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Acceptability and design preferences of supervised injection services among people who inject drugs in… Mitra, Sanjana; Rachlis, Beth; Scheim, Ayden; Bardwell, Geoff; Rourke, Sean B; Kerr, Thomas Jul 14, 2017

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RESEARCH Open AccessAcceptability and design preferences ofsupervised injection services among peoplewho inject drugs in a mid-sized CanadianCitySanjana Mitra1, Beth Rachlis1,2, Ayden Scheim3, Geoff Bardwell4, Sean B. Rourke1,5 and Thomas Kerr4,6,7*AbstractBackground: Supervised injection services (SIS) have been shown to reduce the public- and individual-level harmsassociated with injection drug use. While SIS feasibility research has been conducted in large urban centres, little isknown about the acceptability of these services among people who inject drugs (PWID) in mid-sized cities. Weassessed the prevalence and correlates of willingness to use SIS as well as design and operational preferencesamong PWID in London, Canada.Methods: Between March and April 2016, peer research associates administered a cross-sectional survey to PWIDin London. Socio-demographic characteristics, drug-use patterns, and behaviours associated with willingness touse SIS were estimated using bivariable and multivariable logistic regression models. Chi-square tests were used tocompare characteristics with expected frequency of SIS use among those willing to use SIS. Design and operationalpreferences are also described.Results: Of 197 PWID included in this analysis (median age, 39; interquartile range (IQR), 33–50; 38% female), 170(86%) reported willingness to use SIS. In multivariable analyses, being female (adjusted odds ratio (AOR) 0.29; 95%confidence interval (CI) 0.11–0.75) was negatively associated with willingness to use, while public injecting in thelast 6 months (AOR 2.76; 95% CI 1.00–7.62) was positively associated with willingness to use. Participants living inunstable housing, those injecting in public, and those injecting opioids and crystal methamphetamine dailyreported higher expected frequency of SIS use (p < 0.05). A majority preferred private cubicles for injecting spacesand daytime operational hours, while just under half preferred PWID involved in service operations.Conclusions: High levels of willingness to use SIS were found among PWID in this setting, suggesting that theseservices may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS,programme planners and policy makers should consider the effects of gender and views of PWID regarding SISdesign and operational preferences.Keywords: Supervised injection services, Supervised consumption facilities, Feasibility research, People who inject drugs* Correspondence: uhri-tk@cfenet.ubc.ca4BC Centre on Substance Use, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada6BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 BurrardStreet, Vancouver V6Z 1Y6, BC, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Mitra et al. Harm Reduction Journal  (2017) 14:46 DOI 10.1186/s12954-017-0174-xBackgroundInjection drug use is associated with a wide range ofhealth and social harms, including endocarditis [1], softtissue infections [2], human immunodeficiency virus(HIV) [3, 4], hepatitis C (HCV) [5], and overdose [6].Aside from the individual-level harms experiencedamong people who use injection drugs (PWID), at thecommunity level, injection drug use in public spacescontributes to the improper disposal of injection-relatedlitter and is perceived as a public nuisance [7]. Likewise,costs due to injection drug use-related infections take afinancial toll on the health care system [8–10].To address the harms associated with injection druguse, supervised injection services (SIS), also called saferinjecting facilities or supervised injection sites, have beenimplemented in many settings globally, with more than90 established services in Western Europe, Australia,and Canada [11, 12]. SIS are health services that offer asafe and hygienic environment where people can injectpreviously obtained illicit substances under the supervi-sion of nurses or other trained health care staff [13, 14].In addition to allowing