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We conducted this systematic review and meta-analysis study to better understand the factors (being drug use, drug type (methamphetamine vs others), sex partner, frequency of injection, homelessness and being HIV positive) associated with injecting-related risk behaviors (lending and/or borrowing already used syringes) among people who inject drugs (PWID). We searched the English language citations in PubMed, Science Direct, Web of Science, and Cochrane electronic databases for previous studies on risk behaviors among PWID. Two independent researchers reviewed all search results, screened for eligibility and extracted data independently. A meta-analysis was conducted with pooled odds ratio and the 95% confidence intervals for factors associated with injecting risk behaviors among PWID. After detailed assessment of the citations, we included 14 studies in our meta-analysis. Binge drug use (OR, 1.39; 95% CI, 1.06–1.71) and drug type (methamphetamine vs. others) (OR, 1.50; 95% CI, 1.22–1.77) were positively associated with the borrowing of already used syringes among PWID. We also found that drug type (OR, 1.39; 95% CI, 1.16–1.64) and homelessness (OR, 1.89; 95% CI, 1.27–2.51) had a positive association with the lending of already used syringes among PWID. Additionally, being HIV positive was negatively associated with the lending of used syringes among PWID (OR, 0.58; 95% CI, 0.37–0.63). This systematic review and meta-analysis supports harm-reduction initiatives especially the establishment and maintenance of sterile needle syringe programs.
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Journal of Addictive Diseases
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Factors associated with injecting-related risk
behaviors among people who inject drugs: a
systematic review and meta-analysis study
Omid Rezaei , Hesam Ghiasvand , Peter Higgs , Alireza Noroozi , Mehdi
Noroozi , Fatemeh Rezaei , Bahram Armoon & Azadeh Bayani
To cite this article: Omid Rezaei , Hesam Ghiasvand , Peter Higgs , Alireza Noroozi , Mehdi
Noroozi , Fatemeh Rezaei , Bahram Armoon & Azadeh Bayani (2020): Factors associated with
injecting-related risk behaviors among people who inject drugs: a systematic review and meta-
analysis study, Journal of Addictive Diseases, DOI: 10.1080/10550887.2020.1781346
To link to this article: https://doi.org/10.1080/10550887.2020.1781346
Published online: 07 Jul 2020.
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Factors associated with injecting-related risk behaviors among people
who inject drugs: a systematic review and meta-analysis study
Omid Rezaei, MD
a
, Hesam Ghiasvand, PhD
b,c
, Peter Higgs, PhD
d
, Alireza Noroozi, MD
e,f
, Mehdi Noroozi,
PhD
g
, Fatemeh Rezaei, MSc
h
, Bahram Armoon, PhD
i
, and Azadeh Bayani, MSc
j
a
Fellowship of Psychosomatic, Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran;
b
Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran;
c
Health Economics Group,
Medical School, Saint Lukes Campus, University of Exeter, Exeter, UK;
d
Department of Public Health, La Trobe University, Melbourne,
Australia;
e
Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran;
f
Department of
Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran,
Iran;
g
Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran;
h
Department of Epidemiology and Biostatics, Jahrom University of Medical Sciences, Jahrom, Iran;
i
Social Determinants of Health
Research Center, Saveh University of Medical Sciences, Saveh, Iran;
j
Student Research Committee, School of Allied Medical Sciences,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
ABSTRACT
We conducted this systematic review and meta-analysis study to better understand the fac-
tors (being drug use, drug type (methamphetamine vs others), sex partner, frequency of
injection, homelessness and being HIV positive) associated with injecting-related risk behav-
iors (lending and/or borrowing already used syringes) among people who inject drugs
(PWID). We searched the English language citations in PubMed, Science Direct, Web of
Science, and Cochrane electronic databases for previous studies on risk behaviors among
PWID. Two independent researchers reviewed all search results, screened for eligibility and
extracted data independently. A meta-analysis was conducted with pooled odds ratio and
the 95% confidence intervals for factors associated with injecting risk behaviors among
PWID. After detailed assessment of the citations, we included 14 studies in our meta-ana-
lysis. Binge drug use (OR, 1.39; 95% CI, 1.061.71) and drug type (methamphetamine vs.
others) (OR, 1.50; 95% CI, 1.221.77) were positively associated with the borrowing of
already used syringes among PWID. We also found that drug type (OR, 1.39; 95% CI,
1.161.64) and homelessness (OR, 1.89; 95% CI, 1.272.51) had a positive association with
the lending of already used syringes among PWID. Additionally, being HIV positive was
negatively associated with the lending of used syringes among PWID (OR, 0.58; 95% CI,
0.370.63). This systematic review and meta-analysis supports harm-reduction initiatives
especially the establishment and maintenance of sterile needle syringe programs.
KEYWORDS
Risk behaviors; people who
inject drugs; borrowing
syringes; lending syringes
Background
Recent global estimates for the number of people
who inject drugs (PWID) were 15.6 million with
one in six living with HIV and more than half
living with hepatitis C virus (HCV).
1
The sharing
of previously used drug injection paraphernalia
(especially needles and syringes) is the prime rea-
son for transmission of these blood borne viruses
(BBVs) in both developed and developing coun-
tries.
2
Condomless sex among and between
PWID is also noted as a high risk behavior for
BBV transmission, especially HIV and hepatitis
B, though this varies substantially between coun-
tries.
1
Earlier studies regarding HIV-related risk
taking among PWID have generally divided sex-
ual and injecting-related risk behaviors and
shown that those who share syringes, are the
most at risk group for HIV transmission.
3,4
The
borrowing and lending of already used needles
and syringes are the main reason for HCV infec-
tion with previous studies demonstrating the
risks of transmission among PWID.
5,6
Concerns
about individual and community health have
CONTACT Bahram Armoon, PhD bahramarmun@gmail.com Assistant Professor of Health Education and Promotion, Social Determinants of Health
Research Center, Saveh University of Medical Sciences, Saveh, Iran.
Supplemental data for this article can be accessed at https://doi.org/10.1080/10550887.2020.1781346.
ß2020 Taylor & Francis Group, LLC
JOURNAL OF ADDICTIVE DISEASES
https://doi.org/10.1080/10550887.2020.1781346
been raised because of the strong relationship between
injection drug use and spread of BBV infection.
7
Previous research documenting risk taking
behaviors among PWID has mostly been framed
from two perspectives: unsafe (condomless) sex
and the sharing of used injection equipment,
with these two variables being evaluated individu-
ally. The borrowing of used injection equipment
is a high risk for transmission among both HCV
positive and negative Inject drug users (IDUs).
8
Evidence suggests that people living with HCV
who continue to share their injecting equipment
risk reinfection with HCV or superinfection with
different genotypes of HCV.
9,10
Evidence from
San Francisco also suggests that HCV negative
PWID refuse to share their injection equipment
to prevent infection.
11
The sharing of injecting
equipment, as well as condomless sex, increases
the risk of infection with other blood borne
pathogens such as human immunodeficiency
virus (HIV) and hepatitis B virus among
PWID.
1215
While previous research has shown
that PWID are able to modify their behavior to
prevent HIV,
14,1619
few studies identifying risk
behaviors have only considered injecting risk
behaviors such as the lending and borrowing
of syringes.
Increasing awareness of the factors associated
with borrowing and lending of already used nee-
dles, syringes or other injecting paraphernalia are
important for policy-making and public health
planning purposes.
20
While previous systematic
reviews on the effectiveness of sterile needle and
syringe programs
21
have shown them to be one
of the best ways to reduce BBV transmission,
2125
there has yet to be a systematic review and meta-
analysis assessing the factors associated with bor-
rowing and lending of used syringes among
PWID. This study differs from prior studies in
three important respects. First, we have included
data from studies published between 1987 and
2018, thereby updating previous reviews
24,26
by
over 15 years. In Ksobiechs study
24
the focus was
on associations between needle syringe program
27
attendance and reductions in needle sharing-
related risk behaviors. They found that needle
and syringe programmes (NSPs) reduced risk
behaviors of PWID including the borrowing and
lending of already used injecting equipment.
