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IntroductionStudies examining the use of pre‐exposure prophylaxis (PrEP) to prevent HIV transmission among people who inject drugs (PWIDs) have not been adequately summarized. Recently, the Bangkok Tenofovir Study has shown that PrEP may be effective at reducing new HIV infections among this high‐risk group. This randomized controlled trial was the first study to specifically examine the efficacy of PrEP among PWIDs. In this review, we present the current state of evidence regarding the use of PrEP to prevent HIV infection in PWID populations, and set an agenda for future research to inform the most effective implementation of PrEP in the context of existing evidence‐based HIV prevention strategies.DiscussionDespite positive trial results confirming that PrEP may prevent HIV transmission among PWIDs, there remain many questions regarding the interpretation of these results, as well as obstacles to the implementation of PrEP regimens within highly diverse drug‐using communities. Aside from the Bangkok Tenofovir Study, we identified only one other published study that has collected empirical data to inform the use of PrEP among PWIDs. The large gap in research regarding the use and implementation of PrEP for PWIDs signals the need for further research and attention.ConclusionsWe recommend that future research efforts focus on elucidating the generalizability of the Bangkok Tenofovir Study results in other injection drug–using populations, examining the willingness of PWIDs to use PrEP in diverse contexts, identifying barriers to adherence to PrEP regimens and determining the most effective ways to implement PrEP programmes within the context of existing evidence‐based prevention strategies, including opioid substitution therapy and needle and syringe distribution programmes.

Background: For decades, Thailand has experienced high rates of illicit drug use and related harms. In response, the Thai government has relied on drug law enforcement to address this problem. Despite these efforts, high rates of drug use persist, and Thailand has been contending with an enduring epidemic of human immunodeficiency virus (HIV) among people who inject drugs (IDU). Methods: In response to concerns regarding drug-related harm in Thailand and a lack of research focused on the experiences and needs of Thai IDU, the Mitsampan Community Research Project was launched in 2008. The project involved administering surveys capturing a range of behavioral and other data to community-recruited IDU in Bangkok in 2008 and 2009. Results: In total, 468 IDU in Bangkok were enrolled in the project. Results revealed high rates of midazolam injection, non-fatal overdose and incarceration. Syringe sharing remained widespread among this population, driven primarily by problems with access to syringes and methamphetamine injection. As well, reports of police abuse were common and found to be associated with high-risk behavior. Problems with access to evidence-based drug treatment and HIV prevention programs were also documented. Although compulsory drug detention centers are widely used in Thailand, data suggested that these centers have little impact on drug use behaviors among IDU in Bangkok. Conclusions: The findings from this project highlight many ongoing health and social problems related to illicit drug use and drug policies in Bangkok. They also suggest that the emphasis on criminal justice approaches has resulted in human rights violations at the hands of police, and harms associated with compulsory drug detention and incarceration. Collectively, the findings indicate the urgent need for the implementation of evidence-based policies and programs in this setting. ; Interdisciplinary Studies (CFIS), College for ; Medicine, Faculty of ; Non UBC ; Other UBC ; Reviewed ; Faculty

Abstract Background Drug policy in Thailand has relied heavily on law enforcement-based approaches. Qualitative reports indicate that police in Thailand have resorted to planting drugs on suspected drug users to extort money or provide grounds for arrest. The present study sought to describe the prevalence and factors associated with this form of evidence planting by police among injection drug users (IDU) in Bangkok. Methods Multivariate logistic regression was used to identify factors associated with evidence planting of drugs by police among a community-based sample of IDU in Bangkok. We also examined the prevalence and average amount of money paid by IDU to police in order to avoid arrest. Results 252 IDU were recruited between July and August, 2008, among whom 66 (26.2%) were female and the median age was 36.5 years. In total, 122 (48.4%) participants reported having drugs planted on them by police. In multivariate analyses, this form of evidence planting was positively associated with midazolam use (Adjusted Odds Ratio [AOR] = 2.84; 95% Confidence Interval [CI]: 1.58 - 5.11), recent non-fatal overdose (AOR = 2.56; 95%CI: 1.40 - 4.66), syringe lending (AOR = 2.08; 95%CI: 1.19 - 3.66), and forced drug treatment (AOR = 1.88; 95%CI: 1.05 - 3.36). Among those who reported having drugs planted on them, 59 (48.3%) paid police a bribe in order to avoid arrest. Conclusion A high proportion of community-recruited IDU participating in this study reported having drugs planted on them by police. Drug planting was found to be associated with numerous risk factors including syringe sharing and participation in government-run drug treatment programs. Immediate action should be taken to address this form of abuse of power reportedly used by police.