people to inject drugs in a low-risk environment, SIS provide clients with access to ster-ile injecting equipment, connect people to basic medicalcare, and provide referrals to other health and social ser-vices, including treatment for addiction [14, 15].Previous research has established that SIS have posi-tive impacts on the communities in which they are lo-cated, reducing the health and social harms associatedwith injection drug use. Rigorous evaluation of Insite,North America’s first legally sanctioned supervised injec-tion site located in Vancouver, Canada, demonstratesthat SIS reduce the risk of HIV transmission [16, 17]and fatal overdose [18] and increase the uptake of medicalcare and addiction treatment [19, 20]. The service hasbeen shown to reduce the extent of public injecting andthe number of discarded syringes and other injection-related litter in public spaces [7, 21]. Evaluations of theservices from Australia have also demonstrated a reducednumber of overdose-related ambulance callouts in theneighbourhoods surrounding the services [22].SIS feasibility research has been conducted in varioussettings to inform the implementation of SIS and estab-lish the acceptability and willingness to use such servicesamong PWID [23–26]. Importantly, consistent withother literature suggesting that intention is a reasonablepredictor of health-related behaviour, intention to useSIS has been shown to predict actual use once SIS areestablished. DeBeck et al. [27] demonstrated that initialwillingness to use a safe injection facility (SIF) amongPWID was independently associated with subsequent at-tendance at a Vancouver-based SIF, even after adjustingfor other determinants of willingness to use [27]. WhileSIS feasibility research has been conducted in largeurban centres in North America including San Francisco[23], Vancouver [25, 26], Toronto, and Ottawa [24],little is known about the acceptability and designpreferences of SIS among people who inject drugs inmid-sized cities.Despite often receiving fewer resources, at presentmany mid-size cities are contending with the same is-sues related to injection drug use as large urban centres.This is no more evident as in the present opioid andoverdose crises spanning across small- to mid-sizedNorth American cities [28]. However, there are some dif-ferences between mid- and large-sized cities with respectto barriers of SIS implementation. Existing literature onharm reduction and injection drug use indicates thatPWID living in smaller and remote communities oftenexperience limited access to formalized networks ofharm reduction and social services, lack anonymitywhen accessing services [29], and experience inconsist-ent access to transportation [30]. Social and culturalnorms of smaller communities can also make it challen-ging for PWID to access services. In contrast to large-size cities, smaller communities often face more rigidnorms of individualism, self-sufficiency, and conserva-tism and can lack liberal attitudes toward harm reduc-tion and injection drug use [30, 31]. Subsequentexperiences of stigma can lead to the desire of keepingone’s substance use hidden or lead to social isolation,making it difficult for PWID to seek help [30]. Similarchallenges may also constrain efforts to implement andpromote uptake of SIS and other harm reduction ser-vices in mid-sized cities.London, Canada, is a mid-sized city located in south-western Ontario, with a population of approximately370,000 [32]. When compared to other cities similar insize, London bears a disproportionately high burden of in-jection drug use [33]. The Public Health Agency ofCanada estimates that PWID from London experienceconsiderably higher rates of non-prescription opioid injec-tion (69–76%), borrowing and loaning of needles (20 and27%, respectively), and HCV (79%) compared to nationalaverages [34]. In 2015, London experienced an outbreakof new HIV diagnoses with PWID accounting for twothirds of diagnoses, compared to 12% reported provin-cially [35]. The harms associated with injection drug usealso burden local health services with Emergency MedicalServices responding to 603 overdoses in 2013, and rates ofopioid-related emergency department visits are 1.5 timeshigher