Data from these studies include a large num-
ber of needle sharing variables, so they cannot
detect the importance of the borrowing and lend-
ing already used equipment. We designed this
systematic review and meta-analysis study to bet-
ter understand the factors (being drug use, drug
type (methamphetamine versus others), sex part-
ner, frequency of injection, homelessness and
being HIV positive) associated with injecting-
related risk behaviors (lending and/or borrowing
of needles and syringes) among PWID.
Methods
This study used the risk factors identified from
Protocols of Systematic Reviews and Meta-
Analyses (PRISMA).
2831
Search strategy and study selection
We searched the PubMed, Science Direct, Web of
Science, and Cochrane electronic databases to find
previous studies on risk taking behaviors among
PWID for the period June 1980 February 2018.
The study search strategy is presented in Table 1.
Furthermore, other available reviews regarding
high-risk behaviors among PWID were assessed.
All papers with an English language abstract were
included in the search. Post assessment with a
duplicate filter two independent researchers (B.A.
and H.Gh.) analyzed the search results based on
title, abstract and relevance to the subject.
Any study design (Cross-sectional, cohort, and
case-control studies) were included in the review.
Qualitative studies, secondary studies, systematic
reviews and meta-analysis studies and papers in
languages other than English were excluded.
Inclusion criteria based on PICO:
Population: Studies that were conducted
among PWID.
Intervention: Outcomes of interest included drug
use, drug type (methamphetamine versus others),
sex partner, frequency of injection, homelessness
and being HIV positive in each of the studies
and these were considered as the intervention.
Comparison Group: Participants not reporting
the borrowing and/or lending of already used
needles and syringes.
2 O. REZAEI ET AL.
Outcomes: Lending and/or borrowing syringe
were considered as the risk behaviors of interest.
Data extraction and study quality assessment
The items extracted from the chosen studies
included the first authors name and publication
year, sample characteristics, location, and design
of the study, and also data on the exposure and
outcomes variables. We considered significant
factors, effect measure, performed adjustments,
and the analytical methods used. If we had any
ambiguities, we contacted the authors to resolve
them. We used previously defined worksheets for
recording the required data separately. First, the
authors reviewed and deleted any duplicate title
and abstract. Agreement between reviewers
according to the criteria one through three was
89%. In the second phase titles/abstracts that
qualified based on the defined criteria were
chosen for full-text review (96% agreement). For
the quality evaluation, we performed the
unweighted kappa approach to assess the
agreement between the two authors (B.A. and
A.B.). We defined the levels of agreement (poor,
slight, fair, moderate, substantial) with the values
of 0, 010.02, 0.0210.04, 0.0410.06, 0.0610.08,
and 0.0811.00, respectively.
32
Microsoft Excel software was used to extract
the data and two researchers (H.Gh. and B.A.)
reviewed and assessed papers independently
using a standardized data collection form. Any
conflict of ideas among reviewers was resolved
through discussion with other authors (H.Gh.
and M.N.). Researchers extracted the required
data including the year of publication, demo-
graphic data of samples (age, sex) and other
characteristics like binge drug use (defined as
going on drug ‘‘runs’’ or ‘‘binges’’ indicating
drugswereusedmorethanusualinonesitting),
the frequency of drug injecting, types of drug
used (methamphetamine use), history of HIV
testing, and HIV status independently. The qual-
ity of all reviewed papers was evaluated by the
Newcastle-Ottawa Scale
33
suggested by the
Cochrane Collaboration.
34
Table 1. Search strategy by indexing website.
PubMed (Syringe Program[Title])) OR borrowing syringes[Title/Abstract]) OR lent syringes[Title/
Abstract]) OR Receptive sharing[Title/Abstract]) OR Distributive sharing[Title/Abstract])
AND Needle Sharing[MeSH Terms] OR Syringes[MeSH Terms]
ScienceDirect TITLE-ABSTR-KEY(Needle Sharing) and TITLE-ABSTR-KEY(borrowing syringes).
TITLE-ABSTR-KEY(Needle Sharing) and TITLE-ABSTR-KEY(Receptive sharing).
TITLE-ABSTR-KEY(Needle-Exchange Programs) and TITLE-ABSTR-KEY(borrowing syringes).
TITLE-ABSTR-KEY(Needle-Exchange Programs) and TITLE-ABSTR-KEY(Receptive sharing).
TITLE-ABSTR-KEY(Needle Sharing) and TITLE-ABSTR-KEY(lent syringes).
TITLE-ABSTR-KEY(Needle Sharing) and TITLE-ABSTR-KEY(Distributive sharing).
TITLE-ABSTR-KEY(Needle-Exchange Programs) and TITLE-ABSTR-KEY(lent syringes).
TITLE-ABSTR-KEY(Needle-Exchange Programs) and TITLE-ABSTR-KEY(Distributive sharing).
Web of Knowledge TS¼(Needle-Exchange ProgramsAND borrowing syringes) OR TS¼(Needle-Exchange
ProgramsAND lent syringes) Timespan: All years.
TS¼(Needle-Exchange ProgramsAND Receptive sharing) OR TS¼(Needle-Exchange
ProgramsAND Distributive sharing) Timespan: All years.
TS¼(Syringe ProgramAND borrowing syringes) OR TS¼(Syringe ProgramAND
lent syringes)
TS¼( Needle Sharing AND borrowing syringes) OR
TS¼( Needle Sharing AND lent syringes)
TS¼(Syringe ProgramAND Receptive sharing) OR TS¼(Syringe ProgramAND
lent syringes)
TS¼( Needle Sharing AND Receptive sharing) OR
TS¼( Needle Sharing AND Distributive sharing)
TI¼(EffectivenessAND Needle Sharing) OR TI¼(Syringe ProgramAND lent syringes)
TI¼(impactAND Needle Sharing) OR TI¼(Syringe ProgramAND lent syringes)
TI¼(EffectivenessAND Needle Sharing) OR TI¼(Syringe ProgramAND
borrowing syringes)
TI¼(impactAND Needle Sharing) OR TI¼(Syringe ProgramAND lent syringes)
TI¼(EffectivenessAND Needle Sharing) OR TI¼(Syringe ProgramAND
Receptive sharing)
TI¼(impactAND Needle Sharing) OR TI¼(Syringe ProgramAND Distributive sharing)
Cochrane MeSH descriptor: [Needle-Exchange Programs] explode all trees OR MeSH descriptor:
[Syringes] explode all trees AND borrowing syringes:ti,ab,kw OR Receptive sharing:ti,ab,kw
(Word variations have been searched) AND lent syringes:ti,ab,kw OR Distributive
sharing:ti,ab,kw (Word variations have been searched)
JOURNAL OF ADDICTIVE DISEASES 3
Data synthesis and statistical analysis
A meta-analysis was conducted with procreate
pooled odds ratios
35
and the confidence intervals
of 95% on associated factors of injecting risk
behaviors among PWID. Odds ratios (OR) of
research was assessed in 2 2 tables. An OR 1
was considered as not having a positive relation-
ship between being drug use, drug type (metham-
phetamine versus others), homelessness and
being HIV positive) with injecting-related risk
behaviors (lending and/or borrowing syringes).
An OR >1 (as the statistical threshold for evalu-
ating the relationship between outcome variables
and expositive variables) indicates a protective
association between variables and vice versa.
To understand the lack of correlation between
variables, we used Q test with a P value <0.05 and
I
2
statistics with a cutoff of 50%, while 95%
uncertainty intervals were also assessed for I
2
.We
considered any negative values to I
2
as equal to
zero. Considering the varied sampling methods of
the studies, the random effect model was applied
with the aim of evaluating pooled estimation.
