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The perspectives of injection drug users regarding safer injecting education delivered through a supervised… Fast, Danya; Small, Will; Wood, Evan; Kerr, Thomas Oct 29, 2008

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchThe perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facilityDanya Fast1, Will Small1, Evan Wood1,2 and Thomas Kerr*1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, British Columbia, Canada and 2Department of Medicine, Faculty of Medicine, University of British Columbia, CanadaEmail: Danya Fast - dfast@cfenet.ubc.ca; Will Small - wsmall@cfenet.ubc.ca; Evan Wood - uhri-ew@cfenet.ubc.ca; Thomas Kerr* - uhri-tk@cfenet.ubc.ca* Corresponding author    AbstractBackground: Unsafe injection practices are prevalent among injection drug users (IDU) and haveresulted in numerous forms of drug-related harm including HIV/HCV transmission and otherbacterial and viral infections. North America's first supervised injection facility (SIF) was establishedin Vancouver in order to address injection-related harms among IDU. This study sought to examineinjection drug users' experiences receiving safer injecting education in the context of a SIF.Methods: Semi-structured qualitative interviews were conducted with 50 individuals recruitedfrom a cohort of SIF users known as the Scientific Evaluation of Supervised Injection (SEOSI)cohort. Audio recorded interviews elicited IDU perspectives regarding the provision of saferinjecting education within the context of a SIF. Interviews were transcribed verbatim and a thematicanalysis was conducted.Results: Participant narratives indicate that significant gaps in knowledge regarding safer injectingpractices exist among local IDU, and that these knowledge deficits result in unsafe injectingpractices and negative health outcomes. However, IDU perspectives reveal that the SIF allowsclients to identify and address these gaps in knowledge through a number of mechanisms that areunique to this facility, including targeted educational messaging that occurs as a part of the drug usecycle and not outside of it, in situ demonstration of safer injecting techniques that takes place themoment a client is experiencing difficulties, and enhanced opportunities to seek help from 'expert'healthcare professionals. Importantly, study participants indicated that the overall environment ofthe SIF promotes the adoption of safer injecting practices over time, both within and outside of thefacility.Conclusion: We conclude that the SIF has been particularly effective in transmitting educationalmessages targeting unsafe and unhygienic injection practices to a population of active IDU.Consistent with previous work, results of this study indicate that SIFs represent a unique 'micro-environment' that can facilitate the reduction of numerous drug related harms.Published: 29 October 2008Harm Reduction Journal 2008, 5:32 doi:10.1186/1477-7517-5-32Received: 11 July 2008Accepted: 29 October 2008This article is available from: http://www.harmreductionjournal.com/content/5/1/32© 2008 Fast et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8(page number not for citation purposes)Harm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/32BackgroundInjection drug use continues to present a major publichealth challenge in urban settings around the world [1,2].Unsafe injection practices result in numerous forms ofdrug-related harm, including overdose [3], HIV/HCVtransmission [4,5], and other forms of bacterial and viralinfections [6].Safer injecting education has been widely employed inorder to address the harms associated with injection druguse [7,8]. For example, numerous harm reduction pro-grams provide information on safer injecting and streetoutreach programs work to seek out injection drug users(IDU) in the public venues they frequent in order to pro-vide safer injecting education and other forms of support[9]. However, supervised injection facilities (SIFs) consti-tute a unique form of intervention, in that they provide asanctioned drug-using environment that is constantlysupervised by healthcare professionals [10].In September 2003, North America's first SIF, known as"Insite," opened its doors in Vancouver's Downtown East-side. To date, over 7000 IDU have attended the facility,and approximately 600 injections are supervised at thefacility each day [11]. Healthcare professionals are presentat all times to supervise injections, intervene in the eventof an overdose, and provide safer injecting education.Previously, a quantitative study was conducted to exam-ine the prevalence and correlates of receiving safer inject-ing education within the Vancouver SIF [12]. While theresults of that study indicated that a significant proportionof SIF users received safer injecting education within thefacility, little is known about how safer injecting educa-tion is delivered within