than the provincial average [34].Despite a wide range of programming and servicesavailable to PWID in London, including naloxone andneedle distribution programmes, addictions treatment,street outreach, and supportive housing, problems dueto injection drug use persist [34–36]. The potential roleand acceptability of SIS in London, however, remainsMitra et al. Harm Reduction Journal  (2017) 14:46 Page 2 of 9unknown. Therefore, we assessed the prevalence andcorrelates of willingness to use SIS among PWID inLondon, Canada, and describe the design and oper-ational preferences among PWID who expressed willing-ness to use SIS.MethodsSurvey data were collected from the Ontario IntegratedSupervised Injection Services Feasibility Study con-ducted in London, Canada [37]. Between March andApril 2016, the research team worked with three peer re-search associates (PRAs) who administered a cross-sectional quantitative survey to PWID. PWID who were18 or older and injected drugs in the last 6 months wereeligible for participation. Participants were recruitedthrough city-wide peer outreach efforts, word of mouth,and recruitment flyers posted at local health and socialservice agencies. Potential participants were then invitedfor appointment or drop-in interview sessions at threesites. The survey, which was programmed on electronictablets and took approximately 45 min to complete, col-lected data on socio-demographic characteristics, drug-using behaviours and related harms, access to health ser-vices, willingness to use SIS, and SIS design preferences.The questionnaire was adapted from previous supervisedinjection services feasibility studies [25]. All participantswere provided a $25 honorarium and provided writteninformed consent.The study was supported by the Ontario HIV Treat-ment Network in partnership with the Regional HIV/AIDS Connection, a local AIDS Service Organization,and was guided by an Advisory Committee, composedof local health care and social service providers, andother stakeholders. Ethics approval was obtained fromthe University of Toronto and the University of BritishColumbia’s research ethics boards.Measures and outcomesOur primary outcome was willingness to use SIS.Responses were categorized into yes (i.e. those willing touse SIS) and maybe/no (i.e. those who may be willing ornot willing to use SIS). Participants were also asked “If aSIS was established in a location convenient to you, howoften would you use it?” with response options thatincluded: always (100% of the time), usually (over 75% ofthe time), sometimes (between 25 and 75% of the time),occasionally (less than 25% of the time), and never.Responses were categorized into always or usually andsometime or occasionally (i.e. high and low expectedfrequency of SIS use, respectively, defined as always/usuallyand sometimes/occasionally).Socio-demographic variables considered for analysisincluded age (in years), gender (female versus male),ethnicity (White versus Indigenous/Persons of colour),housing status (homeless or unstably housed versus liv-ing alone, with a partner, or with family) and involve-ment in sex work in the past 6 months (yes versus no).Drug-using behaviours were assessed for the past 6 monthsand included: any public injecting (yes versus no), anyinjecting alone (yes versus no), any help needed duringinjecting (yes versus no), any syringe sharing (categorizedas borrowing or loaning; yes versus no), and daily opioidinjecting and daily crystal methamphetamine injecting(both defined as daily versus less than daily or never). Life-time history of drug overdose (yes versus no) and historyof drug treatment (including past use of one or a combin-ation of the following: detox programmes, opioid substitu-tion therapy, addictions case management, drug court,residential drug treatment and outpatient counselling; yesversus no) were also explored.Data were also collected on SIS design preferences,willingness to use an integrated service, willingness towalk or bus to SIS, preferred set-up for injecting space,hours of operation, involvement of PWID in service op-eration, and important amenities for SIS.Data analysisWe used descriptive statistics including proportions forcategorical variables