Factors associated with injecting risk behaviors
among PWID were explored through an OR and
95% CI, and results were shown in forest plots.
Metan and meta bias commands in STATA ver-
sion 13.0, were applied for data analysis (STATA
Corporation, College Station, TX). In order to
understand any publication bias, we used Beggs
and Eggers publication bias method.
36,37
We
considered a P value 0.05 as statistically
significant.
Results
Study selection
A flow diagram depicting the study selection pro-
cess is presented in Figure 1.Intotal,2,704papers
were identified from the four databases and from
additional searches of the reference lists of these
papers. Of these, 2,080 articles were selected for
abstract review. After a detailed assessment of the
citations, we included 14 studies.
3850
Study characteristics
Table 2 presents the characteristics of the studies.
Synthesis of results/Meta-analysis
There are several risk factors influencing the bor-
rowing and/or the lending of needles and syringes
among PWID. These are shown in Figures2,3,4,
5and 6by forest plots.
Impact of age on borrowing of needles and
syringes among PWID
Figure S1 (supplementary material) is the forest
plot of the effect that age has on the borrowing
of needles and syringes among PWID.
Seven studies
3843,50
examined the relationship
between age and borrowing and lending of nee-
dles and syringes among PWID. Five studies
were conducted in high-income countries,
3843
and one in an upper middle-income country
(Thailand).
50
The dates of studies ranged from
1987 to 2017, and the sample sizes were between
145 and 901. Five studies were assessed as having
high quality of evidence and two studies were
categorized as having satisfactory quality of evi-
dence. Six studies used a cohort approach for
their analysis
38,39,41,43,50
and one study used a
crosssectional design.
42
As illustrated in Figure
S1 (supplementary material) age is negatively
associated with the reporting of lending and/or
borrowing of used needles and syringes and the
heterogeneity is 86.2% and the pooled effect size
implies no significant association. (OR, 0.98; 95%
CI, 0.931.03).
Impact of binge drug use on borrowing of needles
and syringes among PWID
Figure 2 shows the effect of binge drug useon
the borrowing of syringes among PWID. The
heterogeneity is 0%, and the pooled effect size is
1.39 which implies an association between binge
drug use on borrowing of syringe among PWID.
Three studies
38,44,50
examined the relationship
between binge drug use and borrowing of needles
and syringes among PWID. Two studies were
conducted in high-income countries,
38,44
and one
in an upper middle-income country (Thailand).
50
The dates of studies ranged from 1997 to 2017,
and the sample sizes were between 154 and 505.
Two studies were assessed as having high qual-
ity evidence and one study was categorized as
4 O. REZAEI ET AL.
having a satisfactory quality of evidence. One
study used a cohort approach for their analysis,
38
one study used a crosssectional design
51
and
another used a case-control design.
44
PWID who reported binge drug use were 1.39
timesmorelikelytoalsoreporttheborrowingofnee-
dles and syringes (OR ¼1.39, 95%CI ¼1.06, 1.71).
Impact of type of drug used (methamphetamine
versus others) on borrowing of needles and
syringes among PWID
Figure 3 presents the association between the
type of drug used (methamphetamine versus
others) and the borrowing of used needles and
syringes among PWID.
Six studies
41,4345,50
examined the relationship
between methamphetamine use and borrowing of
needles and syringes among PWID. Five studies
were conducted in high-income coun-
tries,
41,43,44,50,52
and one in an upper middle-
income country (Thailand).
50
The dates of studies
ranged from 1992 to 2012, and the sample sizes
were between 125 and 1228. Four studies were
assessed as having high quality evidence and two
studies were categorized as having a satisfactory
quality of evidence. Four studies used a cohort
approach for their analysis,
39,41,43,50
one study
used a crosssectional design
51
and there was one
case-control designed study.
44
The use of methamphetamine has a positive
impact on the borrowing of already used syringes
among PWID. The pooled effect size is 1.50 with
a confidence interval of between 1.22 and 1.77.
The overall heterogeneity is 46.9%. PWID who
report methamphetamine use were 1.50 times
Figure 1. PRISMA flow diagram.
JOURNAL OF ADDICTIVE DISEASES 5
more likely to report the borrowing of used nee-
dles and syringes (OR, 1.50; 95% CI, 1.221.77).
Impact of having a sex partner who also injects
on borrowing of needles and syringes
among PWID
Five studies
40,41,44,52,53
examined the relationship
between having a sex partner who also injects
and borrowing of needles and syringes among
PWID. Five studies were conducted in high-
income countries,
3843
and one in an upper mid-
dle-income country (Thailand).
50
The studies
were published between 1987 and 2017 with sam-
ple sizes between 145 and 901.
Three studies were assessed as having high quality
evidence and two studies were categorized as having
a satisfactory quality of evidence. Two studies were
cross-sectional,
45,46
one study used a cohort design
41
andonestudyusedacase-controldesign.
44
Figure S2 (supplementary material) indicates that
the calculated pooled effect size is 0.60 for the impact
of sex partner on reporting the borrowing of already
used syringes among PWID. The confidence interval
was 0.11 through 1.10 indicating a notable but not
significant association between the effect of sex part-
ner on the borrowing of used syringes among PWID.
Although the heterogeneity is 88.8%, the low number
of sex partners has a limited impact on risk behaviors
among PWID (OR, 0.60; 95% CI, 0.111.10).
Impact of HIV testing on borrowing of needles
and syringes among PWID
Three studies
39,44,51
examined the relationship
between HIV testing and borrowing of needles
Table 2. Characteristics of studies investigating factors associated with injecting risky behaviors among people who inject drugs.
Authors Country Year Sample size Study design
Reported
risky behaviors
Quality assessment
criteria
Bozinoff et al. [1] Canada 2017 505 Cohort Borrowing and Lending Good
Hartgers et al. [2] Netherlands 1989 145 Cohort Borrowing Satisfactory
Fisher et al. [3] Canada 2002 653 Not applicable Borrowing Good
Huo and Ouellet [4] U.S.A 2007 901 Cohort Borrowing and Lending Good
Jenness et al. [5] U.S.A 2011 500 Cross section Borrowing Satisfactory
Kerr et al. [6] Canada 2010 1228 Cohort Borrowing and Lending Good
Rachlis et al. [7]. Canada 2010 620 Cohort Borrowing Good
Kerr et al. [7] Thailands 2011 240 Cross section Borrowing Good
Strathdee et al. [8] Canada 1997 154 case-control Borrowing Satisfactory
Hartgers et al. [9] Netherlands 1992 125 Cross section Borrowing Satisfactory
Belanger et al. [10] Canada 2002 459 Cross section Borrowing and Lending Good
Kral et al. [11] U.S.A 2004 531 Cross section Lending Good
Rezaie et al. [12]. Iran 2016 500 Cross section Lending Good
Laktin and Forman [13] U.S.A 2001 741 Cross section Lending Satisfactory
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2. Hartgers C, Buning EC, Vansanten GW, Verster AD, Coutinho RA: THE IMPACT OF THE NEEDLE AND SYRINGE-EXCHANGE PROGRAM IN AMSTERDAM ON
INJECTING RISK BEHAVIOR. Aids 1989, 3(9):571-576.
3. Fisher DG, Harbke CR, Canty JR, Reynolds GL: Needle and syringe cleaning practices among injection drug users. Journal of drug education 2002,
32(2):167-178.
4. Huo DZ, Ouellet LJ: Needle exchange and injection-related risk behaviors in Chicago - A longitudinal study. Jaids-Journal of Acquired Immune Deficiency
Syndromes 2007, 45(1):108-114.
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to Sterile Syringes. American Journal of Public Health 2010, 100(8):1449-1453.
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6 O. REZAEI ET AL.
and syringes among PWID. Three studies were
conducted in high-income countries. The dates
the studies were published ranged from 1989 to
2010, and the sample sizes were between 154 and
1228. One had a high quality of evidence and
two studies were categorized as having a satisfac-
tory quality of evidence. Two studies used a
cohort design
39,51
and one study used a case-con-
trol design. As illustrated in Figure S3 (supple-
mentary material) HIV testing is not associated
with the borrowing of used needles and syringes.
