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Assisted injection among people who inject drugs in Thailand Lee, William K; Ti, Lianping; Hayashi, Kanna; Kaplan, Karyn; Suwannawong, Paisan; Wood, Evan; Kerr, Thomas Sep 10, 2013

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RESEARCH Open AccessAssisted injection among people who injectdrugs in ThailandWilliam K Lee1, Lianping Ti1, Kanna Hayashi1, Karyn Kaplan1,3, Paisan Suwannawong1,3, Evan Wood1,2and Thomas Kerr1,2*AbstractBackground: Assisted injection is common among people who inject drugs (IDU), and has been associated withelevated risk for HIV infection and overdose. However, this practice has not been explored in the Asian context,including in Thailand, where HIV prevalence among IDU remains high.Methods: Using multivariate logistic regression, we examined the prevalence and correlates of assisted injectingamong IDU participating in the Mitsampan Community Research Project in Bangkok. We also sought to identifyreasons for engaging in assisted injecting and those who provide this form of assistance.Results: In total, 430 IDU participated in this study, including 376 (87.5%) who reported having ever requiredassistance injecting, and 81 (18.8%) who reported assisted injecting in the previous six months. In multivariateanalyses, assisted injecting in the previous six months was independently and positively associated withbeing female (adjusted odds ratio [AOR] = 2.42; 95% confidence interval [CI]: 1.40 – 4.18), being a weekly heroininjector (AOR = 1.78; 95% CI: 0.99 – 3.20), syringe sharing (AOR = 2.08; 95% CI: 1.18 – 3.68) and soft-tissue infection(AOR = 3.51; 95% CI: 1.43 – 2.53). Having a longer injecting career (AOR = 0.96; 95% CI: 0.94 – 0.99) was negativelyassociated with assisted injecting. Primary reasons given for engaging in assisted injecting included being new toinjecting and lacking knowledge on how to inject. The most common providers of assistance with injecting wereclose friends.Conclusion: We found a high prevalence of assisted injecting among IDU in Bangkok, with females, frequentheroin injectors, those with shorter injecting careers being more likely to engage in this practice. Those who requirehelp with the injecting process are more likely to share syringes, and have skin infections. These findings indicatethe need for interventions focused on promoting safer and self-administered injections.Keywords: Injection drug use, Thailand, Assisted injectionIntroductionThe injection of illicit drugs remains an internationalpublic health concern and has been associated with thetransmission of the human immunodeficiency virus(HIV) and other serious health-related problems [1,2].As such, various harm reduction strategies, includingneedle distribution programs, have been implemented tomitigate high-risk behaviors such as syringe sharing,which contribute to the spread of blood-borne diseases[3-6]. Despite these measures, people who inject drugs(IDU) continue to be exposed to a range of drug-relatedharms [7].In North American settings, the provision of manualassistance with injections among people who injectdrugs (IDU) has received increasing attention, as it hasbeen demonstrated to be independently associated withelevated risk for blood-borne disease transmission, infec-tions, non-fatal overdose and other health-related prob-lems [4,8]. One study indicated that syringe sharing – abehavior strongly associated with HIV transmission – isfour times more likely to occur among those who re-ceive help with drug injections than regular IDU, as the“street doctors” (injectors) are likely to reuse a needle* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, V6Z 1Y6, Vancouver, BC, Canada2Department of Medicine, University of British Columbia, 2775 Laurel Street,10th Floor, V5Z 1M9, Vancouver, BC, CanadaFull list of author information is available at the end of the article© 2013 Lee et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwisestated.Lee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32http://www.substanceabusepolicy.com/content/8/1/32that they have already used on themselves wheninjecting others [4]. Furthermore, Kral et al. found thatthe use of blood-contaminated materials such as usedcottons or thumbs to clean the injection site is morecommonly observed among those who receive help withtheir injections compared to those who self-administertheir injections in the San Francisco Bay area [4]. Such abehavior allows for possible routes of HCV (Hepatitis