and report the median (and inter-quartile range) for age as a continuous variable. Logisticregression was used to model socio-demographic anddrug-using behaviours associated with willingness to useSIS. To adjust for potential confounding, all variables wereentered into a multivariable logistic model. Using back-wards selection, the least significant variable was droppedfrom the multivariable model, unless dropping it changedthe statistical significance of other variables. Reducedmodels were continually refit until the all variables wereeither significant (p < 0.05) or were considered potentialconfounders. We explored the expected frequency of SISuse (high versus low frequency) by socio-demographicand drug-using behaviour using chi-square tests or Fishersexact tests (when appropriate). The frequency of designpreferences and important amenities for SIS are reported.All analyses were conducted in SAS 9.4 [38].ResultsIn total, of 199 participants who were interviewed, 197(99%) provided complete data on willingness to use SIS(Table 1). Seventy-five (38%) were female, the medianage was 39 years (interquartile range (IQR) 33–50), 73%identified as White, and 139 (72%) reported publicinjecting in the past 6 months.A total of 170 (86%) reported willingness to use SIS. Inbivariable analyses (Table 1), those who expressed will-ingness to use SIS were less likely to be female (oddsratio (OR) 0.25; 95% confidence interval (CI) 0.11–0.60)and more likely to report any public injecting in the pastMitra et al. Harm Reduction Journal  (2017) 14:46 Page 3 of 9Table 1 Demographic, drug use characteristics, and treatment history characteristics associated with willingness to use SIS among PWIDCharacteristic Total sample(n = 197)Willingness to use SIS Unadjusted OR(95% CI)Adjusted OR(95% CI)Yes(n = 170)n (%)No or maybe(n = 27)n (%)Age, yearMedian (IQR) 39 (33–50) 39 (32–50) 40 (35–48) 0.99 (0.95–1.03) 1.00 (0.96–1.05)GenderFemale 75 (38.1) 57 (76.0) 18 (24.0) 0.25* (0.11–0.60) 0.29* (0.11–0.75)Male 122 (61.9) 113 (92.6) 9 (7.4)EthnicityWhite 139 (72.8) 120 (86.3) 19 (13.7) 0.98 (0.39–2.50) 0.63 (0.22–1.77)Other 52 (27.2) 45 (86.5) 7 (13.5)HousingUnstable 114 (57.9) 103 (90.3) 11 (9.7) 2.24 (0.97–5.11) 1.42 (0.53–3.80)Stable 83 (42.1) 67 (80.7) 16 (19.3)Sex workYes 38 (19.3) 33 (86.8) 5 (13.2) 1.06 (0.37–3.01) –No 159 (80.7) 137 (86.2) 22 (13.8)Any public injectingaYes 139 (71.9) 127 (91.4) 12 (8.6) 3.61* (1.55–8.44) 2.76* (1.00–7.62)No 55 (28.4) 41 (74.5) 14 (25.5)Any injecting aloneaYes 172 (87.3) 151 (87.8) 21 (12.2) 2.27 (0.82–6.33) 1.68 (0.56–5.10)No 25 (12.7) 19 (76.0) 6 (24)Any help injectinga –Yes 63 (32.0) 56 (88.9) 7 (11.0) 1.40 (0.56–3.52)No 134 (68.0) 114 (85.1) 20 (14.9)Syringe sharinga –Yes 44 (22.4) 39 (88.6) 5 (11.4) 1.32 (0.47–3.72)No 152 (77.6) 130 (88.5) 22 (14.5)Daily opioidb injectinga –Yes 106 (53.8) 95 (89.6) 11 (10.4) 1.84 (0.81–4.20)No 91 (46.2) 75 (82.4) 16 (17.6)Daily crystal meth injectingaYes 70 (35.5) 64 (91.4) 6 (8.6) 2.11 (0.81–5.51) –No 127 (64.5) 106 (83.5) 21 (16.5)Ever OD? –Yes 48 (24.7) 42 (87.5) 6 (12.5) 1.18 (0.45–3.11)No 146 (75.3) 125 (85.6) 21 (14.4)Drug treatment history –Yes 83 (42.8) 73 (88.0) 10 (12.0) 1.32 (0.57–3.05)No 111 (57.2) 94 (84.7) 17 (15.3)*p < 0.05aIn the past 6 monthsbOpioids include heroin, methadone (prescribed and non-prescribed), Hydros (Dilaudid and Hydromorph Contin), generic oxycodone, Oxy Neo, percocet, and fentanylMitra et al. Harm Reduction Journal  (2017) 14:46 Page 4 of 96 months (OR 3.61; 95% CI 1.55–8.44). In multivariableanalyses, being female remained negatively associatedwith willingness to use SIS (adjusted odds ratio (AOR)0.29; 95% CI 0.11–0.75), while public injecting in thepast 6 months remained positively associated (AOR:2.76; 95% CI: 1.00–7.62). Given our finding regardinggender, we tested all potential two-way interactions(where sufficient counts were available). No two-wayinteraction effects were found.Among those who reported willingness to use, 106(63%) said they would always/usually use SIS, while 62(37%) said they would sometimes/occasionally use SIS(Table 2). Higher proportions of participants living inunstable housing (69 vs. 55%), and reporting any publicinjecting (68 vs. 50%), daily