The heterogeneity is 88.4% and the pooled effect
size implies no significant association (OR, 0.70;
95% CI, 0.161.24).
Impact of frequency of injection on borrowing
of needles and syringes among PWID
Figure S4 (supplementary material) presents the
possible association between frequency of injec-
tion and the borrowing of syringes among
PWID. Reduced frequency of injection has a
positive impact on the borrowing of syringes
among PWID. The heterogeneity statistic is 0%,
and the pooled effect size implies no significant
association, although the confidence interval is
wide and ranges between 0.79 and 3.16 (OR,
1.98; 95% CI, 0.793.16).
Impact of type of drug used (methamphetamine
use versus others) on lending of needles and
syringes among PWID
Figure 4 shows the association between type of
drug used (methamphetamine use versus others)
and the lending of used syringes among PWID.
Two studies examined the relationship between
type of drug used (methamphetamine use versus
others) and the lending of used syringes among
PWID. Two studies
41,51
were conducted in high-
income countries. The dates of studies ranged
from 2007 to 2010, and the sample sizes were
between 901 and 1228. Both studies used a
cohort design and were assessed as having a high
quality level of evidence.
Figure 2. Forest plot of binge drug use on borrowing of syringe showing the OR and 95% CI by sub-groups.
JOURNAL OF ADDICTIVE DISEASES 7
Figure 3. Forest plot of type of drug used (methamphetamine vs others) on borrowing of syringe showing the OR and 95% CI by
sub-groups.
Figure 4. Forest plot of type of drug used (methamphetamine vs others) on lending syringe showing the OR and 95% CI by
sub-groups.
8 O. REZAEI ET AL.
Methamphetamine use was positively associ-
ated with the lending of syringes among PWID.
The pooled effect size is about 1.39 with a confi-
dence interval between 1.33 and 1.64. The overall
heterogeneity was 60.1%. Those PWID who
reported methamphetamine use were 1.39 times
more likely to report the lending of used needles
and syringes (OR, 1.39; 95% CI, 1.131.64).
Impact of homelessness on lending of needles and
syringes among PWID
Figure 5 is the forest plot outlining the effect of
homelessness on the reporting of lending used
needles and syringes among PWID.
Three studies examined the relationship
between homelessness and the lending of previ-
ously used needles and syringes among PWID.
Two studies
38,47
were conducted in high-income
countries and one of them in an upper middle
income country.
48
The dates of studies ranged
from 2004 to 2017, and the sample sizes were
between 500 and 531. Three studies were assessed
as high quality. Two studies were cross sectional
and one used a cohort design.
As illustrated in Figure 5, homelessness was
positively associated with the lending of syringes
among PWID. The heterogeneity statistics is
38.2%, and the pooled effect size implies an asso-
ciation, although the confidence interval is wide
(range between 1.27 and 2.51). Homeless PWID
were 1.89 times more likely to report the lending
of needles and syringes (OR, 1.89; 95%
CI, 1.272.51).
Impact of HIV status on lending of needles and
syringes among PWID
Figure 6 is the forest plot of the effect of HIV
status on lending of syringes among PWID.
Three studies
41,49,51
examined the relationship
between HIV status and of lending used needles
and syringes among PWID. Three studies were
conducted in high-income countries. The dates of
studies ranged from 2001to 2010, and the sample
sizes were between 741 and 1228. Three studies
were assessed as having a high quality of evi-
dence. Two studies used a cohort design and one
study used a cross section design.
As illustrated in Figure 6 current HIV positive
status has a negative impact on the lending of used
syringes among PWID. The heterogeneity statistic
is about 24.7%, and the pooled effect size implies
a relative neutral association. Those respondents
Figure 5. Forest plot of homelessness on lending syringes showing the OR and 95% CI by sub-groups.
JOURNAL OF ADDICTIVE DISEASES 9
who reported being currently HIV positive were
0.50 times less likely to lend already used needles
and syringes (OR, 0.50; 95% CI, 0.370.63).
To identify the publication bias, we used
Eggers plot and this did not demonstrate
significant bias (P ¼0.08,) (Figure S5).
Discussion
This systematic review and meta-analysis shows
the key factors associated with injection-related
risk behaviors among PWID. The specific focus is
on the reporting of borrowing and/or lending of
already used injecting equipment. Fourteen studies
met the eligibility criteria of the study. Details of
the studies included are shown in Table 2. In our
analysis we investigated nine factors related to
injection-related risk taking among PWID. While
we found no significant relationship between age
and the borrowing of used syringes (pooled OR:
0.98; %95 CI: 0.93-1.03) previous research con-
ducted in Iran established that older PWID were
more likely to report lifetime syringe sharing.
54
Australian research has found older PWID report
lower levels of current injecting-related risk taking,
including the sharing of needles and syringes,
when compared to younger PWID
55
suggesting
that over time PWID can change their behaviors.
It is important to note evidence of PWID describ-
ing needle borrowing as a behavior which makes
them more socially connected to other PWID but
not necessarily regarding this sharing as risky.
56
A number of studies conducted in the late 1990s
found between 40-45% of PWID reported recent
borrowing of a used syringe.
5759
These studies
identified a wide range of issues as related to
sharing behavior, including demographic charac-
teristics,
53
social dimension,
60
sexual behaviors,
61
injecting behaviors,
52
and the normalization of
sharing within injecting partnerships.
62
Other
studies found that being of younger age,
6366
hav-
ing a shorter injection history,
64,67,68
and being in
a sexual relationship with other injectors
63,69,70
were commonly associated with the borrowing of
already used syringes. A Canadian longitudinal
cohort study of young injectors found that almost
40% (N¼191) of the sample reported either
syringe borrowing, syringe lending, or both over a
10 year period.
38
Similarly, an Iranian-based study
showed that 35.8% of PWID reported a lifetime
experience of needle and syringe sharing.
54
Recent
injecting drug use prevalence estimates showed
varied ages for PWID globally but noted evidence
for ageing populations of PWID particularly in
Figure 6. Forest plot of HIV status on lending syringes showing the OR and 95% CI by sub-groups.
10 O. REZAEI ET AL.
Europe, North America, and Australia.
1
Results
from a longitudinal cohort study with younger
injectors in San Francisco showed a positive rela-
tionship between receptive syringe sharing and
younger age.
71
Research with younger PWID sug-
gests they have less extensive experience with
injecting and that this may lead to re-use and shar-
ing of previously used syringes.
7274
Our results
indicated a significant relationship between binge
drug use and the borrowing of syringes (pooled
OR: 1.39; %95 CI: 1.06-1.71). This finding is con-
sistent with previous studies which found that
cocaine injection (often used in binge sessions)
was significantly associated with increased odds of
becoming infected with HCV.
7577
We also identified several related associations
with binge drug use, including syringe lending
and borrowing and HIV seroconversion. Public
health policy makers would do well to design
public health interventions to decrease vulnerabil-
ities related to binge drug use. The borrowing
and lending of syringes among PWID on a binge
may be due to the policies and regulations of cer-
tain NSP.
78
Clearly changing these policies and
regulations so as to ensure increased availability
of sterile syringes will decrease the negative pub-
lic health consequences associated with binge
injection drug use.
79
In line with the results of previous studies
showing frequent methamphetamine injection is
positively associated with syringe sharing
75,80
our
research further suggests that methamphetamine
use had a positive effect on the borrowing of nee-
dles and syringes (pooled OR: 1.50; %95CI: 1.22-
1.77). This finding is in line with the previously
published Australian research that linked fre-
quent cocaine injection to syringe sharing.
75
Our results related to drug specific HIV-risk
behaviors show that injection-related risk practices
(borrowing and lending of already used needles
and syringes) indicate another mode for possible
HIV transmission among methamphetamine
users.
