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Assisted injection in outdoor venues : an observational study of risks and implications for service delivery… Lloyd-Smith, Elisa; Rachlis, Beth Stephanie; Tobin, Diane; Stone, Dave; Li, Kathy; Small, Will; Wood, Evan; Kerr, Thomas Mar 19, 2010

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RESEARCH Open AccessAssisted injection in outdoor venues:an observational study of risks and implicationsfor service delivery and harm reductionprogrammingElisa Lloyd-Smith1, Beth S Rachlis1, Diane Tobin2, Dave Stone2, Kathy Li1, Will Small1, Evan Wood1, Thomas Kerr1*AbstractBackground: Assisted injection and public injection have both been associated with a variety of individual harmsincluding an increased risk of HIV infection. As a means of informing local IDU-driven interventions that target orseek to address assisted injection, we examined the correlates of receiving assistance with injecting in outdoorsettings among a cohort of persons who inject drugs (IDU).Methods: Using data from the Vancouver Injection Drug Users Study (VIDUS), an observational cohort study ofIDU, generalized estimating equations (GEE) were performed to examine socio-demographic and behaviouralfactors associated with reports of receiving assistance with injecting in outdoor settings.Results: From January 2004 to December 2005, a total of 620 participants were eligible for the present analysis.Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The proportion ofparticipants who reported assisted injection outdoors ranged over time between 8% and 15%. Assisted injectionoutdoors was independently and positively associated with being female (Adjusted Odds Ratio (AOR) = 1.74, 95%Confidence Intervals (CI): 1.21-2.50), daily cocaine injection (AOR = 1.70, 95% CI: 1.29-2.24), and sex tradeinvolvement (AOR = 1.44, 95% CI: 1.00-2.06) and was negatively associated with Aboriginal ethnicity (AOR = 0.58,95% CI: 0.41-0.82).Conclusions: Our findings indicate that a substantial proportion of local IDU engage in assisted injecting inoutdoor settings and that the practice is associated with other markers of drug-related harm, including beingfemale, daily cocaine injecting and sex trade involvement. These findings suggest that novel interventions areneeded to address the needs of this subpopulation of IDU.BackgroundThe injection of illicit substances is associated with anarray of harms. The transmission of bacterial and viralinfections and risk of overdose persists in a range of set-tings despite considerable differences in drugs consumedand local injecting practices [1]. In response, a range ofinterventions have been developed to target unsafeinjecting [1]. However, unsafe injection often continuesdespite a growing availability of interventions that speci-fically target these problems.Supervised injection facilities (SIF) are a novel form ofintervention that typically involve providing a hygienicenvironment where persons who inject drugs (IDU) caninject under the supervision of health care professionals[2]. North America’s first SIF is situated in Vancouver,Canada’s Downtown Eastside (DTES) [2], a neighbour-hood characterized by extreme poverty, high crime,homelessness, poor housing, and high rates of alcoholand drug abuse [3]. Research on the SIF has demon-strated success in attracting high-risk injectors [4], aswell as improvements in safer injecting practices such asreduced levels of syringe sharing [5]. However, as withmany other interventions that target unsafe injecting,* Correspondence: uhritk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, British Columbia, CanadaLloyd-Smith et al. Harm Reduction Journal 2010, 7:6http://www.harmreductionjournal.com/content/7/1/6© 2010 Lloyd-Smith 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.concerns regarding barriers to SIF use remain. In parti-cular, assisted injection, or being physically injected bysomeone else, is prohibited [6]. The prohibition onassisted injection at the SIF is structured by the federalguidelines governing supervised injecting, as well as thestipulations of the exemption granted to the SIF [7] andstems from the potential for criminal and civil liabilityfrom assisted injection [8]. Therefore, IDU who requireassistance with injection, including IDU with physicaldisabilities, are unable to benefit from this service. Inturn, there is concern that these individuals are left toobtain assistance with their injections in unsafe injectingenvironments, including public and unhygienic settingssuch as alleyways [9]. Furthermore, research has consis-tently demonstrated the high risks associated withassisted injection such as increased syringe sharing[10,11], non fatal overdose [12], and elevated HIV