Background: Drug policy in Thailand has relied heavily on law enforcement-based approaches. Qualitative reports indicate that police in Thailand have resorted to planting drugs on suspected drug users to extort money or provide grounds for arrest. The present study sought to describe the prevalence and factors associated with this form of evidence planting by police among injection drug users (IDU) in Bangkok. Methods Multivariate logistic regression was used to identify factors associated with evidence planting of drugs by police among a community-based sample of IDU in Bangkok. We also examined the prevalence and average amount of money paid by IDU to police in order to avoid arrest. Results 252 IDU were recruited between July and August, 2008, among whom 66 (26.2%) were female and the median age was 36.5 years. In total, 122 (48.4%) participants reported having drugs planted on them by police. In multivariate analyses, this form of evidence planting was positively associated with midazolam use (Adjusted Odds Ratio [AOR] = 2.84; 95% Confidence Interval [CI]: 1.58 - 5.11), recent non-fatal overdose (AOR = 2.56; 95%CI: 1.40 - 4.66), syringe lending (AOR = 2.08; 95%CI: 1.19 - 3.66), and forced drug treatment (AOR = 1.88; 95%CI: 1.05 - 3.36). Among those who reported having drugs planted on them, 59 (48.3%) paid police a bribe in order to avoid arrest. Conclusion A high proportion of community-recruited IDU participating in this study reported having drugs planted on them by police. Drug planting was found to be associated with numerous risk factors including syringe sharing and participation in government-run drug treatment programs. Immediate action should be taken to address this form of abuse of power reportedly used by police. ; Medicine, Department of ; Non UBC ; Ophthalmology and Visual Sciences, Department of ; Medicine, Faculty of ; Reviewed ; Faculty

North America's first government sanctioned medically supervised injection facility (SIF) was opened during September 2003 in Vancouver, Canada. This was in response to a large open public drug scene, high rates of HIV and hepatitis C transmission, fatal drug overdoses, and poor health outcomes among the city's injection drug users. Between December 2003 and April 2005, a representative sample of 1,035 SIF participants were enrolled in a prospective cohort that required completing an interviewer-administered questionnaire and providing a blood sample for HIV testing. HIV infection was detected in 170/1007 (17%) participants and was associated with Aboriginal ethnicity (adjusted Odds Ratio [aOR], 2.70, 95% Confidence Interval [95% CI], 1.84–3.97), a history of borrowing used needles/syringes (aOR, 2.0, 95% CI, 1.37–2.93), previous incarceration (aOR, 1.87, 95% CI, 1.11–3.14), and daily injection cocaine use (aOR, 1.42, 95% CI, 1.00–2.03). The SIF has attracted a large number of marginalized injection drug users and presents an excellent opportunity to enhance HIV prevention through education, the provision of sterile injecting equipment, and a supervised environment to self-inject. In addition, the SIF is an important point of contact for HIV positive individuals who may not be participating in HIV care and treatment. ; Medicine, Department of ; Medicine, Faculty of ; Other UBC ; Non UBC ; Reviewed ; Faculty

Although there have been repeated calls for the establishment of safe injection facilities (SIFs) in Vancouver since the early 1990s, questions remain concerning the feasibility of SIFs due to the high prevalence of injection cocaine and the concomitant problems cocaine use presents. Therefore, we determined the prevalence of willingness to attend SIFs among cocaine injectors in Vancouver and explored the factors associated with this willingness, using data from the Vancouver Injection Drug Users Study. After considering the results derived from this analysis, additional qualitative methods were employed to explore further willingness to use SIFs, barriers and facilitators of SIF utilization, and methods of maximizing use among selected subpopulations of cocaine injectors. The results suggest that a high proportion of cocaine injectors, including some of those most at risk, would attend an SIF if one were available. However, in order to better accommodate cocaine injectors, several modifications could be made to conventional SIF service design and delivery. The vast majority of these modifications relate to ensuring effective responses to cocaine toxicity. Given the acceptability of SIFs among cocaine injectors, it appears that an SIF pilot could result in significant and immediate benefits in terms of public health and community safety.