81
Methamphetamine production has been
reported as highly profitable, easily concealed and
demand for the drug is growing.
82
Law enforce-
ment may have a partial influence on use
83
but will
never eliminate use and therefore, evidence-based
HIV prevention and drug treatment programs for
methamphetamine injectors are required to reduce
the most negative harms associated with its use.
84
Results of the current study showed no statistic-
ally significant correlation between having a cur-
rent sex partner who injects and the borrowing of
used syringes (pooled OR: 0.60; %95 CI: 0.11-1.01).
Gender and power dynamics for female PWID are
important risk factors for borrowing and lending
of used needles and syringes.
85
There is a great
deal of previous research highlighting that female
PWID who inject together with their sex partners
might be at higher risk primarily because they use
after and with the used equipment of their
partners.
44,63,77,80,86,87
Our study did not find a statistically significant
correlation between recent HIV testing and syr-
inge borrowing (pooled OR: 0.70; %95 CI: 0.16-
1.24). The present meta-analysis showed no sig-
nificant effect of frequency of injection on syr-
inge borrowing (pooled OR: 1.98; %95 CI: 0.79-
3.16). However, this contradicts results from
another study showing a positive association
between needle sharing and higher frequency of
injection,
88
one possible explanation for this dif-
ference could be the wide confidence intervals of
the studies.
HIV prevention interventions targeting PWID,
such as sterile syringe programs and evidence-based
treatment, should be up scaled and implemented for
methamphetamine usage.
89
NSPs are one of the most
important public-health interventions for BBV
prevention among PWID. These programs not only
supply sterile injecting equipment for active injectors,
but are also in a position to provide other prevention
materials(condomsandice-pipes),primary
health care, legal and social services, as well as drug
treatment all of which contribute to reducing the
marginalization of drug users.
90
Consistent with other studies
80,91
our results
showed that
92
use is positively associated with the
lending of syringes (pooled OR: 1.39; %95 CI:
1.13-1.64) and there is a significant association
between methamphetamine use and HIV risk
among PWID.
Our results indicate the need for continued
efforts to develop effective BBV prevention
programs and further research to better under-
stand the implications of increasing rates of
methamphetamine injection. There clearly remain
JOURNAL OF ADDICTIVE DISEASES 11
imposing structural factors that impact adequate
access to sterile syringes among PWID,
51,93
and
these together with the substantial stigma
experienced mean that peer-facilitated syringe
distribution may be beneficial and provide
necessary BBV prevention tools to PWID.
31
While access to sterile syringe distribution
services has improved across many countries,
more is needed to ensure these services are avail-
able for methamphetamine injectors specifically
as many programs were designed and developed
to work with PWID who inject opioids.
94
Our analysis found a statistically significant
relationship between syringe lending and syringe
borrowing and homelessness.
38,91
Unstable hous-
ing has a direct impact on the safe and secure
places where PWID can inject and it is more
common for them to report using in public set-
tings where they are at risk of arrest by police.
95
Public injecting has also been shown to be more
rushed, less safe and less hygienic.
96
PWID who
inject in public places are more likely to report
needle and syringe sharing than those who do
not use in public settings
28,97
and homelessness
has also been associated with drug injecting
98102
other social vulnerabilities including poverty,
103
poor mental health,
99
and incarceration.
103
Qualitative research studies indicate that
homelessness is related with more drug use to
increase sleep or to stay awake, both of which
may increase opportunities for syringe sharing.
99
Also, homeless PWID have reported unstable
housing as a reason police use to harass them.
104
Our findings indicate an association between
homelessness and syringe sharing and point to
the need for policy interventions that improve
the accessibility of stable and affordable housing
and thereby reduce opportunities for syringe
sharing among PWID. As noted above the devel-
opment of one-stop-shop models for a range of
vulnerable PWID may prove to be the best way
of reducing overall harms.
There are limitations to this study that need to
be acknowledged and considered when conduct-
ing future research on this topic. First, a major
weakness was that some of the studies did not
provide sufficient information for inclusion in
the meta-analysis, for other studies there was no
response to author correspondence requesting
this information. With the number of included
studies we were conscious of the need to improve
the precision and estimations for our pooled OR.
A second limitation is that the studies were
observational meaning statistical measures
including ORand RRwere less available.
The selected studies used a range of covariates
and different methods to develop their logistic
and linear models and performed univariate and
other multivariate approaches. The covariate clas-
sifications that contained education and income
levels were not consistent across studies. There
were few studies that directly included data on
lending and/or borrowing of syringes, so this gap
remains in the literature. Our results only present
the data that were reported in the articles.
Although understanding the relationship between
polydrug drug use, daily heroin use, incarceration
and alcohol use and increased lending and/or
borrowing of syringes are essential for the devel-
opment of appropriate prevention interventions,
only one of the included studies specifically
reports on the factors associated with lending
and/or borrowing syringes. For a number of the
papers cited in the discussion, the independent
variables were not borrowing or lending of
syringes. Instead syringe sharing in general is
used so we could not consider them as borrowing
or lending specifically. These differences in the
measurement of sharing between studies meant
that we could not include some studies in the
analysis. Moreover, the selected studies used
different logistic and linear models and applied
both univariate and other multivariate approaches
in their analysis. The covariate classifications that
were different between studies included educa-
tion, social support, and income levels. Therefore,
we specified some conditions to allow for the
integration of data and to conduct the meta-
analysis. A strength of our analysis is that the
time interval for study inclusion covered the
problems identified in a previous meta-analysis.
24
Conclusion
This systematic review and meta-analysis supports
the development of initiatives that reduce drug-
related harms including the establishment and
maintenance of sterile needle syringe programs.
27
12 O. REZAEI ET AL.
The data collected and reported suggest that pro-
gram developers and policymakers across all levels
of government should initiate and expand programs
that facilitate the distribution and collection of ster-
ile injecting equipment for PWID.
Declaration of interest
Ethical approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials
The datasets used and/or analyzed during the
current study are available from the correspond-
ing author on reasonable request.
Competing interests
The authors declare that there are no conflicts
of interest.
Funding
This research did not receive any specific grant
from funding agencies in the public, commercial,
or nonprofit sector.
Authorscontributions
Study concept and design BA, AB and HGh.
Analysis and interpretation of data: EA, and FR:
Drafting the manuscript. MN, PH and AN:
Critical revision of the manuscript:OR. All
authors read and approved the final manuscript.
Acknowledgements
The authors would like to acknowledge the contributions of
Haedar Mohammadi to the work of this review of
the evidence.
Abbreviations
HCV hepatitis C virus;
PWID people who inject drugs;
BBVs blood borne viruses;
OR odds ratios;
CI: confidence interval;
PRISMA Protocols of Systematic Reviews and
Meta-Analyses;
NSPs needle syringe programs
ORCID
Bahram Armoon http://orcid.org/0000-0001-5467-9889
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... The substance also impairs decision-making, which increases the likelihood of condomless and group-based sex (Lodge et al., 2022). Additionally, intravenous methamphetamine use is associated with syringe sharing (Rezaei et al., 2020). Sharing syringes, as well as skin tearing and condomless and group-based sex, are risk factors for infectious disease transmission (Maxwell et al., 2019;Tomkins et al., 2019) that partially account for elevated HCV, syphilis, HIV, and other sexually transmitted infections among MSM who use methamphetamine (Maxwell et al., 2019;Tomkins et al., 2019). ...
... The rise in methamphetamine use and the established association between use and risk behavior underscore the need to estimate the pooled prevalence of methamphetamine use among MSM (Bourne & Weatherburn, 2017;Halkitis et al., 2005;Halkitis & Shrem, 2006;Maxwell et al., 2019;Rajasingham et al., 2012;Rezaei et al., 2020;Vu et al., 2015). Previous meta-analyses focused on MSM engaged in sexualized drug use, provided estimates other than methamphetamine use prevalence (e.g., association between amphetamine-type stimulant use and sexually transmitted infections), did not disaggregate methamphetamine from other stimulants in analyses, or were regionally-specific (e.g., East and South Asia) (Guerra et al., 2020;Nevendorff et al., 2023;Wang et al., 2023). ...