CVirus) and possibly HIV transmission to occur. Skin-popping (i.e., injecting subcutaneously or intramuscu-larly) was also more likely to occur among IDU whoreceive help with their injections. This behavior has beenassociated with a higher risk of acquiring skin infectionssuch as abscesses and necrotizing fasciitis [9]. The prac-tice of assisted injecting has been found to be morecommon among women, those who are newer toinjecting, and frequent cocaine injectors [8,10]. Severalreasons for requiring help injecting have been identifiedand include perceived loss of accessible veins, difficultywith injecting because of shaky hands, and lack of famil-iarity with injection techniques [8].Although assisted injecting has been identified in vari-ous settings as being a high-risk behavior, this practicehas not been explored in the Asian context, including inThailand where HIV prevalence among IDU hasremained persistently high [11]. In an effort to informrelated public health responses, this study aims to iden-tify the prevalence and correlates of assisted injectingamong IDU in Bangkok, Thailand. We also sought toidentify reasons for needing assistance with injectingand those who typically provide this type of assistance.MethodsStudy designData for this study were derived from the MitsampanCommunity Research Project, a collaborative researcheffort involving the Mitsampan Harm Reduction Center(MSHRC), a drug user–run drop-in centre in Bangkok,Thailand, the Thai AIDS Treatment Action Group(Bangkok, Thailand), Chulalongkorn University (Bangkok,Thailand), and the British Columbia Centre for Excellencein HIV/AIDS/University of British Columbia (Vancouver,Canada).Between July and October of 2011, the research part-ners recruited and surveyed 440 IDU. Potential partici-pants were recruited through peer outreach efforts andword-of-mouth, and were invited to attend the MSHRCor O-Zone House (another drop-in centre in Bangkok)in order to be part of the study. Adults residing inBangkok or in adjacent provinces who had injecteddrug(s) in the past six months were eligible for participa-tion. All participants provided informed consent and com-pleted an interviewer-administered questionnaire elicitinga range of information, including socio-demographiccharacteristics, drug use patterns, and experiences withdrug law enforcement and accessing healthcare. Peer re-searchers (i.e., current and former IDU) trained to conductoutreach were sent offsite in pairs to areas with a highdensity of IDU to recruit participants. Potential partici-pants were given information cards with directions to theMSHRC or O-Zone House and further contact instruc-tion. All participants provided informed consent and com-pleted an interviewer-administered questionnaire elicitinga range of information, including socio-demographiccharacteristics, drug use patterns, and experiences withdrug law enforcement and accessing healthcare. The ques-tionnaire was administered by a group of peer researcherswho underwent proper and extensive training by frontlinestaff from the BC Centre for Excellence in HIV/AIDS.Upon completion of the questionnaire, participants re-ceived a stipend of 350 Thai baht (approximately US$12).The study was approved by the research ethics boards atChulalongkorn University and the University of BritishColumbia.For the present analyses, the primary outcome ofinterest was reporting assisted injecting in the past sixmonths by responding “always”; ”most of the time”;“sometimes” or “not very often” (as opposed to “never”)to the question: “In the last 6 months, how often didanyone help you inject?” We considered several potentialexplanatory variables of interest, including: gender(female vs. male); median age (≥ 38 years vs. < 38 years);education (≥ secondary education vs. < secondary educa-tion); relationship status (married or having a regular part-ner vs. other); heroin injection (> weekly vs. ≤ weekly vs. noinjection), midazolam injection (> weekly vs. ≤ weekly vs.no injection); methamphetamine “yaba” injection (≥ weeklyvs. ≤ weekly vs. no injection), crystal methamphetamine“ice” injection (≥ weekly vs. ≤ weekly vs. no injection),lent or borrowed syringes to/from others (yes vs. no);used drugs in combination (yes vs. no) length ofinjecting career (per year longer), non-fatal overdose(yes vs. no) and soft-tissue infections (yes vs. no). Allvariables referred to the previous six months unlessotherwise indicated. The covariates in our study werechosen based on a number of studies in