inci-dence [10,13].In an effort to address the severe harms experiencedamong IDU who continue to require assistance withtheir injections in public settings, the Vancouver AreaNetwork of Drug Users (VANDU), a drug-user led orga-nization, formed the Injection Support Team (IST). TheIST responds to the unique needs of this population byproviding peer-based education and support on saferinjection practices, referring IDU to nearby social andhealth-related services, as well as distributing sterileinjecting paraphernalia via conventional outreach meth-ods. To inform the activities of the IST, a community-based research partnership was developed betweenVANDU and the British Columbia Centre for Excellencein HIV/AIDS. As part of this collaborative effort, weundertook the following analyses to examine the preva-lence of assisted injection in outdoor venues, as well asthe characteristics associated with those engaging in thispractice.MethodsCommunity-based research projectSince 2005, the VANDU IST has engaged with indivi-duals who require assistance with injection or who areinjecting unsafely outdoors. All IST members have beeninjecting for at least 10 years and have experience pro-viding assisted injections (i.e., “hit doctors”) in theDTES. There are no medical personnel on the IST.Through monthly meetings with the IST, our researchteam engaged in face-to-face discussions with IST tohelp define our study question and select variables forexamination. Several members nominated by the ISTwere subsequently consulted to provide their expertiseregarding the interpretations of the study findings,which helped navigate our selection of supporting litera-ture for the discussion.Vancouver Injection Drug Users Study (VIDUS)The following analyses are derived from the VancouverInjection Drug Users Study (VIDUS). VIDUS is an openprospective study that has followed 1603 IDU recruitedthrough self-referral or street outreach from Vancou-ver’s DTES since May 1996. The cohort has beendescribed previously in detail [14,15]. Briefly, individualswere eligible for participation if they were 14 years ofage or older, had injected illicit drugs at least once inthe month prior to enrolment, resided in the GreaterVancouver area and provided written informed consent.At baseline and semi-annually, participants complete aninterviewer-administered questionnaire, which elicitsdemographic data, and information regarding drug use,injection practices, sexual risk behaviours, and enrol-ment into addiction treatment. Participants also providevenous blood samples, which are tested for HIV andHCV antibodies. All subjects receive a $20 stipend ateach visit to compensate for their time and cover trans-portation costs to the facility. This study has beenapproved by the University of British Columbia’sResearch Ethics Board.Statistical AnalysisOur analyses examined the prevalence and correlates ofreporting assisted injection in outdoors settings. Ouroutcome was based on the question “In the past 6months, has anyone ever helped you to inject outdoors(i.e., street or alley)?” All participants who were cur-rently injecting and had at least one follow-up visitbetween January 2004 and December 2005 were eligiblefor inclusion in the present analysis. Independent vari-ables of interest included socio-demographic informa-tion: age (per year older), sex (female vs. male),Aboriginal ethnicity (yes/no), DTES residence (yes/no),homelessness (yes/no) and HIV status (yes/no). Home-lessness was defined as having no-fixed address (NFA)or living on the street, in a shelter or hostel. Drug usevariables of interest included: years injecting (per year),police presence (yes/no), daily heroin injection (yes/no),daily cocaine injection (yes/no), incarceration (yes/no),and involvement in the sex trade (yes/no). Police pre-sence refers to being affected in terms of where an indi-vidual buys or uses drugs. Unless otherwise noted, allbehavioural variables, both dependent and independent,refer to the six-month period prior to the interviewWe examined the prevalence of receiving assistancewith injection outdoors and examined factors potentiallyassociated with reporting this practice during follow-up.As the analyses of factors correlated with assisted injec-tion outdoors during the study period included numer-ous observations per participant, generalized estimatingequations (GEE) were used for binary outcomes with aLloyd-Smith et al. Harm Reduction Journal 2010, 7:6http://www.harmreductionjournal.com/content/7/1/6Page 2 of 5logit link to determine factors independently associatedwith our outcome throughout the follow-up period (i.e.,January 2004-December 2005). These methods providedstandard errors adjusted by multiple observations perperson using an