Objectives: In Canada, and elsewhere, Indigenous people who use illicit drugs and/or alcohol (WUID/A) experience a disproportionate burden of HIV-related harm. This study examined HIV risk perceptions and behaviours among Indigenous people WUID/A living in the Downtown Eastside (DTES) and the policies and practices that shape inequities and vulnerabilities for them in HIV testing and treatment. Further, we aimed to situate the vulnerabilities of Indigenous people WUID/A in HIV care within the context of wider structural inequality and generate recommendations for culturally relevant and safe HIV treatment options.
Methods: This research employed an Indigenous-led community-based participatory approach using talking circles to explore experiences of Indigenous people living with HIV. Under the participatory research framework, community researchers led the study design, data collection, and analysis. Talking circles elicited participants' experiences of HIV knowledge, testing, and treatment, and were audio-recorded and transcribed. Data were coded line-by-line and codes were organized into themes.
Results: Five key themes were identified via the talking circles: evolving HIV risk perceptions (e.g., HIV knowledge and testing, and "intentional exposure"); research as an avenue for HIV testing; HIV treatment and discussions about grief and loss; HIV-related stigma and discrimination; and the importance of culturally-relevant and safe HIV treatment options for Indigenous people WUID/A.
Discussion: Our work reveals that Indigenous people WUID/A do not have adequate access to HIV knowledge and education, often limiting their ability to access HIV testing and supports. Participant stories revealed both internalized and community stigma and discrimination, which at times compromised connection with participants' home communities. Further, our findings point to a failure in the public health system to deliver accessible HIV information to Indigenous Peoples, hence, many participants have solely relied on participation in community-based research studies in the Downtown Eastside (DTES) for HIV education and knowledge. There is an urgent need for accessible, culturally safe, and community-based education and treatment options for Indigenous people WUID/A within HIV care.

IntroductionIn 2006, the Vancouver Police Department (VPD) developed an organization‐wide drug policy approach, which included endorsing harm reduction strategies for people who inject drugs (PWID). We sought to examine rates of potentially harmful policing exposures and associated HIV risk behaviour among PWID in Vancouver, Canada before and after the VPD policy change.MethodsData were derived from two prospective cohort studies of PWID. Multivariable generalized estimating equation models were used to examine changes in the risk of confiscation of drug use paraphernalia and physical violence by the police, as well as changes in the relationship between exposures to the two policing practices and sharing of drug use paraphernalia, before and after the policy change.ResultsAmong 2193 participants, including 757 (34.5%) women, the rates of experiencing police confiscation of drug use paraphernalia declined from 22.3% in 2002 to 2.8% in 2014, and the rates of reporting experiencing physical violence by the police also declined from 14.1% in 2004 to 2.9% in 2014. In multivariable analyses, the post‐policy change period remained independently and negatively associated with reports of confiscation of drug use paraphernalia (adjusted odds ratio (AOR): 0.25; 95% confidence interval (CI): 0.21 to 0.31) and reported physical violence by the police (AOR: 0.76; 95% CI: 0.63 to 0.91). However, experiencing both confiscation of drug use paraphernalia and physical violence by the police (AOR: 1.92; 95% CI: 1.10 to 3.33) and experiencing only confiscation of drug use paraphernalia (AOR: 1.71; 95% CI: 1.34 to 2.19) remained independently and positively associated with sharing of drug use paraphernalia during the post‐policy change period.ConclusionsIn our study, two policing practices known to increase HIV risk among PWID have declined significantly since the local police launched an evidence‐based drug policy approach. However, these practices remained independently associated with elevated HIV risk after the post‐policy change. Although there remains a continued need to ensure that policing activities do not undermine public health efforts, these findings demonstrate that a major shift towards a public health approach to policing is possible for a municipal police force.