the NorthAmerican context that suggest significant and inde-pendent associations with assisted injecting [10].Bivariate statistics and multivariate logistic regressionwere applied to identify factors associated with assistedinjecting. Categorical explanatory variables were ana-lyzed using Pearson’s Chi-square test and Fisher’s exacttest (when one or more cells contained values less thanor equal to five), and continuous variables were analyzedusing simple logistic regression. We then applied ana priori-defined statistical protocol based on examin-ation of the Akaike Information Criterion (AIC) andp-values to construct an explanatory multivariate logisticLee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32 Page 2 of 7http://www.substanceabusepolicy.com/content/8/1/32regression model. As a first step, we constructed amodel including all variables significantly associated withthe outcome at p ≤ 0.10 in bivariate analyses. After theAIC of the model was noted, subsequent variables withthe largest p-value were individually removed and a re-duced model was built. We continued this iterativeprocess until a combination of variables with the lowestp-value yielded the lowest possible AIC value. Allp-values were two-sided.In secondary analyses, participants who ever reportedrequiring help injecting were asked why they neededhelp injecting. Furthermore, these participants wereasked who provided them assistance with injecting.These data are presented using descriptive statistics.ResultsIn total, 430 IDU, including 83 (19.3%) females, providedcomplete data and were included in this analysis. Themedian age of participants was 38 years (interquartilerange: 34 – 48 years). In total, 376 (87.4%) reported hav-ing ever required assistance injecting, while 81 (18.8%)participants reported that they had engaged in assistedinjection in the last six months. Among those who havereported needing help injecting in the last 6 months, 12(14.8%) said they always required help, 10 (12.3%) saidthey needed help most of the time, 25 (30.9%) requiredhelp some times, and 34 (42.0%) did not require assist-ance very often.As shown in Table 1, in bivariate analyses, factorspositively associated with assisted injecting at the 0.10level included being female (odds ratio [OR] = 2.42; 95%confidence interval [CI]: 1.40 – 4.18), heroin injection ofmore than once a week (OR = 1.78; 95% CI: 0.99 – 3.20),being in a relationship (OR = 1.60; 95% CI: 0.98 – 2.59),shared syringes (OR = 2.08; 95% CI: 1.18 – 3.68), useddrugs in combination (OR = 1.53; 95% CI: 0.92 – 2.53) andsoft-tissue infections (OR = 3.51; 95% CI: 1.43 – 8.64). Fac-tors negatively associated with assisted injecting includedbeing older or equal to the age of 38 (OR = 0.52; 95%CI: 0.32 – 0.84), heroin injection once a week or less(OR = 0.61; 95% CI: 0.33 – 1.10) and having a longer injec-tion career (OR = 0.96; 95% CI: 0.94 – 0.99).As indicated in Table 2, in multivariate analyses,assisted injecting remained independently associatedwith being female (AOR = 2.45; 95% CI: 1.33 – 4.48),being a frequent heroin injector (AOR = 1.41; 95%CI: 1.01 – 1.98), syringe sharing (AOR = 2.17; 95%CI: 1.18 – 3.94) and soft-tissue infections (AOR = 3.02;95% CI: 1.14 – 7.72). Having a longer injecting career(AOR = 0.97; 95% CI: 0.94 – 0.99) remained negativelyassociated with assisted injecting.The two most common self-reported reasons for re-quiring assistance with injecting include being new toinjecting (68.7%) and not knowing how to inject (56.1%),and 21.8% attributed bad veins as being a reason for whythey needed help injecting. Less common reasons for re-quiring assistance injecting include requiring groin injec-tion (9.7%), having shaky hands (5.8%), being drug-sick(4.1%), and hating needles (3.4%). Finally, of the partici-pants who ever needed assistance with injecting, 327(84.9%) received assistance from a close friend, 42(10.9%) reported receiving help from a regular partner,followed by 33 (8.6%) who received assistance from anacquaintance.DiscussionIn the present analysis, we found that approximately88% of a community-recruited sample of IDU inBangkok had reported previously needing assistance toinject drugs, and 19% reporting receiving assistance withan injection in the past six months. In multivariate ana-lyses, we found five variables that remained positivelyand independently associated with assisted injecting.Soft-tissue infection was the variable most strongly asso-ciated with the outcome, with people who have soft-tissue