... Understanding the prevalence of methamphetamine use is critically important for identifying for whom targeted interventions to reduce methamphetamine use are needed. Our findings underscore that among MSM, a population for whom methamphetamine use is associated with poor health outcomes, including co-occurring substance use and HIV (Bourne & Weatherburn, 2017;Halkitis et al., 2005;Maxwell et al., 2019;Palamar & Halkitis, 2006;Rajasingham et al., 2012;Rezaei et al., 2020), intervention work is warranted. This meta-analysis affords a robust estimate of the prevalence of methamphetamine use among MSM across prevalence periods, which is useful in steering resource allocation toward developing and implementing interventions to address this issue among MSM. ...
Article
Background: International efforts have reduced the availability of methamphetamine precursors, but its distribution and use continue to rise. Methamphetamine use can lead to short-and long-term adverse effects, including addiction, physical and psychosocial health problems, socioeconomic troubles, incarceration, overdose, and death. Gay, bisexual, and other men who have sex with men (MSM) have been shown to have an elevated prevalence of methamphetamine use. Methods: We conducted a systematic review and meta-analysis to estimate the prevalence of methamphetamine use among MSM. We searched electronic databases, such as PubMed, for peer-reviewed literature published between 2011 and 2022. Data on methamphetamine use were extracted, including study features, location, study design, sampling method, recruitment period, specific MSM subgroups, prevalence period, and demographics. Employing a random-effects model, we computed the pooled prevalence of methamphetamine use among MSM across two prevalence periods: recent use (i.e., one month, three months, six months, one year) and lifetime use. Results: The systematic review included 56 studies with a total of 25,953 MSM who use methamphetamine. Most studies were conducted in Europe, with the highest prevalence reported in the United Kingdom. The studies primarily used cross-sectional or cohort study designs with convenience sampling. The pooled prevalence rates across recent use (i.e., past month, past three months, past six months, and past year) was 15% (95% CI [11-19%]). Additionally, we pooled lifetime use, which was 23% (95% CI [9-38%]). High heterogeneity (I 2 > 99%) was observed, indicating significant variation. Conclusion: This systematic review and meta-analysis provide a pooled prevalence of methamphetamine use among MSM. The analysis accounts for study design, prevalence period, specific MSM subgroups, and geographical areas to estimate methamphetamine use in diverse settings and populations. The review highlights the need for targeted interventions and harm reduction strategies focused on prevention, education, healthcare access, and stakeholder collaboration to address the multifaceted challenges of methamphetamine use among MSM.
... Homelessness is related to other environmental factors that may influence cognitive processes like self-efficacy. For example, people experiencing homelessness have limited capacity to carry sterile injection equipment and access harm reduction services in light of regular displacement, police harassment, violence, and incarceration [72][73][74]. Involuntary displacement of PWUD experiencing homelessness is a common practice that exacerbates health problems [73]. Interventions to expand access to low-barrier, stable housing may help reduce injection risk behaviors [75] and improve many other health outcomes for this population [76]. ...
... For example, people experiencing homelessness have limited capacity to carry sterile injection equipment and access harm reduction services in light of regular displacement, police harassment, violence, and incarceration [72][73][74]. Involuntary displacement of PWUD experiencing homelessness is a common practice that exacerbates health problems [73]. Interventions to expand access to low-barrier, stable housing may help reduce injection risk behaviors [75] and improve many other health outcomes for this population [76]. ...
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Background Safe injection self-efficacy (SISE) is negatively associated with injection risk behaviors among people who inject drugs (PWID) but has not been examined in differing risk environments. We compared responses to a validated SISE scale between PWID in San Diego, California and Tijuana, Mexico, and examine correlates of SISE among PWID in Tijuana. Methods PWID were recruited via street outreach for a longitudinal cohort study from October 2020 to September 2021. We compared SISE scale items by city. Due to low variability in SISE scores among San Diego residents, we restricted analysis of factors associated with SISE to Tijuana residents and identified correlates of SISE scores (low, medium, high) using ordinal logistic regression. Results Of 474 participants, most were male (74%), Latinx (78%) and Tijuana residents (73%). Mean age was 44. Mean SISE scores among San Diego residents were high (3.46 of 4 maximum) relative to Tijuana residents (mean: 1.93). Among Tijuana residents, White race and having previously resided in San Diego were associated with higher SISE scores. HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were associated with lower SISE scores. Conclusions We found profound inequalities between Tijuana and San Diego SISE, likely attributable to differential risk environments. Associations with fentanyl and polysubstance co-injection, injection frequency, and both HIV and HCV seropositivity suggest that SISE contribute to blood-borne infection transmission risks in Tijuana. SISE reflects an actionable intervention target to reduce injection risk behaviors, but structural interventions are required to intervene upon the risk environment.
... Bingeing may be accompanied by risk behaviours given that individuals' psychological and physiological state becomes increasingly compromised while engaging in the practice (Bourgois & Bruneau, 2000;Ciccarone, 2011;Tyndall et al., 2003). Although no standardized definition exists, studies using various indicators have previously linked binge-type practices to needle-syringe sharing (Rezaei et al., 2020), non-fatal overdose (Kerr et al., 2007), psychological distress (Minoyan et al., 2021), suicide attempts (Fournier et al., 2018) and HIV infection (Miller et al., 2006) among PWID. However, no studies to our knowledge have reported detailed data on the substances and circumstances involved in binge drug injection. ...
... At baseline, 14% of participants reported bingeing in the past 3 months and roughly one-third reported doing so at some point over the course of follow-up. Binge episodes tended to involve a large number of injections, loss of control over consumption and long sleepless periods; these factors may in turn contribute to impaired decision-making and lapses in preventive behaviours, consistent with studies linking binge to sharing of injection equipment (Rezaei et al., 2020;Wood et al., 2002) and HIV transmission (Miller et al., 2006). Binges may also exacerbate risk of overdose (Kerr et al., 2007) Binge is sometimes conflated with stimulant use due to the consumption patterns that stem from the short half-life of this drug class (e.g. ...
Article
Full-text available
We describe binge drug injection in a longitudinal cohort study of people who inject drugs (PWID) in Montreal, Canada (eligibility: age ≥ 18, past-6-month injection drug use; follow-up: 3-monthly interviews). Bingeing was defined as injecting large quantities of drugs over a limited period, until participants ran out or were unable to continue, in the past 3 months. We recorded substances and circumstances typically involved in binge episodes. Eight hundred five participants (82% male, median age 41) provided 8158 observations (2011–2020). Thirty-six per cent reported bingeing throughout follow-up. Binges involved a diverse range of substances and social contexts. Cocaine was involved in a majority of recent binges (73% of visits). Injection of multiple drug classes (24% of visits) and use of non-injection drugs (63% of visits) were common, as were opioid injection (42%) and injecting alone (41%). Binge drug use may thus be an important yet overlooked trigger of overdose and other harms among PWID. This understudied high-risk behavior warrants further research and public health attention.
... The 2021 Australian Needle Syringe Program survey found that 18% of respondents reported receptive sharing of needles and syringes (injecting with another person's unsterile needle/syringe) in the last month [21]. A systematic review and meta-analysis found that binge drug use and methamphetamine use were positively associated with the receptive sharing of used syringes [43]. This is of particular relevance in Australia as the 2021 IDRS demonstrated that methamphetamine has now surpassed heroin as the most common drug of choice in Australia [23]. ...