<b><i>Background:</i></b> There is equivocal evidence regarding whether people who use heroin substitute heroin for alcohol upon entry to methadone maintenance therapy (MMT). We aimed to examine the impact of MMT enrolment on the onset of heavy drinking among people who use heroin. <b><i>Methods:</i></b> We derived data from prospective, community-based cohorts of people who inject drugs in Vancouver, Canada, between December 1, 2005, and May 31, 2014. Multivariable extended Cox regression analysis examined the effect of MMT enrolment on the onset of heavy drinking among people who used heroin at baseline. <b><i>Results:</i></b> In total, 357 people who use heroin were included in this study. Of these, 208 (58%) enrolled in MMT at some point during follow-up, and 115 (32%) reported initiating heavy drinking during follow-up for an incidence density of 7.8 events (95% CI 6.4-9.5) per 100 person-years. The incidence density of heavy drinking was significantly lower among those enrolled in MMT at some point during follow-up compared to those who did not (4.6 vs. 16.2; p < 0.001). MMT enrolment was not significantly associated with time to initiate heavy drinking (adjusted relative hazard (ARH) 1.27; 95% CI 0.78-2.07) after adjustment for relevant demographic and substance-use characteristics. Age and cannabis use were the only variables that were independently associated with the time to onset of heavy drinking (ARH 0.74; 95% CI 0.58-0.94 and ARH 2.06; 95% CI 1.32-3.19, respectively). <b><i>Conclusion:</i></b> In this study, MMT enrolment did not predict heavy drinking and may even appear to decrease the initiation of heavy drinking. Our findings suggest younger age and cannabis use may predict heavy drinking. These findings could help inform on-going discussions about the effects of opioid agonist therapy on alcohol consumption among people who use heroin.

Background: Street-involved youth are more likely to experience trauma and adverse events in childhood; however, little is known about exposure to the child welfare system among this vulnerable population. This study sought to examine the prevalence and correlates of being in government care among street-involved youth in Vancouver, Canada. Methods: From September 2005 to November 2012, data were collected from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14–26 who use illicit drugs. Logistic regression analysis was employed to identify factors associated with a history of being in government care. Results: Among our sample of 937 street-involved youth, 455 (49%) reported being in government care at some point in their childhood. In a multivariate analysis, Aboriginal ancestry (adjusted odds ratio [AOR] = 2.07; 95% confidence interval [CI]: 1.50 – 2.85), younger age at first "hard" substance use (AOR = 1.10; 95% CI: 1.05 – 1.16), high school incompletion (AOR = 1.40; 95% CI: 1.00 – 1.95), having a parent that drank heavily or used illicit drugs (AOR = 1.48; 95% CI: 1.09 – 2.01), and experiencing physical abuse (AOR = 1.90; 95% CI: 1.22 – 2.96) were independently associated with exposure to the child welfare system. Conclusions: Youth with a history of being in government care appear to be at high-risk of adverse illicit substance-related behaviours. Evidence-based interventions are required to better support vulnerable children and youth with histories of being in the child welfare system, and prevent problematic substance use and street-involvement among this population. ; Medicine, Department of ; Medicine, Faculty of ; Other UBC ; Non UBC ; Reviewed ; Faculty