infections being approximately three times morelikely to need assistance with injecting. Those who arefemale and those who have shared syringes were bothfound to be more than twice as likely to engage inassisted injecting. Frequent heroin injectors were about1.5 times more likely to require help with injecting.Lastly, having a longer injecting career was slightly nega-tively associated with assisted injecting. The most com-mon reasons given for requiring assisted injecting arenot knowing how to inject and being new to injecting.Despite the fact that this is, to our knowledge, the firststudy to explore the practice of assisted injecting inThailand, some of our findings are consistent with alarge body of literature on assisted injecting in NorthAmerican settings [6,8,10]. For instance, we found thatfemale IDU were approximately twice as likely to engagein assisted injecting compared to male IDU. This may bepartly explained by the gender dynamics commonamong IDU populations, whereby men often retain con-trol over the possession and administration of drugs[12-14]. Accordingly, women are often injected by malefriends [5], and as a consequence often do not learn howto self-administer their injections. In a study conductedby Fairbairn and colleagues in Canada, women gave nar-rative accounts of assisted injecting, detailing the oppor-tunity to share the injecting process and drug high withmen, hence fostering an increased sense of trust and in-timacy [15]. Another reason that females in the Thaicontext might be more than twice as likely to engage inassisted injecting than males is because females naturallyhave smaller veins and may not know how to injectthemselves, as has been shown in other settings [5]. Al-though many other studies have shown the importanceLee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32 Page 3 of 7http://www.substanceabusepolicy.com/content/8/1/32Table 1 Bivariate analyses of factors associated with assisted injecting in the past six months among IDU in Bangkok,Thailand (n = 430)Required help injecting*Characteristic Yes 81 (18.8%) No 349 (81.2%) Odds ratio (95% CI) p - valueMedian Age≥ 38 years 32 (39.5) 195 (55.9) 0.51 (0.31 – 0.84) 0.008< 38 years 49 (60.5) 154 (44.1)GenderFemale 26 (32.1) 57 (16.3) 2.42 (1.40 – 4.18) 0.001Male 55 (67.9) 292 (83.7)Education≥ Secondary education 51 (63.0) 212 (60.7) 1.10 (0.67 – 1.81) 0.712< Secondary education 30 (37.0) 137 (39.3)Relationship statusMarried or having a regular partner 44 (54.3) 149 (42.7) 1.60 (0.98 – 2.59) 0.058Other 37 (45.7) 200 (57.3)Heroin injection*>Weekly 27 (33.3) 64 (18.3) 1.78 (0.99 – 3.20) 0.054≤Weekly 21 (25.9) 146 (41.8) 0.61 (0.33 – 1.10) 0.096No injection 33 (40.7) 139 (39.8)Midazolam injection*>Weekly 42 (51.9) 195 (55.9) 0.92 (0.52 – 1.63) 0.776≤Weekly 17 (21.0) 60 (17.2) 1.21 (0.59 – 2.46) 0.598No injection 22 (27.2) 94 (26.9)Yaba injection*>Weekly 16 (19.8) 72 (20.6) 1.08 (0.57 – 2.04) 0.818≤Weekly 25 (30.9) 83 (23.8) 1.46 (0.83 – 2.56) 0.185No injection 40 (49.4) 194 (55.6)Ice injection*>Weekly 2 (2.5) 17 (4.9) 0.50 (0.11 – 2.21) 0.546≤Weekly 10 (12.3) 39 (11.2) 1.09 (0.52 – 2.29) 0.847No injection 69 (85.2) 293 (84.0)Shared syringes*Yes 22 (27.2) 53 (15.2) 2.08 (1.18 – 3.68) 0.011No 59 (72.8) 296 (84.8)Number of years injectingMedian (IQR) 17 (8 – 21) 19 (15 – 27) 0.96 (0.94 – 0.99) 0.003Non-fatal overdose*Yes 4 (4.9) 11 (3.2) 1.60 (0.50 – 5.15) 0.498No 77 (95.1) 338 (96.8)Used drugs in combination*Yes 53 (65.4) 193 (55.3) 1.53 (0.92 – 2.53) 0.097No 28 (34.6) 156 (44.7)Lee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32 Page 4 of 7http://www.substanceabusepolicy.com/content/8/1/32of gender dynamics in influencing the injection processamong women, it is important to note that being in a re-lationship, a status sometimes associated with trust andintimacy, was not independently associated with assistedinjecting in our study. This inconsistency further high-lights the need to explore gender dynamics, outside ofintimate relationships, and the impact of such dynamicson assisted injecting among female IDU in Thailand.Our study also found that more experienced IDU wereless likely to require help injecting. These findings arefurther reflected in our sub-analyses where the mostcommon reasons given for needing assistance withinjecting were being new to injecting and not knowinghow to inject. Our multivariate analysis also supportsthis finding by demonstrating that IDU who hadshorter injection careers were more likely to require as-sistance with