SIFs, and whether this settingoffers advantages over conventional clinic-based or streetoutreach safer injecting education programs. Further, weknow of no studies that have assessed IDU perspectivesregarding safer injecting education delivered in the con-text of SIFs, and there are few qualitative explorations ofIDU experiences within SIFs. Therefore, while previousquantitative research has demonstrated the importance ofsafer injecting education for drug using populations[8,12-15], we aim to extend this work by exploring injec-tion drug users' experiences with receiving safer injectingeducation in the context of a local SIF.MethodsWe drew upon data from 50 in-depth qualitative inter-views conducted from November 2005 to February 2006.Interviewees were recruited from the Scientific Evaluationof Supervised Injecting (SEOSI) cohort, which is com-posed of over 1000 randomly selected SIF users in Van-couver [16]. Interview participants were selected on adaily basis from persons attending the research office forquantitative cohort interviews. Recruiting efforts inten-tionally created a sample composed of individuals withdiffering levels of SIF utilization that was also representa-tive of the local injecting population in terms of gender,age, and ethnicity (see Table 1). Interviews were under-taken by three trained interviewers (two male and onefemale) and facilitated through the use of a topic guideencouraging discussion of SIF use and experiences withreceiving safer injecting education within the facility.Interviews lasted between 30 and 60 minutes, were tape-recorded, and were later transcribed verbatim. The con-tent of transcribed interviews was reviewed, and all textsegments (both positive and negative) related to saferinjecting education received within the SIF were cata-logued. The catalogued data was subsequently subjectedto a thematic analysis which focused on the social proc-esses and characteristics of the SIF which were reported toinfluence experiences with safer injecting education.All participants provided informed consent to participate,and the study was undertaken with appropriate ethicalapproval granted by the Providence Healthcare/Universityof British Columbia Research Ethics Board. Participantswere compensated for their time with a twenty dollar hon-orarium. There were no refusals of the offer to participatein the interview, and no drop-outs occurred during theinterview process.Table 1: Characteristics of qualitative study sample compared to a representative sample of SIF clients (SEOSI)Qualitative Interview Participants SEOSI CohortTotal Number 50 1090Median Age (range) 38 (25–60) 38.4 (18.9–63.7)GenderFemale, n (%) 21(42) 313(29)Male, n (%) 28(56) 773(71)Trans-gendered, n (%) 1 (2) 4 (< 1)Aboriginal EthnicityYes, n (%) 13(26) 211(19)Page 2 of 8(page number not for citation purposes)No, n (%) 37(74) 879(81)Harm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/32ResultsThe sample of qualitative interview participants was com-posed of 21 women, 28 men and one trans-gendered indi-vidual. The age of participants ranged from 25 years to 60years, and the median age of participants was 38. Excerptsfrom the qualitative interviews are presented below inorder to illustrate the central themes that emerged in theanalysis. Considerable overlap was observed across the-matic areas.Participant narratives indicate that significant gaps inknowledge regarding safer injecting practices exist amonglocal IDU; however, study participants also indicated thatthe SIF allows clients to identify and address these gaps inknowledge through a number of mechanisms that areunique to this facility.1. Gaps in knowledgeSeveral participants articulated a general lack of knowl-edge regarding safer injecting practices prior to using theSIF. This lack of knowledge was not limited to new injec-tors:R: I learned one thing in there that I didn't know after twenty-three years of using and that's the bevel side up! Y'know, withyour, with your, ah, syringe. (Female Participant #11)R: I think that since the injection site has been open I've learnedhow to inject properly . . . and there were things I never evenknew, in all the whole 20 years I've been shooting dope.