BioMed Central ; Background: Street-involved youth are more likely to experience trauma and adverse events in childhood; however, little is known about exposure to the child welfare system among this vulnerable population. This study sought to examine the prevalence and correlates of being in government care among street-involved youth in Vancouver, Canada. Methods: From September 2005 to November 2012, data were collected from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14–26 who use illicit drugs. Logistic regression analysis was employed to identify factors associated with a history of being in government care. Results: Among our sample of 937 street-involved youth, 455 (49%) reported being in government care at some point in their childhood. In a multivariate analysis, Aboriginal ancestry (adjusted odds ratio [AOR] = 2.07; 95% confidence interval [CI]: 1.50 – 2.85), younger age at first "hard" substance use (AOR = 1.10; 95% CI: 1.05 – 1.16), high school incompletion (AOR = 1.40; 95% CI: 1.00 – 1.95), having a parent that drank heavily or used illicit drugs (AOR = 1.48; 95% CI: 1.09 – 2.01), and experiencing physical abuse (AOR = 1.90; 95% CI: 1.22 – 2.96) were independently associated with exposure to the child welfare system. Conclusions: Youth with a history of being in government care appear to be at high-risk of adverse illicit substance-related behaviours. Evidence-based interventions are required to better support vulnerable children and youth with histories of being in the child welfare system, and prevent problematic substance use and street-involvement among this population. ; The study was supported by the US National Institutes of Health [R01-DA028532] and the Canadian Institutes of Health Research [MOP–102742]. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine, which supports Dr. Evan Wood. Dr. Kora DeBeck is supported by a MSFHR/St. Paul's Hospital ...

In 2003, the city of Vancouver, British Columbia, opened North America's first government-sanctioned safer injecting facility, where injection drug users (IDUs) can inject preobtained illicit drugs under the supervision of nurses. Use of the service by IDUs was followed by measurable reductions in public drug use and syringe sharing. IDUs who are frequently using the program tend to be high-intensity cocaine and heroin injectors and homeless individuals.

Background: Despite Thailand's official reclassification of drug users as "patients" deserving care and not "criminals," the Thai government has continued to rely heavily on punitive responses to drug use such as "boot camp"-style compulsory "treatment" centers. There is very little research on experiences with compulsory treatment centers among people who use drugs. The work reported here is a first step toward filling that gap. Methods We examined experiences of compulsory drug treatment among 252 Thai people who inject drugs (IDU) participating in the Mitsampan Community Research Project in Bangkok. Multivariate logistic regression was used to identify factors independently associated with a history of compulsory treatment experience. Results In total, 80 (31.7%) participants reported a history of compulsory treatment. In multivariate analyses, compulsory drug detention experience was positively associated with current spending on drugs per day (adjusted odds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22) and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15). Among those with compulsory treatment experience, 77 (96.3%) reported injecting in the past week, and no difference in intensity of drug use was observed between those with and without a history of compulsory detention. Conclusion These findings raise concerns about the current approach to compulsory drug detention in Thailand. Exposure to compulsory drug detention was associated with police abuse and high rates of relapse into drug use, although additional research is needed to determine the precise impact of exposure to this form of detention on future drug use. More broadly, compulsory "treatment" based on a penal approach is not consistent with scientific evidence on addressing drug addiction and should be phased out in favor of evidence-based interventions. ; Medicine, Department of ; Medicine, Faculty of ; Non UBC ; Reviewed ; Faculty

Despite Thailand's official reclassification of drug users as "patients" deserving care and not "criminals," the Thai government has continued to rely heavily on punitive responses to drug use such as "boot camp"-style compulsory "treatment" centers. There is very little research on experiences with compulsory treatment centers among people who use drugs. The work reported here is a first step toward filling that gap. We examined experiences of compulsory drug treatment among 252 Thai people who inject drugs (IDU) participating in the Mitsampan Community Research Project in Bangkok. Multivariate logistic regression was used to identify factors independently associated with a history of compulsory treatment experience. In total, 80 (31.7%) participants reported a history of compulsory treatment. In multivariate analyses, compulsory drug detention experience was positively associated with current spending on drugs per day (adjusted odds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22) and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15). Among those with compulsory treatment experience, 77 (96.3%) reported injecting in the past week, and no difference in intensity of drug use was observed between those with and without a history of compulsory detention. These findings raise concerns about the current approach to compulsory drug detention in Thailand. Exposure to compulsory drug detention was associated with police abuse and high rates of relapse into drug use, although additional research is needed to determine the precise impact of exposure to this form of detention on future drug use. More broadly, compulsory "treatment" based on a penal approach is not consistent with scientific evidence on addressing drug addiction and should be phased out in favor of evidence-based interventions.