exchangeable correlation structure [16].This approach also accommodates changes in predictorvariables over time. As a first step, variables potentiallyassociated with reporting assisted injection outdoors wasexamined in bivariate GEE analyses. To determine inde-pendent predictors of this outcome, we fit a multivariatelogistic GEE model using an a priori defined modelbuilding protocol that involved adjusting for all explana-tory variables that were found to be statistically signifi-cant at the p < 0.05 in bivariate analyses. All statisticalanalyses were performed using SAS software version 8.0(SAS, Cary, NC).ResultsIn total, 620 participants were actively injecting and hadat least one follow-up visit between January 2004 andDecember 2005 and thus were eligible for inclusion inthe present analysis. The median age of the sample was31.9 (Interquartile range 25.4-39.3), 251 (40.5%) partici-pants were female, and 203 (32.7%) self-identified asAboriginal.The proportion of VIDUS participants who reportedassisted injection outdoors varied with each follow-upbetween 2004 and 2005 and ranged between 8% and15%. Univariate and multivariate results are displayed inTable 1. In multivariate analyses, assisted injection out-doors was positively associated with being female(Adjusted Odds Ratio (AOR) = 1.74, 95% ConfidenceIntervals (CI): 1.21-2.50), daily cocaine injection (AOR =1.70, 95% CI: 1.29-2.24), and sex trade involvement(AOR = 1.44, 95% CI: 1.00-2.06). Aboriginal ethnicityremained negatively associated with the outcome (AOR =0.58, 95% CI: 0.41-0.82).DiscussionIn our study, between 8 and 15% of local IDU reportedreceiving assistance with injecting in outdoor settingsand this practice was independently and positively asso-ciated with being female, daily cocaine injection, and sextrade involvement. Aboriginal ethnicity was negativelyassociated with reporting assisted injection outdoors.Given that assisted injection has been shown to be inde-pendently associated with syringe sharing [10,11] and isa risk factor for HIV infection [10,13] and overdose[12], these findings indicate that novel programs areneeded to target the distinct needs of this subpopulationof IDU who engage in this practice in outdoor venues.In the present study, we demonstrated that beingfemale was associated with receiving assistance withinjecting in outdoor settings. This finding is consistentwith previous literature that demonstrates females areoverrepresented among those that require assistancewith their injections [10,13,17]. Females likely requirehelp with injecting for different reasons than men; speci-fically, females are more likely to report that they do notknow how to inject themselves [18]. Based on this find-ing, a gender-sensitive approach may be needed toensure that when members of the IST approach femalesinjecting outdoors, they are offered effective and appro-priate education and advice on how to self-inject safely.In the present study, reporting assisted injection out-doors was associated with daily cocaine injection. Thereis a dearth of information on the relationship betweenassisted injection outdoors and frequent cocaine injec-tion. However, the aspect of binge drug use as it relatesto daily cocaine injection may offer some insight. Dueto cocaine’s short half-life, there is a need to inject moreoften (e.g., 20 times a day) in order to maintain a high[15]. During periods of binge drug use, individuals canbecome highly stimulated, be more likely to hang out inTable 1 Socio-demographic and behavioural factorsassociated with reporting requiring help injectingoutdoors among participants of the Vancouver InjectionDrug User StudyVariable Requiring help injecting outdoors n = 163Odds Ratio (OR)(95% CI)Adjusted OR(95% CI)Age(year older) 1.06 (1.04-1.09) ** 0.98 (0.95-1.01)Years injecting(per year) 0.97 (0.95-0.99)** 1.00 (0.98-1.01)Sex(female vs. male) 2.80 (1.87-4.20)** 1.74 (1.21-2.50)*Aboriginal ethnicity(yes vs. no) 1.07 (0.70-1.64) 0.58 (0.41-0.82)*DTES residence(yes vs. no) 1.40 (0.96-2.06) -HIV(yes vs. no) 1.02 (0.67-1.57) -Homeless(yes vs. no) 1.88 (1.22-2.90)** 1.24 (0.75-1.79)Daily heroin(yes vs. no) 2.35 (1.65-3.34)** 1.25 (0.95-1.66)Daily cocaine(yes vs. no) 1.45 (1.05-2.01)* 1.70 (1.29-2.24)*Sex trade(yes vs. no) 2.85 (1.91-4.26)** 1.44 (1.00-2.06)*Incarceration(yes vs. no) 1.82 (1.18-2.80)** 1.24 (0.87-1.77)Police presence(yes vs. no) 2.35 (1.64-3.37)** 1.22 (0.91-1.65)Note: *p < 0.050 **p < 0.001, CI = Confidence IntervalLloyd-Smith et al. Harm Reduction Journal 2010, 7:6http://www.harmreductionjournal.com/content/7/1/6Page 3 of 5the open drug scene, and experience sleep deprivation[19], and therefore may have reduced ability to self-administer injections. Often individuals have preferenceabout