opioid injecting (71 vs. 50%)and daily crystal methamphetamine injecting (77 vs.55%) in the past 6 months, reported higher expected fre-quency of SIS use if services were available (all p < 0.05).Design preferences and the top ten amenities deemedimportant are described in Table 3. Approximately 84%of those who reported willingness to use SIS preferredprivate cubicles as set-up for injecting spaces, 82% wouldbe willing to use an integrated service, located in a com-munity health centre, hospital, doctor’s clinic, or socialservice agency, and 73% preferred daytime hours (8 amto 4 pm) for operation of services. Forty-nine percent re-ported that PWID should be involved in operating theservice. No differences in design preferences were foundby expected frequency of use (data not shown). Themost important amenities identified for SIS include dis-tribution of sterile injecting equipment, preventing andresponding to overdoses, needle distribution, HIV/HCVtesting, and washrooms (see Table 3 for top 10).DiscussionThis study found high levels of willingness to use SISamong PWID in the mid-size city of London, Canada.Willingness to use SIS was positively associated withpublic injecting in the past 6 months and negativelyassociated with being female. Among those who werewilling to use SIS, we found that participants living inunstable housing, those injecting in public, and thoseinjecting opioids and crystal methamphetamine dailyreported higher expected frequency of SIS use. We alsocharacterized important considerations for implement-ing SIS locally. These findings have implications formaximizing the uptake and full potential of SIS inLondon, particularly among vulnerable groups of PWID.While there are currently only two legally sanctioned su-pervised injection facilities established in North America[39, 40], both in Vancouver, numerous cities have con-ducted feasibility studies to determine the acceptability ofthese services among PWID, and to inform design and op-erational preferences. High levels of willingness to use SISTable 2 Demographic, drug use characteristics, and treatmenthistory characteristics associated with expected frequency ofuse among PWID willing to use SISCharacteristic Expected frequency of SIS use p valuebAlways or usually(n = 106)n (%)Sometimes oroccasionally(n = 62)n (%)GenderFemale 35 (62.5) 21 (37.5) 0.9100Male 71 (63.4) 41 (36.6)EthnicityWhite 78 (61.4) 49 (38.5) 0.4276Other 28 (68.3) 13 (31.7)HousingUnstable 70 (68.6) 32 (31.4) 0.0447*Stable 36 (54.6) 30 (45.4)Sex workYes 17 (53.1) 15 (46.9) 0.1939No 89 (65.4) 47 (34.6)Any public injectingaYes 85 (67.5) 41 (32.5) 0.0460*No 20 (50.0) 20 (50.0)Any injecting aloneaYes 94 (63.1) 55 (36.9) 0.9952No 12 (63.2) 7 (36.8)Any help injectingaYes 35 (64.8) 19 (35.2) 0.7506No 71 (62.3) 43 (37.7)Syringe sharingaYes 27 (69.2) 12 (30.8) 0.3480No 78 (60.9) 50 (39.1)Daily opioidc injectingaYes 74 (71.2) 30 (28.9) 0.0058*No 32 (50.0) 32 (50.0)Daily crystal meth injectingaYes 49 (76.6) 15 (23.4) 0.0045*No 57 (54.8) 47 (45.2)Ever OD?Yes 30 (71.4) 12 (28.6) 0.1916No 74 (60.2) 49 (39.9)Drug treatment historyYes 44 (62.0) 27 (38.0) 0.8066No 60 (63.8) 34 (36.2)*p < 0.05aIn the past 6 monthsbDetermined through chi-square tests or Fishers exact, where appropriatecOpioids include heroin, methadone (prescribed and non-prescribed), Hydros(Dilaudid and Hydromorph Contin), generic oxycodone, Oxy Neo, percocet,and fentanylMitra et al. Harm Reduction Journal  (2017) 14:46 Page 5 of 9have generally been found across various large urbancentres. A study conducted among an established cohort ofPWID who were followed for 1 year between 2001 and2002 in Vancouver found that 37% of PWID expressed will-ingness to use SIS [26]. However, a later study conducted in2003 by the same authors among a different group of injec-tion drug users in Vancouver found 92% willingness to usesuch a service [25]. Authors attributed the higher propor-tion of willingness in the latter study to the study’s partici-pants who were active street-based injectors originating thecentre of Vancouver’s open drug scene, the DowntownEastside [25]. In more recent studies, willingness to use asafer injecting facility in San Francisco was 85% amongPWID [23], while