(Female Participant #44)Participants connected gaps in knowledge and improperinjecting techniques with negative health consequences,such as scarring or repeated injection-related infectionssuch as abscesses:R: [Before using Insite] I wasn't cleaning [my skin]. I wasn't– the needle wasn't facing up. I was just sticking it in anywhere,poking holes in myself. Using dull needles. Using the same oneover and over again. Not tying it off. Not doing anything prop-erly.I: Can I just ask: how long have you been fixing for?R: I'm twenty seven. The first drug I ever did was heroin, andit was in a needle at eleven years old. And I've been using stead-ily since I was twelve, but I still use it a lot.I: So that's a long time to go without really knowing how toinject properly.R: Yeah. Yeah. Real long time. That's why I have all the scarsIn a number of cases, participants were not aware thatthey were injecting unsafely until they began using the SIFand receiving safer injecting education from on-sitehealthcare professionals. Visits to the SIF allowed partici-pants to identify and address specific gaps in knowledge,resulting in the adoption of safer injecting practices andimproved health outcomes in several cases:R: I learned how to fix myself properly in there . . . I think it'shad an affect on, well, I know it has [had an effect on myhealth] because I know how to inject properly now. And I knowit has for other people, too. (Female Participant #11)R: Well, when I first went there [to the SIF] I used to just takemy dope and shake it, and they [the nurses]  said, "Well, youshould be cooking it because it takes all the impurities out. Andyou should use an alcohol wipe, like, to sterilize your --"I: Yeah, clean up your skin or whatever.R: And I never used to do that. And since I've been doing that,and since they showed me the right way, I haven't had anyabscesses. So, I credit them with that. (Female Participant#30)2. Addressing gaps in knowledgeA. Educational messages delivered within a sanctioned drug-using environmentDespite the availability of safer injecting education via anumber of other service providers in locations throughoutthe Downtown Eastside, several participants noted thatthe SIF was the first place that they had successfully beenable to receive help:I: Okay, so where would you be getting this help if you weren'tgetting it from Insite?R: I've never looked at [getting help] before Insite so, I don'tknow . . . (Male Participant #39)I: What would you have to say about the help that you've got[at Insite]?R: I think it's very fair, and it's sufficient . . . I can't really com-pare it to anything else 'cause I've never really gotten any helpanywhere else, other than there. (Trans-gendered Participant#2)Participants articulated the benefits of receiving educa-tional messages within a sanctioned drug-using environ-ment that is a part of the drug using cycle and not outsideof it. Multiple visits to the SIF for the primary purpose ofconsuming drugs meant that educational messages werePage 3 of 8(page number not for citation purposes)I do ... (Male Participant #27) both highly accessible and reinforced over time. Receivingregular safer injecting education during the process ofHarm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/32consuming drugs was contrasted with receiving educa-tional messages at other times, when priorities associatedwith a lifestyle of addiction – such as obtaining drugs orobtaining the money to buy drugs – would likely out-weigh the perceived need to access assistance from health-care professionals:R: Being an addict . . . you do want to go out and utilize the[service] facilities, but if it's [on the] way y'know? [If] it's noton the way to go get your money to get better [i.e. use drugs],and once you get better, you got to go get more money for thenext day or whatever, but if something's right then and therethen it's like perfect. (Female Participant #38)B. Enhanced opportunities to seek help from healthcare professionalsMultiple visits to the SIF for the primary purpose of con-suming drugs was also said to facilitate the developmentof meaningful relationships with 'expert' healthcare pro-fessionals. For those participants who had not been ableto access help previously, SIF nursing staff represented anessential source of reliable and accurate information. Thesafer injecting education received at the SIF from health-care professionals was contrasted with educational mes-sages or information one could pick up 'on the street'from other IDU:I: You know a lot about how to inject safely, it sounds like. Isthis stuff you knew before [using Insite]?R: No, I didn't . . . I always had to have someone [inject] it forme, so, most of this, most of the information that I got is justfrom people [on the street] . . . from Insite, you know, like, [Ilearned] the proper way I guess. You know, a lot of people [onthe street] don't really tell you about the cleaning or using alco-hol swabs and stuff like that. They always neglect to leave thatstuff in, put that stuff in when they're telling you [how toinject]. Insite was where I learned that you should use the alco-hol swabs. I didn't know that before . . . (Trans-Gendered Par-ticipant #2)While it was acknowledged that one's peers could notalways be relied upon to provide complete educationalmessages, SIF nurses were viewed as experts who could betrusted to deliver accurate and comprehensive safer inject-ing education:R: I mean you have people [i.e. nurses] who are experienced.You have people who know what they're talking about, whatthey're doing, showing you how to do it properly, how to do itsafely, how to do