who provides assisted injection but preferencesshift during periods of drug withdrawal or availability[18], which may result in a variety of people providingassistance with injections. Further, cutaneous injection-related infections (CIRI), such as abscesses and cellulitis,can result in vascular damage, which may impair theability of IDU to administer their own injections. Suchinfections have been also associated with frequentcocaine injection [20,21]. In addition, daily cocaineinjection remains a strong predictor of HIV risk amongIDU highlighting vulnerability in this population [15,22].Importantly, sex trade involvement was associatedwith reporting assisted injection outdoors, and this asso-ciation was independent from the association of femalesex. When drugs are shared among sex workers andtheir clients, some clients are assuming responsibility forthe preparation and administration of drugs [23].Further, in our setting, Shannon et al. recently demon-strated that individuals involved in sex trade work arebeing pushed to work and inject in remote outdoorlocations due to heavy police presence and laws thatprevent sex workers from working in regulated indoorsex work venues [24]. The displacement of sex workinto outdoor settings may explain the associationbetween sex work and outdoor assisted injection locally.Our results support further development of gender-based interventions that build personal capability to selfinject. These initiatives are currently supported by theSIF and the IST, but their role could improve if thecapacity of these services was increased. The SIF hasbeen described as a setting in the DTES where IDU canobtain safer injection education [25]. Further, the SIFhas been able to attract female injectors and individualswho require assistance with injection for CIRI care[25,26]. Importantly, drug user led organizations havebeen emerging globally and have demonstrated thatdrug users can organize themselves and make valuablecontributions to their communities [27]. In particular,VANDU (all IST members are VANDU members) per-forms a critical education function by exposing outsidersto the realities of daily life for drug users in Vancouver’sDTES [27]. Drug related harm, including risk of bacter-ial and viral infections, overdose, theft, and missed injec-tion has been extensively documented among those whorequire assistance with injection [10,11,13,18]. There-fore, increasing number and types of services offeredby the IST, who do not receive compensation for theinjection related support they provide, could reduce thedrug related harm in this setting. In the absence ofround the clock SIF operation and to ensure remoteoutdoor access to clean injection supplies, injectionparaphernalia vending machines may be considered asfurther novel intervention. In addition, the dynamic ofingrained injection routines and assisted injection byintimate partners or clients of sex trade workers[17,18,23] need to be acknowledged and consideredwhen developing interventions (e.g., education materialor individual instruction of safer injection practices) spe-cific to females and sex trade workers. Importantly,further research is required to elucidate why Aboriginalethnicity was the only variable negatively associated withrequiring assistance with injection in outdoor settings.There are limitations of this study to be considered.VIDUS is not a random sample. Therefore, findingsfrom this analysis are not necessarily generalizable tothe wider population of IDU in our setting or elsewhere.However, research has suggested that the VIDUS cohortis representative of IDU in the DTES community [28].Our finding may also not be generalizable to cities withdifferent climates from Vancouver. Additionally, sinceour study relied on self-report data regarding drug andinjecting practices, our analysis could be subject tosocial desirability bias. However, other studies have sug-gested self-report among IDU to be valid [29]. Finally,unmeasured factors predictive of high-risk activityamong IDU, including social network dynamics andmembership in a large socio-metric risk network [30],may have also contributed to the observed findings butare not incorporated into our analysis. Other potentialexplanatory factors specific to the outdoor injectingenvironment, such as lack of a physically clean spaceand inadequate lighting [9], were not considered andmay be better understood through qualitativeinvestigation.ConclusionsThere are important implications of the findings fromthe present study. It is recommended that the regula-tions at the SIF be changed to allow individuals whorequire assistance with their injection to inject at theSIF. These findings highlight the importance of ensuringthat peer-based outreach programs