in Toronto and Ottawa, up to 75% ofpeople who use drugs said they would use such a facility, ifit were available [24]. Findings from the present study re-veal that high levels of willingness to use SIS (86%), com-parable to large urban centres, may also be found amongPWID living in mid-sized cities.High proportions (72%) of PWID in London reportedinjecting in public or semi-public spaces. Consistent withprevious feasibility studies conducted [23, 24], we alsofound that public injecting was associated willingness touse SIS. Public injecting poses risks to individual healththrough rushed injection practices and reduced ability toensure privacy, safety and hygiene [41–43]. It is also asso-ciated with elevated risk of syringe sharing, blood-borneinfections, and overdose [43, 44]. Interestingly, amongthose who expressed willingness to use SIS, those who re-ported higher expected frequency of SIS use representmore vulnerable groups of PWID, such as those who livein unstable housing, and those reporting public injectingand daily opioid or crystal methamphetamine injection.This finding has significant implications, suggesting thatthose who are especially vulnerable to adverse health out-comes would more frequently use the service, if available.Similar findings have been reported in Vancouver, whereSIFs were found to attract those who injected in public,those who were homeless or unstably housed, and thosewho injected heroin daily [45]. Accordingly, SIS may be ef-fective in attracting and connecting vulnerable groups ofPWID to medical care, access to clean injecting equip-ment, emergency response to drug overdose, and referralsto addiction treatment and other support services. Like-wise, given the association between public injecting andhomelessness, SIS present the opportunity to link PWIDto housing programmes, including “Housing First” initia-tives that offer a recovery-oriented approach centred onproviding independent and permanent housing to individ-uals experiencing homelessness [46]. Therefore, SIS inLondon can potentially reduce the harms associated withinjection drug use, and more specifically, public injecting.At the same time, given that public injecting contributesto the improper disposal of injection-related litter, SIS canalso improve public order through reduced numbers ofpublicly discarded syringes and injection-related litter [7].In this way, our findings highlight not only the potentialfor SIS to impact PWID but also broader communitieswhere PWID live and inject.Table 3 Design preferences and important amenities identifiedfor SIS among PWID willing to use SISDesign feature PercentWilling to walk to SIS 88Time willing to walk in the summer months≤20 min 60>20 min 40Time willing to walk in the winter months≤20 min 84>20 min 16Willing to take a bus to SIS 60Time willing to take a bus in the summer months≤20 min 47>20 min 53Time willing to take a bus in the winter months≤20 min 54>20 min 46Willingness to use an integrated SIS 82Preferred set-up for injecting spacePrivate cubicle 84An open plan with benches at one large tableor counter1An open plan with tables and chairs 9A combinatory of above 6Preferred operating hoursDaytime 73Evening 20Overnight 7Involvement of PWID in SIS operation 49Important amenities identified for SIS PercentDistribution of sterile injection equipment 98Preventing and responding to overdoses 98Needle distribution 97HIV/HCV testing 96Washrooms 94Referrals to drug treatment, rehab and otherservices, when ready94Nursing staff for medical care and supervisedinjecting teaching93Access to health services 92Harm reduction education 89Withdrawal management 87Mitra et al. Harm Reduction Journal  (2017) 14:46 Page 6 of 9In the context of injection drug use, sex and gender actas determinants of health, shaping risk profiles betweenmen and women and contributing to unique barriers totreatment and access to services [47–49]. We found thatwomen were less likely to express willingness to use SIS.One possible explanation of this finding could be that com-pared to men, women who use illicit drugs experiencegreater stigmatization, which acts as a barrier to seekingcare, including access to addiction treatment and harm re-duction services [50–52]. Feelings of guilt and shame andlower levels of self-esteem and self-efficacy resulting fromstigma, in addition to experiences of violence related todrug use can prevent women from seeking help or feelinglike they deserved to be helped [50, 51, 53]. Some womenmay also be hesitant to publicly access services which mayresult in the disclosure of their drug use and exacerbate ex-periences of stigma.Given our findings, gender considerations should in-form the design and implementation of SIS to ensureequitable access and uptake, especially in light of pastwork indicating that SIS can provide refuge from gen-dered violence in local drug scenes [53, 54]. Tailoredharm reduction approaches for women may include awomen’s-only SIS, women’s specific drop-in times, andwomen-centred health and social service programming,and case management teams [49, 55, 56].Lower rates of willingness to use SIS among women inthis setting stands out in contrast to other SIS feasibilitywork undertaken in large urban centres [23, 24] and pastresearch showing similar rates of actual SIS uptake acrossgenders [57]. Future research should seek to explore thesedifferences. However, it should be noted that while in ourmultivariable model women appear less likely to expresswillingness to use SIS, the raw values still express a highwillingness (76% for women, 93% for men).This research also provided important information onthe design and operational preferences of PWID inLondon that can inform the implementation of SIS.Among those who were willing to use SIS, most were will-ing to walk or take the bus to access the service. Interest-ingly, we found that fewer PWID were willing to walklonger (i.e. greater than 20 min) in winter monthscompared to summer months (16% compared to 40%).However, when it came to taking a bus, there was lessdifference in willingness to take bus in terms of timebetween winter and summer months (46% compared to53%). This is somewhat in contrast to work undertakenelsewhere, which found that PWID were not generallywilling to travel distances to use a SIS [58]. Further, mostPWID preferred private cubicles for injecting and daytimeservice hours, while just under half believed PWID shouldbe involved in the operation of services. With regard toprivate cubicles, this may reflect PWIDs’ awareness ofInsite, Canada’s first sanctioned SIS, which uses privatecubicles, or may reflect the needs of some, in particularwomen, to ensure privacy and control over their drugsand drug use [53]. Important amenities identified for SISin this setting include distribution of sterile needles andother injection equipment, preventing and responding tooverdoses, access to HIV and HCV testing, availability ofwashrooms, access to health services, referrals to drugtreatment and other support services, harm reductioneducation and withdrawal management. Similar importantservices to provide alongside SIS were found in feasibilitywork done in Ottawa, but not in Toronto, where access tonursing and medical staff, food, drug counsellors and ur-gent detox beds were identified, highlighting the distinctpreferences of PWID in each setting [24].Given the current opioid and overdose epidemics ex-perienced across North America, the findings from thepresent study are timely and have implications for othersmall or mid-sized cities that are dealing with a dispro-portionately high burden of injection drug use. Thepresent study suggests that PWID of mid-sized cities areoverwhelmingly willing to use SIS, taking into consider-ation distinct design and operational preferences.Further, the findings of the present study, in line withthe outcomes of a recent study from London that foundoverall community stakeholder support of SIS imple-mentation [59], challenge past research suggesting thatin contrast to large urban centres, all smaller cities lackliberal perspectives toward harm reduction and injectiondrug use [31].There were limitations in this study. Participants re-cruited were not randomly sampled, and therefore maynot be representative of all PWID in London. Althoughefforts were made to recruit participants from a diverserange of settings, this may have resulted in some groupor social networks being