbunden kontakt med en mottagning. I resultatet framkom att det var viktigt attvården var tillgänglig och att PSID fick ordentlig information om behandlingen. Det upplevdesäven som positivt om det fanns fungerande samverkan med både PSID och mellan deverksamheter som de kom i kontakt med. Stigmatiseringen av HCV och PSID upplevdessom ett centralt hinder för följsamhet. / Background: Hepatitis C (HCV) is a viral disease which is transmitted through blood. Peoplewho inject drugs (PWID) are at risk of developing HCV as a result of injection-related riskbehaviors. There is effective treatment for HCV, but it requires some degree of adherence. Aim: The aim was to investigate nurses’ experiences of adherence to treatment for hepatitisC in people who inject drugs. Method: A qualitative interview study was conducted. Eight nurses from four clinics wereinterviewed. The data was analyzed according to Lundberg and Graneheim's model forqualitative content analysis. Results: The results were summarized under four main categories: Life situation,Collaboration, Treatment-related factors and Stigma. Thirteen subcategories were identified. Conclusion: Nurses experienced large variations in adherence to treatment among PWID. Itwas perceived as positive for adherence if PWID had stable living conditions and regularcontact with a clinic. Availability and information about the treatment were important factors.It was also perceived as positive if there was functioning collaboration with PWID andbetween the institutions they came in contact with. The stigmatization of HCV and PWID wasperceived as a key obstacle to adherence.

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.

No description available.