have strong femalerepresentation as a means of ensuring that the uniqueneeds of female IDU are addressed. It may also beimportant for the IST to target more remote outdoorareas that are frequented by sex workers. Furthermore,given the binge nature of cocaine injection, it would bevaluable to offer SIF and IST services 24 hours a day.Receiving assistance with injecting in outdoor settingswas reported by 8 to 15% of local IDU over time. In thepresent study, individuals who reported assisted injec-tion outdoors were more likely to be female, dailycocaine injectors, and individuals involved in the sextrade, and were less likely to be Aboriginal. Our findingshave implications for the role of peer education andLloyd-Smith et al. Harm Reduction Journal 2010, 7:6http://www.harmreductionjournal.com/content/7/1/6Page 4 of 5outreach programs run by drug users. This study pointsto the need for a broad set of interventions, such ashousing and treatment initiatives, which complementcurrent harm reduction services to reduce the levels ofunsafe injecting occurring outdoors in our setting.AcknowledgementsWe would particularly like to thank the VIDUS participants for theirwillingness to be included in the study, as well as current and past VIDUSinvestigators and staff. We would specifically like to thank Deborah Graham,Tricia Collingham, Caitlin Johnston, Steve Kain, and Calvin Lai for theirresearch and administrative assistance. The study was supported by the USNational Institutes of Health and the Canadian Institutes of Health Research.TK, ELS, WS are supported by the Michael Smith Foundation for HealthResearch and the Canadian Institutes of Health Research. BR, ELS, and WSare supported by Canadian Institutes of Health Research Doctoral ResearchAward.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, British Columbia, Canada. 2Injection Support Team, VancouverArea Network of Drug Users, Vancouver, British Columbia, Canada.Authors’ contributionsELS, BR and TK conceived the study. ELS and BR coordinated and designedthe study. KL analyzed the data. ELS drafted the manuscript. All authorsassisted in interpretation of findings or revisions for intellectual content andhave given final approval of the manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 9 July 2009 Accepted: 19 March 2010Published: 19 March 2010References1. UNAIDS: High Coverage Sites HIV Prevention among Injecting DrugUsers in Transitional and Developing Countries: Case Studies. Geneva2008.2. Wood E, Kerr T, Lloyd-Smith E, Buchner C, Marsh D, Montaner J, et al:Methodology for evaluating Insite: Canada’s first medically supervisedsafer injection facility for injection drug users. Harm Reduct J 2004, 1:9.3. Buxton J: Vancouver drug use epidemiology: Vancouver site report forthe Canadian Community Epidemiology Network on Drug Use(CCENDU). The Netowrk 2005 [http://vancouver.ca/fourpillars/pdf/report_vancouver_2005.pdf].4. Wood E, Tyndall M, Li K, Lloyd-Smith E, Small W, Montaner J, et al: DoSupervised Injecting Facilities Attract Higher-Risk Injection Drug Users?Am J Prev Med 2005, 29:126-130.5. Kerr T, Tyndall M, Li K, Montaner J, Wood E: Safer injection facility use andsyringe sharing in injection drug users. Lancet 2005, 366:316-318.6. 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Small W, Wood E, Lloyd-Smith E, Tyndall M, Kerr T: Accessing care forinjection-related injections through a medically supervised injectingfacility: a qualitative study. Drug Alcohol Depend 2008, 98:159-162.26. Lloyd-Smith E, Wood E, Zhang R, Tyndall MW, Montaner JS, Kerr T:Determinants of cutaneous injection-related infection care at asupervised injection facility. Ann Epidemiol 2009, 19:404-409.27. Kerr T, Small W, Peeace W, Douglas D, Pierre A, Wood W: Harm reducationby a ‘user-run’ organization: a case study of the Vancouver AreaNetwork of Drug Users (VANDU). International J Drug Policy 2006, 17:61-69.28. Tyndall MW, Craib KJ, Currie S, Li K, O’Shaughnessy MV, Schechter MT:Impact of HIV infection on mortality in a cohort of injection drug users.J Acquir Immune Defic Syndr 2001, 28:351-357.29. Darke S: Self-report among injecting drug users: a review. Drug AlcoholDepend 1998, 51:253-263.30. Lovell AM: Risking risk: the influence of types of capital and socialnetworks on the injection practices of drug users. Soc Sci Med 2002,55:803-821.doi:10.1186/1477-7517-7-6Cite this article as: Lloyd-Smith et al.: Assisted injection in outdoorvenues: an observational study of risks and implications for servicedelivery and harm reduction programming. Harm Reduction Journal 20107:6.Lloyd-Smith et al. Harm Reduction Journal 2010, 7:6http://www.harmreductionjournal.com/content/7/1/6Page 5 of 5


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