over-represented in our sample.We also relied on self-reported data collected by peer re-search associates, which may be subject to response bias,including social desirability and recall bias. However, itis worth noting that self-reported responses from PWIDcan be valid and reliable [60].ConclusionsIn conclusion, a high proportion of PWID in Londonwere willing to use SIS if services were available, withwillingness to use being positively associated with publicinjecting and negatively associated with being female.Likewise, among those expressing willingness to use SIS,those who reported higher expected frequency of SISuse represented more vulnerable groups of PWID. Thesefindings suggest that SIS may play a role in addressingthe harms associated with injection drug use, particularlyamong vulnerable groups of PWID. With high levels ofSIS acceptability among PWID and London’s Board ofHealth recently approving to move forward with exploringMitra et al. Harm Reduction Journal  (2017) 14:46 Page 7 of 9the implementation of SIS [61], next steps for London in-clude the consultation of a diverse range of stakeholdersand the broader community, including the City ofLondon, the Middlesex-London Health Unit, London Po-lice Service, local businesses, and residents. Nonetheless ifimplemented, to maximize the uptake and potential bene-fits of SIS, policy makers and programme planners shouldtake into the consideration the attributes and preferencesof local PWID.AbbreviationsAOR: Adjusted odds ratio; CI: Confidence interval; HCV: Hepatitis C virus;HIV: Human immunodeficiency virus; OR: Odds ratio; PRA: Peer researchassociate; PWID: People who inject drugs; SIF: Safe injection facility;SIS: Supervised injection servicesAcknowledgementsWe would like to thank the study participants, research staff (including AndyMacLean, Elaine Hamm, and Samantha Scott), and the Advisory Committeemembers for their contributions. This study was conducted by the OntarioHIV Treatment Network in collaboration with Regional HIV/AIDS Connection.FundingThis study was funded by the Canadian Institutes of Health Research (CIHR)Centre for REACH in HIV/AIDS and Thomas Kerr’s CIHR Foundation Grant(FDN-148476). Ayden Scheim was supported by the Pierre Elliott TrudeauFoundation and Vanier Canada Graduate Scholarships.Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.Authors’ contributionsTK designed the Ontario Integrated Supervised Injection Services FeasibilityStudy. GB, SM and AS were responsible for the day-to-day running of the re-search study and acquired the data. BR conducted the analysis. SM wrotethe manuscript. All authors contributed to the interpretation of findings andrevision of the manuscript for intellectual content, and approved the finalversion to be published.Ethics approval and consent to participateEthical approval was obtained from the University of Toronto and Universityof British Columbia’s research ethics boards.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.Author details1The Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto,ON M4T 1X3, Canada. 2Division of Clinical Public Health, Dalla Lana School ofPublic Health, University of Toronto, 155 College Street, 6th floor, Toronto,ON M5T 3M7, Canada. 3Department of Epidemiology and Biostatistics, TheUniversity of Western Ontario, K201 Kresge Building, London, ON N6A 5C1,Canada. 4BC Centre on Substance Use, St. Paul’s Hospital, 608-1081 BurrardStreet, Vancouver, BC V6Z 1Y6, Canada. 5Centre for Urban Health Solutions, LiKa Shing Knowledge Institute of St. Michael’s Hospital, 209 Victoria Street,Toronto, ON M5B 1T8, Canada. 6BC Centre for Excellence in HIV/AIDS, St.Paul’s Hospital, 608-1081 Burrard Street, Vancouver V6Z 1Y6, BC, Canada.7Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.Received: 13 April 2017 Accepted: 5 July 2017References1. 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Drug Alcohol Depend.1998;51:253–63.61. Middlesex-London Health Unit. Board of health report: supervised injectionservices feasibility in middlesex-London. 2017.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Mitra et al. Harm Reduction Journal  (2017) 14:46 Page 9 of 9


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