... Eighty-one percent of people interviewed as part of the IDRS interviews in 2022 reported methamphetamine use within the past 6 months, compared to 60% in 2010 [23]. Methamphetamine use is associated with high-risk behaviours and drug-related harms and there is clear evidence that hospital admissions related to crystal methamphetamine use have been increasing in Australia since 2010 [43,71,72]. ...
Article
Issues People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described. Approach We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health. Key Findings The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care. Implications Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health‐care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors. Conclusion Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health‐care systems. Flexible health‐care models, such as low‐threshold wound clinics, would help directly target, and address early interventions, for these infections.
... In the context of tailoring clinical care to a patient's substance use pattern, rapid HCV care may be more critical for those who use stimulants and opioids, as this population may use more frequently compared to those who use either substance alone [62]. Also, there are no FDA-approved medication assisted treatment options for stimulants [63], and there is a greater likelihood of overlap with other potential risks for transmission, such as sharing drug use equipment [64] and engaging in unprotected sex [65]. From a medical care perspective, it needs to be determined if HCV treatment providers in rural communities are not adhering to treatment policies by refusing treatment to those who use both opioids and stimulants or if the participants who use both are less likely to engage in care. ...
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... In our study, homelessness was associated with lower levels of SISE, which is an environmental factor consistently found to be associated with riskier drug use behaviors among people who use drugs (PWUD) [72,73]. Homelessness is related to other environmental factors that may influence cognitive processes like self-efficacy. ...
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... Propensity score matching was used to create comparison samples for transgender individuals with cisgender women or cisgender men. Samples were matched using sociodemographic factors known to influence the nature of substance use and patterns of treatment engagement including age, education, race (49), stable housing (50), and being employed either full-or part time (51). ...
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Introduction This study describes the differences and similarities in mental health, substance use, and substance use treatment outcomes between people presenting for SUD treatment who identified as transgender and those who identified as cisgender men or women. Methods We compared 64 individuals who self-identified as transgender and presented for SUD treatment to samples of cisgender men and women (separately) matched based on propensity scores which were created based on sociodemographic factors known to influence both the nature of substance use and patterns of treatment engagement including age, education, race, stable housing, and employment status. Comparisons were made using χ² tests and t-tests in over 150 variables collected at treatment intake regarding physical and mental health, substance use patterns, events that led to treatment, reasons for seeking treatment, and treatment outcomes. Results The transgender sample endorsed six of the seven suicide-related items more often than at least one of the cisgender-matched samples. Furthermore, the transgender sample remained in treatment significantly longer (M = 32.3, SD = 22.2) than the cisgender male sample (M = 19.5, SD = 26.1, t = 2.17, p = 0.03). Discussion This study is a first step into understanding gender minority population experiences during SUD treatment. While there was no significant difference between the cisgender and transgender samples on most variables, there was an elevated prevalence of suicidal ideation and behaviors in the transgender sample, which warrants further investigation.
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The present meta-analysis aimed to investigate the effect of injection duration on injection and sexual high-risk behaviors among people who inject drugs (PWID), in order to inform development of intensive HIV prevention services for selected PWID sub-populations. We searched PubMed, Science Direct, Web of Science, and Cochrane electronic databases independently in December 2018. After reviewing for duplication, full-texts of selected articles were assessed for eligibility using certain Population, Intervention, Comparator, Outcomes (PICO) criteria. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR) and 95% confidence intervals (CI). Our result indicated significant association between age of injection initiation > 17 years, frequency of drug injection > 5 times/day, injection by others, having sex partner, history of imprisonment with new injectors (OR = 0.93, 95%CI = 0.87–0.98), (OR = 0.51, 95%CI = 0.29–0.73), (OR = 1.11, 95%CI = 1.05–1.17), (OR = 2.08, 95%CI = 1.02–3.14) and (OR = 1.20, 95%CI = 1.03–1.37). Our research found that new injectors were more likely to report frequency of injections injected by others, has sex partner and prison detention. Our findings are significant for policy makers and public health practitioners to implement and design HIV prevention programs among PWID with shorter periods of injection. The findings of the present study extend our knowledge about new injection drug users, the significance of assured behaviors at IDUs’ initial injection, and the educational importance of syringe exchange programs.
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Background: The high prevalence of skin and soft tissue infections (SSTIs) is a significant health concern among people who inject drugs (PWIDs). This meta-analysis estimates the prevalence of SSTIs and its related risk behaviors among PWIDs. Methods: We searched PubMed, Science Direct, Web of Science, and Cochrane electronic databases independently in February 2018. After reviewing for duplication, full-text of selected articles were assessed for eligibility using certain Population, Intervention, Comparator, Outcomes (PICO) criteria. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR) and 95% confidence intervals (CI). Results: After a detailed assessment, a total of 20 studies containing 9,502 patients met the eligibility criteria. A pooled prevalence of 44% (95% CI, 31–56%) was estimated for SSTIs among PWIDs. Among the potential risk factors, only injecting frequency has a significant positive relationship with SSTIs among PWIDs (OR = 1.20, 95%CI = 1.03–1.37). Conclusion: The results of the present study indicate that PWIDs have a very high burden of SSTs infection, and also emphasized the potential role of higher injecting frequency on the prevalence of SSTs among PWIDs. These results suggest that more interventions to reduce of injection frequency might be useful in decreasing of SSTs burden among PWIDs.
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We sought to characterize the association between a forensic event (arrest or incarceration) with housing vulnerability and mental and physical health status over a four-year follow-up among a cohort of homeless and vulnerably housed individuals in Vancouver, Toronto and Ottawa. Data were obtained from the Health and Housing in Transition Study, a prospective cohort study of homeless and vulnerably housed individuals between 2009 and 2012. Participants were interviewed in-person at baseline (N = 1190) and at four annual follow-up time points. We used generalized estimating equations to characterize the independent associations between a forensic event and the number of residential moves and SF-12 physical and mental health component scores over the four-year follow-up period. We analyzed data from 1173 homeless and vulnerably housed participants. Forensic events were reported by 446 participants at baseline. In multivariate analyses, a history of forensic event in the preceding twelve months was independently associated with an increased number of residential moves over the four-year follow-up period (ARR 1.24; 95% CI 1.19–1.3). It was not, however, independently associated with a change in physical or mental health status (respective ß-estimates; 95% CI: -0.34; -1.02, 0.34, and -0.69; -1.5, 0.2). Female gender and a history of problematic substance use were significantly associated with all three primary outcomes. This suggests arrest or incarceration is associated with increased housing vulnerability. The results underline the importance of supporting individuals experiencing arrest or incarceration with post-release planning in order to obtain stable housing after discharge.
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Background: Global estimates suggest there are 15.6 million people who inject drugs (PWID) of whom 17.8% are living with HIV.Few studies have characterized newly-onset injectors with long-term injectors and its association with injecting risk behaviors. Objectives: We examined the relationship between length of injection and risk behaviors among people who inject drugs (PWID) in Tehran, Iran. Methods: A cross-sectional study was conducted among PWID, from March to August 2016 in Tehran, Iran. PWID were recruited by convenience and snowball sampling from five Drop-in Centers (DIC) located in the south of Tehran. Our primary independent variable was length of injecting career, defined as the number of months since injecting initiation. Those defined as new injectors (were injecting for less than 18 months), and long-term injectors (as injecting drugs for more than 18 months). We reported the adjusted odds ratio (aOR) point estimate and 95% confidence interval (CI95%) as the effect measure. The level of significance used in multiple logistic regression model was 0.05. We used STATA v. 11 for all analyzes. Results: The analytical sample comprised of 500 participants (100% male). Mean (±SD) age of PWID with a length of injection history was 31.2 ± 7.2 years. Overall, 270 (54%) (CI95%: 49.6%, 58.4%) of participants were long-term injectors. The average age of drug use initiation among long-term injectors group was lower as compared to new injectors group (31.2 vs. 29.4, p < 0.001). The odds of distributive syringe sharing among new injectors were two times higher than long-term injectors (AOR = 2.1, 95% CI 1.4-4.7). The odds of receptive syringe sharing were lower among new injectors group (AOR = 0.7, CI95% 0.2-0.87), compared to long-term injectors. New injectors had higher odds of reusing their own syringes (OR = 2.8, 95% CI: 1.4-5.7; p = 0.01). Conclusions: Improvements in harm reduction service provision can occur through taregted risk reduction education for new injectors focusing on reducing distributive syringe sharing among them.