injection. These results are consistent withO’Connell et al.’s [10] study on assisted injecting as apredictor for HIV infection among IDU in Vancouverwhich found that younger IDU and more recent initiatesto injecting were more at risk to requiring assistanceinjecting. Furthermore, Wood et al.’s [6] findings onVancouver IDU mirror our results, in that 7% of men and13% of women in that study attributed requiring assist-ance with injecting to not knowing how to inject properly.Our study found that frequent heroin injectors weremore likely to engage in assisted injecting compared toless frequent heroin injectors. However, research inNorth America points to frequent stimulant use (cocaineuse in particular) as being more strongly associated withassisted injecting [8,16]. On the other hand, previous re-search has also identified withdrawal effects (i.e., “drugsickness”) as a reason for assisted injecting [6], and thistype of withdrawal is more commonly associated withheroin injecting. This geographical variance observedherein could possibly be accounted for by the fact thatthere are different drug use patterns across differentgeographical regions. For example, it is well known thatcocaine injecting is virtually non-existent among ThaiIDU [17].Our findings indicate that those who are recipients ofinjections are more likely to have soft-tissue infectionssuch as abscesses. Several publications have stated that astrong risk factor for skin infections is skin-popping,where the injection is intramuscular or subcutaneous[4,18]. Although intravenous injection carries its ownrisks, intramuscular injections allow infections to occurbecause foreign substances are introduced directly intothe tissue where it remains localized and concentrated,providing it with an opportunity to fester and infect theskin. It is possible that skin-popping is more commonlyobserved among Thai IDU who are recipients of injec-tions because those who administer the injection maynot know how to inject properly themselves. Thisphenomenon could be social in origin, where youngerand novice injectors tend to use drugs with their friendswho coincidentally would be closer in age to each otherand have similar drug-use experience.Table 2 Multiple logistic regression of factors associated with assisted injecting among IDU in Bangkok, Thailand(n = 431)Variable Adjusted odds ratio (AOR) 95% confidence interval (CI) p - valueGender(Female vs. Male) 2.45 (1.33 – 4.48) 0.004Heroin injection*(>Weekly vs. ≤Weekly vs. No injection) 1.41 (1.01 – 1.98) 0.043Number of years injecting(Per year longer) 0.97 (0.94 – 0.99) 0.022Shared syringes*(Yes vs. No) 2.17 (1.18 – 3.94) 0.011Soft-tissue infections*(Yes vs. No) 3.02 (1.14 – 7.72) 0.022IDU people who inject drugs.*Activities/behaviors in the previous six months.Table 1 Bivariate analyses of factors associated with assisted injecting in the past six months among IDU in Bangkok,Thailand (n = 430) (Continued)Soft-tissue infections*Yes 9 (11.1) 12 (3.4) 3.51 (1.43 – 8.64) 0.004No 72 (88.9) 337 (96.6)IDU people who inject drugs, CI confidence interval, IQR interquartile range.*Activities/behaviors in the previous six months.Lee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32 Page 5 of 7http://www.substanceabusepolicy.com/content/8/1/32One of the greater concerns of assisted injecting is theloss of control of the injection process, which can leadto risky behaviors such as syringe sharing and the over-administration of a drug, which can lead to overdose[8,19]. Although syringe sharing among Thai IDU wasstrongly associated with having engaged in assistedinjecting, non-fatal overdose was not significantly associ-ated with requiring help injecting, which runs counter tothe findings from the North America context [8]. Ac-cordingly, more research is needed to identify the impactof assisted injecting on overdose risk among Thai IDU.Collectively, our findings highlight the need for inter-ventions that reduce the practice of receiving assistedinjecting among Thai IDU. For this reason, based on ourfindings that syringe sharing is independently associatedwith assisted injection among Thai IDU, it would bebeneficial to encourage the wide implementation of suchprograms in the Thai context. However, based on ourcurrent knowledge and the present findings [6,8], theprovision of sterile injection equipment alone would dolittle to avert the practice of assisted injecting altogether.In addition to the provision of clean equipment and edu-cation on safe injection, other