it cleanly . . . She's generally smarter than therest, y'know. I mean, when you have medical questions, she'sthe one to ask ninety percent of the time. (Male Participant #The SIF was described as providing a context in which on-site healthcare professionals are able to guide clientsthrough each step of the safer injecting process at a com-fortable pace, and often over the course of multiple inter-actions. Healthcare professionals are able to tailoreducational messages to suit the specific needs of each cli-ent to address specific deficiencies in practice, and are ableto intervene as a client is experiencing difficulties. Partici-pants valued the non-judgmental attitudes of the SIF staff,and felt able to ask questions and raise concerns themoment they thought of them:R: Like, if you ever are curious or just need information, youknow it's there, and you can ask for it and get it. You don't haveto wonder at all. (Male Participant #40)R: Sometimes there's a point where I asked [the nurse], "I'mhaving troubles getting a vein here, so is there somewhere elsethat I can [inject myself]?" And she, y'know, she showed mea few places. (Female Participant #21)C. In situ demonstration of safer injecting techniquesMany respondents articulated the benefits of being shownspecific safer injecting techniques during the actual proc-ess of injecting, as opposed to simply being told how toinject properly, or provided with more general printededucational materials at another time:R: I remember one time asking the nurse just to give me a kindof a more visual way – showing me how to tie-off and stuff –and she gave me some pointers. (Male Participant #9)R: If I'm at Insite they can show me where there's a vein andbang! – I got it instantly and I don't gotta sit there you know,with a needle for half an hour, you know, blood coming every-where and that. (Trans-Gendered Participant #2)Several participants indicated that they had required helpinjecting prior to using the SIF, or that they sometimescontinued to require help injecting when they were usingdrugs in locations other than the SIF. In some cases, saferinjecting education received within the SIF – and specifi-cally, in situ demonstration of how to locate a viable vein– was connected with developing the skills required toinject more independently:R: [Bevel facing up] was one simple, little thing I didn't realize. . . So bevel up and I'm able to get myself almost every singletime, and I always needed a doctor [i.e. someone who per-forms assisted injections]. Like, my partner always had toinject me, and that was really frustrating. (Female Participant#11)Page 4 of 8(page number not for citation purposes)27) R: They have a nurse there that's qualified, and can show me,and you know, point [veins] out and help me.Harm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/32I: Ok, so you can usually fix yourself, because of the help thatthey've given you?R: Yes, yes.I: Ok, and do you think that if you, in those situations [whenyou can't easily find a vein], if you weren't injecting at Insite,you would be getting help [injecting] from somebody else?R: Yes. (Trans-Gendered Participant #2)Those who were adamant about avoiding assisted injectionalso articulated the benefits of in situ demonstration ofsafer injecting practices to address specific gaps in knowl-edge:R: Y'know, I got a hole in my arm. It's just healing, I've hadplastic surgery on it and, I, I fix in it all the time. Y'know, [thenurses at the SIF] say, "Don't use that! Maybe use your leg,"so the one lady showed me on the doll, showed me where theveins go up your leg, here. Showed me how to, y'know, "Trythere, use a tie", 'cause I never used to use a tie . . . And it'sreally helped, 'cause now I can use that. It works very well,right? . . . Yeah, 'cause I won't let anybody fix me, right?(Female Participant #12)In general, the safer injecting education received at the SIFenabled some participants to take greater control of theirinjecting practices, at least within the SIF.3. An overall environment that promotes safer injecting practicesEven when participants had accessed safer injecting edu-cation prior to using the SIF, it was noted that the overallatmosphere of the SIF made them more conscious of thesemessages, and more diligent about putting them intopractice:I: What do you mean when you say you're more aware whenyou inject [at Insite]?R: I dunno. Just more aware – there could be health issuesinvolved. Like, if I didn't use the alcohol swab, I could get aninfection. If you use a rig more than once, it could be dull andit could hurt, or it could get bacteria on the end of it. Y'know,like, you can give yourself [an] infection which really boggledmy mind the first time I'd heard it . . . It just makes you moreaware that there's a process that can be beneficial to everybody,right?I: Are any of those things that you heard for the first time whenyou were at