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Background Many studies have found significant differences in HIV risk at the community and socioeconomic levels. However, few have considered variations in needle and syringe program (Jin et al., Oral Dis. 1;22(7):609–19) coverage and other community characteristics on HIV risk behaviors among people who inject drugs (PWIDs). Our objective was to study the relationship between individual factors and city-level characteristics (such as the city’s coverage of harm reduction programs) on HIV risk behavior among PWID residing in two cities in Iran. Methods The study was conducted from March to August 2016 in Tehran and Kermanshah provinces. One thousand PWID were recruited by a convenience sampling recruitment at local NSP Drop-in Centers (DIC) and through “snowball sampling” (i.e., using peers to refer participants to the study). We first examined associations between individual-level variables and HIV risk behaviors in bivariate analysis using the chi-square or Fisher’s exact tests, as appropriate. Next, multi-level models were constructed to determine the amount of variability in HIV risk behavior that could be accounted for by individual- and community-level characteristics. Variables with p value < 0.2 were included in the multiple logistic regression model. Results The results of the multilevel modeling showed that 32% of the variability in HIV risk behaviors among PWID could be explained by factors that differed between the two cities. When individual factors including higher HIV knowledge, access to NSP, higher HIV risk perception, and methamphetamine use were all included in the final model, 22% of the variability in HIV risk behaviors could be explained to city-level variables. Conclusion Findings suggest that expanding the accessibility (i.e., hours and venues) and community-level coverage of NSP services by establishing programs where PWID congregate might reduce HIV risk behavior among PWID.
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Background: Limited studies exist on risky sexual behaviors and sociodemographic variables among people who use drugs. Understanding the social determinants of risky sexual behaviors is important for designing appropriate HIV/AIDS interventions. Therefore, to illuminate this uncharted area, we aimed to investigate the social determinants of risky sexual behaviors among people who inject drugs (PWID) in Kermanshah, Iran.Methods: Cross-sectional data were analyzed from the HIV Behavioral Surveillance among PWID, conducted from 2013 to 2014 in Kermanshah, Iran. Additional data were collected by holding interviews to acquire information on sociodemographic characteristics (i.e., age, educational), history of substance use (i.e., age of initiation, use of specific drug types in the past 6 months), sexual behaviors including consistent condom use (yes/no), and type of sexual partners (main, casual, exchange). We analyzed variables individually through bivariate analysis and subsequently ran significant variables (P < 0.2) in a multivariate regression model. P < 0.05 was considered statistically significant. Descriptive statistics and logistic regression were conducted in Stata 11.Results: Participants were between the age of 14 and 78 years (median = 31 years; SD = 11.23 years). Compared to PWIDs who reported no sexual risk behavior, participants that were more likely to partake in sexual risk behaviors were those of low (adjusted odds ratio [AOR] = 3.2, P < 0.05) or moderate (AOR = 2.2, P < 0.05) socioeconomic status and methamphetamine use (AOR = 2.8, P < 0.05).Conclusion: A key finding of this study is that PWID who reported having multiple sex partners with inconsistent condom use were more likely to experience poly-drug use, methamphetamine use, being of low socioeconomic and education level, and refuse to attend harm reduction programs.
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Introduction and aims: In this study, we used a 'coarsened exact matching' method to evaluate the relationship between two levels of needle and syringe program (NSP) utilisation and HIV-related risk behaviours among people who inject drugs (PWID). Design and methods: Using snowball sampling, we recruited 500 PWID (all male) in Kermanshah City, Iran between September and December 2014 in a cross-sectional survey. We categorised participants into two groups, including high (i.e. receiving 60% or more of their syringes from an NSP) and low (i.e. receiving less than 60% of their syringes from NSP) NSP users. Then, we applied coarsened exact matching to match the two groups based on confounding covariates (age, place of residence, income, receiving methadone maintenance treatment) and made statistically equivalent comparison groups to estimate the effect of the NSP on injection risk behaviours. Results: Participants with low NSP use were more likely to report borrowing syringes in past 2 months (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.30, 1.86; P < 0.04), in comparison with participants with high NSP use. Regarding recent syringe lending, low NSP use was also significantly and positively associated with this outcome (OR 3.34; 95% CI 1.70, 5.20; P < 0.02). Reusing one's own syringe was reported more frequently in low NSP use group (OR 1.40; 95% CI 1.22, 3.97; P < 0.03). Discussion and conclusions: NSPs are a promising approach to reduce injection-related risk behaviours among PWID in Kermanshah, Iran. Expanded coverage of high-quality NSPs is recommended.
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Background: According to latest available data there are more of 300,000 people injects drug users (PWID) in Iran. Objectives: In this study, we used a Blinder-Oaxaca (BO) decomposition to explore the relative contributions of inequality in utilization of NSPs and to decompose it to its determinants in Teheran. Methods: We used data from a cross-sectional survey using snowball sampling to recruit 500 PWID from June to July 2016 in Tehran. Participants were reported injecting drug use in the past month, were able to speak and comprehend Farsi enough to respond to survey questions, and were able to provide informed consent to complete the interview. We used a BO method to decompose the role of economic inequality on utilization of needle and syringe programs. Results: A total 520 of clients participated in the study of which data was fully complete for 500. The selected predictor variables (age, education level, marital status, homelessness, HIV risk perception, and HIV knowledge) together explain 54% (8.5% out of 16%) of total inequality in utilization of needle and syringe programs and the remaining 46% constitute the unexplained residual. HIV risk perception status contributed about 38% (3.3% out of 8.5%) to the total health inequality, followed by HIV knowledge (26%) and education level were contributed 20% each, respectively. Conclusion: The results showed that contribution of economic inequalities in utilization of NSPs was primarily explained by the differential effects of HIV risk perception and HIV knowledge among PWID. Reducing HIV risk perception and increasing HIV knowledge might be essential to efforts to eliminate inequalities in access to NSPs among PWID.
Article
Background: People who inject drugs (PWID) do so at varying frequencies. More frequent injecting is associated with skin and soft tissue infection, blood borne viruses, and overdose. The aims of this review are to estimate the prevalence of injecting frequency among PWID and compare these estimates to current needle-syringe distribution coverage estimates, and identify socio-demographic and risk characteristics, and harms associated with daily or more injecting. Methods: We conducted a systematic review of the peer-reviewed and grey literature from 2008 to 2018 and extracted needle-syringe distribution coverage data from a recent systematic review. We generated country-, region-, and global-level estimates of daily or more injecting. We also ran meta-regression analyses to determine associations between daily or more injecting and socio-demographic characteristics, injecting risk behaviour, non-fatal overdose, injection site skin infection, and blood borne virus prevalence. Results: Our search resulted in 61,077 sources, from which 198 studies were eligible for inclusion in this review. There were 74 countries with estimates for injecting frequency. Globally, we estimated that 68.1% (95%CI 64.5-71.6%) of PWID, equating to approximately 10.5 (95% UI 6.8-15.0) million people, inject daily or more frequently. There was a higher percentage of participants reporting daily or more injecting among samples with shorter injecting careers, more male participants and higher reporting of opioids as their main drug injected. Daily or more injecting was also associated with samples reporting a higher prevalence of HIV and hepatitis C antibody (anti-HCV), non-fatal overdose, and receptive needle sharing in the previous month. Implications: WHO recently recommended a needle-syringe distribution target of 300 needles per PWID per year which is unlikely to be sufficient for the majority of PWID injecting daily or more who are out of drug treatment. Funding: The Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, University of New South Wales.