harm reduction strategiessuch as supervised injection facilities (SIFs) may be help-ful in both reducing the harmful effects that accompanyassisted injecting, such as HIV transmission, overdose,public drug use, and reducing the prevalence of thispractice altogether [20-23]. Evaluations have found thatstaff within SIFs often provide education on safer injec-tion techniques, and increases in safer injection practicesamong high-risk IDU have been associated with expos-ure to SIFs [8].However, it should be noted that at most SIFs, assist-ance provided to IDU who need assistance with injectionis limited to verbal directions and minimal manual as-sistance (excluding the actual act of injection). SomeIDU are able to conduct the injection successfully fol-lowing the receipt of such support, but there still remaina number who are unable to properly inject, and conse-quently seek out other IDU to assist with the injection[16]. Therefore, the policies and rules surroundingassisted injection in SIFs deserve further investigation[24]. In addition, given that SIFs have not yet beenimplemented at all in low- and middle-income settings,a site assessment in Bangkok on the feasibility andeffectiveness of operating a SIF should be conductedfirst. For example, the IDU population in Bangkok maybe too dispersed geographically, and therefore a micro-environmental intervention of this kind may not reachhigh levels of coverage [25]. Further, a lack of key stake-holder support may serve to undermine the effectivenessof such an approach.Female and novice IDU attributed requiring helpinjecting to not knowing how to inject properly. Withthe provision of appropriate educational support, thisspecific group of IDU can benefit from learning properinjecting. For those IDU who continue to receive assist-ance with injections, they may be able to learn about thedeleterious effects of using previously used equipment,including the elevated risk of disease transmission. Sucheducational preventative measures have been docu-mented in the North American context and have beenshown to be effective [26,27]. However, it should benoted that the current trend is that messages of safe in-jection assume self-administered injections, thus futureeducational campaigns could shift their focus and beaimed at those who specifically receive or deliver injec-tions. Given that drug use remains heavily criminalizedin Thailand, and IDU experience many social barriers tohealthcare, peer-based educational programming may bemost effective in addressing the problem of assistedinjecting in this setting.This study has limitations. First, the study sample wasnot randomly selected and therefore may not be repre-sentative of all local IDU. Hence, this study may not begeneralizable to Thai IDU or IDU in other settings. How-ever, given that no accessible official registries of IDU existin this setting, deriving a random sample was not possible.Second, the study relied on self-reported data, which maybe subject to response biases. Third, the study was cross-sectional in nature, and therefore we were unable to deter-mine temporal relationships between the outcome andexplanatory variables considered.In conclusion, we found that approximately 88% ofIDU in Bangkok reported a history of assisted injecting,and 18% reported receiving assistance with injecting inthe previous six months. Those engaging in assistedinjecting were more likely to be female and frequent her-oin injectors. Those with longer injecting careers wereless likely to report assisted injecting. A lack of know-ledge of how to inject was the most common reason givenfor engaging in the practice. Assisted injecting among thispopulation was also strongly associated with syringe shar-ing and soft-tissue infections. These findings point to theneed for program development within Thailand to reducethe risks and health consequences associated with assistedinjecting. More specifically, efforts should be made towidely implement educational and peer-based interven-tions focused on safer injecting in this setting.