Insite?Participants reported that the provision of sterile syringesand the necessary ancillary injecting equipment, com-bined with the provision of targeted, in situ safer injectingeducation by trusted experts, all served to reinforce educa-tional messages and contribute to an overall atmospherethat encourages the adoption of safer injecting practices:R: [Insite is] safe because it's constantly supervised. Everythingis clean. Sanitary, hygienic, whatever. All the supplies, obvi-ously . . . If you need any guidance or whatever, there's alwaysa nurse on-hand. (Female Participant #32)R: When I go in there I'm more self-conscious; like, you got yourtie-on there, you got your Band-aids, you got your water, andyou got your filter . . . There I always go through the whole proc-ess properly. So, I should go there all the time. (Male Partici-pant #9)Importantly, IDU narratives reveal that once safer inject-ing habits are established within the SIF, it becomes morelikely that they will practice safer injecting techniques out-side of the SIF as well:R: People are being safer and everything too, eh? It's... y'know,as I say, heroin addicts especially are creatures of habit. They goin there, they get the habit formed of being safe, they'll use thesame quality when they go out on the street. "Oh, do you havea tie-off? Do you--?" Y'know, they'll make sure. . . They'll carryon the same values that are drilled into them in there [at theSIF]. (Male Participant #6)DiscussionIn sum, participant narratives indicate that significantgaps in knowledge regarding safer injecting practices existamong local IDU, and that these knowledge deficits resultin unsafe injecting practices and negative health outcomesfor numerous local IDU. However, IDU perspectivesreveal that the SIF allows clients to identify and addressthese gaps in knowledge through a number of mecha-nisms that are unique to this facility, including targetededucational messaging that occurs as a part of the drug usecycle and not outside of it, in situ demonstration of saferinjecting techniques that takes place the moment a clientis experiencing difficulties, and enhanced opportunities toseek help from 'expert' healthcare professionals. Impor-tantly, study participants indicated that the overall envi-ronment of the SIF – including the provision ofcomprehensive sterile injecting paraphernalia and theconstant presence of healthcare professionals – promotesthe adoption of safer injecting practices over time, bothwithin and outside of the facility. Interestingly, we foundlittle variation in experiences with receiving safer injectingeducation within the SIF according to gender, age or eth-Page 5 of 8(page number not for citation purposes)R: No, I don't think so. It just made me more conscious, self-conscious of it. (Female Participant #32)nicity, in spite of evidence which indicates that womenmay be more likely to require help injecting for a varietyHarm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/32of contextual reasons [17-19], and may therefore be morereceptive to assistance and education from on-site health-care professionals.IDU utilize the SIF for the primary purpose of consumingdrugs; however, multiple visits to the facility give nursesthe opportunity to provide hands-on, client-centered saferinjecting education in a timely and unhurried manner.Within the SIF, in situ demonstration of targeted educa-tional messages can occur the moment a client is experi-encing difficulties, and at a pace that is acceptable to theclient. In combination with the provision of sterilesyringes and the necessary ancillary injecting equipment,this process encourages clients to reflect on and enact saferinjecting practices without feeling rushed. This can becontrasted with the circumstances that often surroundpublic injection, where exposure to police scrutiny andthe possibility of arrest often results in skipped steps andunsafe injecting behavior [20-24], despite the availabilityof safer injecting education and sterile injecting parapher-nalia in public venues via street outreach approaches.Ongoing drug-related harms among IDU indicate thatnovel public health interventions are needed [19,25].Educational approaches have typically been based on theassumption that IDU are autonomous actors operatingwithin relatively stable social environments [26]. Eventhose street outreach approaches that seek out IDU in thepublic venues they frequent oftentimes fail to recognizethe macro- and micro-environmental factors that limit anindividual's ability to initiate behavioral change [27,28].In order for educational approaches to be effective, atten-tion must be paid to the physical and social environmentthat influences the production of safety and risk for indi-viduals who use injection drugs [27,29]. Broader concep-tualizations of risk, such as Rhodes' 'risk environment'framework [28], call for structural and environmentalinterventions that alter aspects of the context in whichinjection drug use occurs, thereby facilitating the adop-tion of safer injecting practices and the reduction of drug-related harms [30]. The results of this study indicate thatSIFs represent one such micro-environmental interven-tion with a unique social composition that serves to mod-ify risk in ways that differ from conventional clinic-basedand street outreach educational approaches. As such, SIFshave significant potential to facilitate the adoption ofsafer injecting practices where other educationalapproaches have failed or been less effective.The results of this study indicate that, by addressing criti-cal gaps in knowledge, SIFs can foster greater injectingindependence among IDU and contribute importantly tothe reduction of injection drug-related harms. Previousing help with injecting [31], and that requiring help withinjecting places individuals at heightened vulnerabilityfor HIV and HCV infection [13]. These observations werereflected in IDU narratives that emphasized the impor-tance of timely and appropriately delivered safer injectingeducation for individuals who engage in assisted injectionas a result of lack of knowledge. The safer injecting educa-tion received at the SIF allowed some study participants totake greater control of their injecting habits. The fact thata previous quantitative study found that requiring helpinjecting was independently associated with receivingsafer injecting education at the Vancouver SIF [12], com-bined with the results of this qualitative analysis, providesgood indication that safer injecting education within theSIF may have significant implications for HIV and HCVprevention among frequent SIF users.The present study has several limitations that warrantacknowledgement. Firstly, our findings are based uponinterviews with local IDU participating in the currentstudy. While an effort was made to ensure that the studysample reflects the demographics of the local SIF-usingpopulation, some perspectives may nonetheless be under-represented. Secondly, although interviewees were toldthat the study was being conducted independently of theSIF, it is possible that social desirability bias affected theresponses of some participants. Thirdly, the data collectedand analyzed here presents only the viewpoints of IDU;the results of this analysis should be compared with thefindings of ethnographic research utilizing participant-observation within the SIF. Interviews with healthcareprofessionals and other SIF staff should be conducted toelicit alternative perspectives. Fourthly, it must be recog-nized that the Vancouver SIF is not accessible to all localIDU; people who rely on others to administer all injec-tions (such as IDU with physical disabilities), or whoengage in assisted injection for a variety of socio-culturalreasons [32], are excluded from the facility as a result ofregulations prohibiting assisted injection within the SIF.Thus, these individuals are not able to receive safer inject-ing education via the SIF, limiting the facility's effective-ness in addressing the needs of diverse local IDU.Furthermore, while those participants who had receivedsafer injecting education within the facility reflected posi-tively on their experiences, a minority of participantsreported that they had not received safer injecting educa-tion within the facility, or that they disliked the overallenvironment within the facility (which would likely dis-couraged them from spending extra time necessary to seekout and engage in safer injecting education with on-sitehealthcare professionals). The results of this analysis sug-gest that the SIF can greatly benefit those individuals whovisit the site regularly and have developed good relation-Page 6 of 8(page number not for citation purposes)research has noted that a lack of knowledge regarding howto safely inject oneself is a primary explanation for requir-ships with on-site healthcare professionals; futureresearch is needed to determine why some individuals useHarm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/32the facility more infrequently than others, and how thisaffects the uptake of safer injecting education.In summary, the results of this study indicate that the SIFhas been effective in transmitting educational messagestargeting unsafe and unhygienic injection practices to apopulation of active IDU. The SIF facilitates the deliveryand adoption of educational messages via a number ofmechanisms that are unique to this facility and highlyacceptable to local IDU. Consistent with previous work,results of this study indicate that SIFs represent a micro-environmental intervention with significant potential toreduce numerous drug-related harms. Importantly, thisstudy contributes to the development of knowledgeregarding alternative mechanisms of connecting IDU withsafer injecting education.