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsThe specific contributions of each author are as follows: WL, LT and TK wereresponsible for the research design; LT conducted the statistical analyses; WLprepared the first draft of the manuscript; All authors provided criticalcomments on the first draft of the manuscript and approved the finalversion to be submitted.Lee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32 Page 6 of 7http://www.substanceabusepolicy.com/content/8/1/32AcknowledgmentsWe would particularly like to thank the staff and volunteers at theMitsampan Harm Reduction Center, Thai AIDS Treatment Action Group andO-Zone House for their support and Dr. Niyada Kiatying-Angsulee of theSocial Research Institute, Chulalongkorn University, for her assistance withdeveloping this project. We also thank Tricia Collingham, Deborah Graham,Caitlin Johnston, Calvin Lai and Peter Vann for their research andadministrative assistance, and Prempreeda Pramoj Na Ayutthaya,Arphatsaporn Chaimongkon and Sattara Hattirat for their assistance withdata collection. The study was supported by the Michael Smith Foundationfor Health Research. This research was undertaken, in part, thanks to fundingfrom the Canada Research Chairs program through a Tier 1 Canada ResearchChair in Inner City Medicine which supports Dr. Evan Wood. Kanna Hayashi issupported by a University of British Columbia Doctoral Fellowship.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, V6Z 1Y6, Vancouver, BC, Canada. 2Department ofMedicine, University of British Columbia, 2775 Laurel Street, 10th Floor, V5Z1M9, Vancouver, BC, Canada. 3Thai AIDS Treatment Action Group, 18/89Vipawadee Road, soi 40 Chatuchak, Bangkok 10900, Thailand.Received: 7 May 2013 Accepted: 6 September 2013Published: 10 September 2013References1. Kitayaporn D, Uneklabh C, Weniger BG, Lohsomboon P, Kaewkungwal J,Morgan WM, Uneklabh T: HIV-1 incidence determined retrospectivelyamong drug users in Bangkok. Thailand. AIDS 1994, 8:1443–1450.2. Kral AH, Bluthenthal RN, Lorvick J, Gee L, Bacchetti P, Edlin BR: Sexualtransmission of HIV-1 among injection drug users in San Francisco USA:risk-factor analysis. Lancet 2001, 357:1397–1401.3. 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Tyndall MW, Currie S, Spittal P: Intensive injection cocaine use as thePrimary risk factor in the Vancouver HIV-1 epidemic. AIDS 2003,17:887–893.17. Werb D, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Lai C, Kerr T:Drug use patterns among Thai illicit drug injectors amidst increasedpolice presence. Subst Abuse Treat Prev Policy 2009, 4:16.18. Francesco L, Bruneau J, Stewart J: Understanding polydrug use: review ofheroin and cocaine co-use. Addiction 2003, 98:7–22.19. Wood E, Kerr T, Montaner JS: Rationale for evaluating North America’s firstmedically supervised safer injecting facility. Lancet Infect Dis 2004,4:301–306.20. Dolan K, Kimber J, Fry C, Fitzgerald J, McDonald D, Frautmann F: Drugconsumption facilities in Europe and the establishment of supervisedinjecting centres in Australia. Drug Alcohol Rev 2000, 19:337–346.21. de Jong W, Weber U: The professional acceptance of drug use: A closerlook at drug consumption rooms in the Netherlands, Germany andSwitzerland. International Journal of Drug Policy 1999, 10:99–108.22. Ronco C, Spuhler G, Coda P, Schopfer R: Evaluation for alley-rooms I, II,and III in Basel. Social and Preventative Medicine 1996, 41:58–68.23. van Beck I, Gilmour S: Preference to have used a medically supervisedinjecting centre among injecting drug users in Kings Cross, Sydney.Australia and New Zealand Journal of Public Health 2000, 24:540–542.24. Small W, Shoveller J, Moore D, Tyndall M, Wood E, Kerr T: Injection druguser’s access to a supervised injection facility in Vancouver, Canada: Theinfluence of operating policies and local drug culture. Qual Health Res2011, 21:743–756.25. Kerr T, Small W, Moore D, Wood E: A micro-environmental intervention toreduce the harms associated with drug-related overdose: Evidence fromthe evaluation of Vancouver’s safer injection facility. International Journalof Drug Policy 2007, 18:37–45.26. Wood E, Kerr T, Spittal PM, Li K, Small W, Tyndall MW: The potential publichealth and community impacts of safer injecting facilities: Evidence froma cohort of injection drug users. J Acquir Immune Defic Syndr 2003, 32:2–8.27. Broadhead RS, Kerr TH, Grund JP, Altice FL: Safer injection facilities inNorth America: Their place in public policy and health initiatives.J Drug Issues 2002, 32:329–355.doi:10.1186/1747-597X-8-32Cite this article as: Lee et al.: Assisted injection among people whoinject drugs in Thailand. Substance Abuse Treatment, Prevention, and Policy2013 8:32.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitLee et al. Substance Abuse Treatment, Prevention, and Policy 2013, 8:32 Page 7 of 7http://www.substanceabusepolicy.com/content/8/1/32

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