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsWS and TK designed the study. TK and DF conducted theanalyses of the data. DF prepared the first draft of the arti-cle. All authors contributed to the revision of the manu-script.AcknowledgementsThe authors wish to thank the study participants for their time and partic-ipation. We also thank the administrative staff at the B.C. Centre for Excel-lence in HIV/AIDS, as well as the SEOSI study staff for their research assistance. Thanks are due to the staff of the InSite SIF, the Portland Hotel Society, and Vancouver Coastal Health. The SIF evaluation has been made possible through a financial contribution from Health Canada, though the views expressed herein do not represent the official policies of Health Can-ada.Will Small is supported a Michael Smith Foundation for Health Research Senior Graduate Studentship and a Canadian Institutes of Health Research Doctoral Research Award. Thomas Kerr is supported by a Michael Smith Foundation for Health Research Scholar Award and a Canadian Institutes of Health Research New Investigator Award.References1. Aceijas C, Stimson GV, Hickman M, Rhodes T: Global overview ofinjecting drug use and HIV infection among injecting drugusers.  AIDS 2004, 18:.2. Drucker E: Drug prohibition and public health: 25 years of evi-dence.  Public Health Rep 1999, 114:14-29.3. O'Driscoll PT, McGough J, Hagan H, Thiede H, Critchlow C, Alexan-der ER: Predictors of accidental fatal drug overdose among acohort of injection drug users.  Am J Public Health 2001,91:984-987.4. 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Spittal PM, Craib KJ, Wood E, Laliberte N, Li K, Tyndall MW,O'Shaughnessy MV, Schechter MT: Risk factors for elevated HIVincidence rates among female injection drug users in Van-couver.  Cmaj 2002, 166:894-899.18. Macrae R, Aalto E: Gendered power dynamics and HIV risk indrug-using sexual relationships.  AIDS Care 2000, 12:505-516.19. Kral AH, Bluthenthal RN, Erringer EA, Lorvick J, Edlin BR: Risk fac-tors among IDUs who give injections to or receive injectionsfrom other drug users.  Addiction 1999, 94:675-683.20. Small W, Kerr T, Charette J, Schechter M, Spittal P: Impacts ofintensified police activity on injection drug users: Evidencefrom an ethnographic investigation.  International Journal of DrugPolicy 2006, 17:85-95.21. Small W, Rhodes T, Wood E, Kerr T: Public injection settings inVancouver: Physical environment, social context and risk.International J Drug Policy 2007, 18:27-36.22. Maher L, Dixon D: Policing and public health: Law enforce-ment and harm minimization in a street-level drug market.Brit J Criminol 1999, 39:488-512.23. Latkin C, Mandell W, Vlahov D, Oziemkowska M, Knowlton A,Celentano D: My place, your place, and no place: behavior set-tings as a risk factor for HIV-related injection practices ofdrug users in Baltimore, Maryland.  Am J Community Psychol 1994,22:415-430.24. Aitken C, Moore D, Higgs P, Kersall J, Kerger M: The impact of apolice crackdown on a street drug scene: evidence from thestreet.  International J Drug Policy 2002, 13:189-198.25. Rhodes T, Kimber J, Small W, Fitzgerald J, Kerr T, Hickman M, Hol-loway G: Public injecting and the need for 'safer environmentinterventions' in the reduction of drug-related harm.  Addic-tion 2006, 101:1384-1393.26. Moore D: Governing street-based injecting drug users: a cri-Page 7 of 8(page number not for citation purposes)users admitted to drug treatment in 6 US cities.  Am J PublicHealth 2002, 92:385-387. tique of heroin overdose prevention in Australia.  Social Scienceand Medicine 2004, 59:1547-1557.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2008, 5:32 http://www.harmreductionjournal.com/content/5/1/3227. Dietze P, Jolley D, Fry C, Bammer G, Moore D: When is a littleknowledge dangerous? Circumstances of recent heroin over-dose and links to knowledge of overdose risk factors.  Drug andAlcohol Dependence 2006, 84:223-230.28. Rhodes T: The 'risk' environment: A framework for under-standing and reducing drug related harm.  International Journalof Drug Policy 2002, 13:85-94.29. Rhodes T, Kimber J, Small W, Fitzgerald J, Kerr T, Hickman M, Hol-loway G: Public injecting and the need for 'safer environmentinterventions' in the reduction of drug-related harm.  Addic-tion 2006, 101:1384-1393.30. Des Jarlais DC: Structural interventions to reduce HIV trans-mission among injecting drug users.  AIDS 2000, 14:S41-46.31. Wood E, Spittal PM, Kerr T, Small W, Tyndall MW, O'ShaughnessyMV, Schechter MT: Requiring help injecting as a risk factor forHIV infection in the Vancouver epidemic: Implications forHIV prevention.  Can J Public Health 2003, 94(5):355-359.32. Bourgois P, Prince B, Moss A: The Everyday Violence of Hepati-tis C Among Young Women Who Inject Drugs in San Fran-cisco.  Hum Organ 2004, 63:253-264.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 8 of 8(page number not for citation purposes)


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