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Harmful microinjecting practices among a cohort of injection drug users in Vancouver Canada Rachlis, Beth Stephanie; Lloyd-Smith, Elisa; Small, Will; Tobin, Diane; Stone, Dave; Li, Kathy; Wood, Evan; Kerr, Thomas Jul 31, 2010

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Harmful microinjecting practices among a cohort of injectiondrug users in Vancouver CanadaBeth Rachlis1, Elisa Lloyd-Smith1, Will Small1, Diane Tobin2, Dave Stone2, Kathy Li1, EvanWood1, and Thomas Kerr11BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada2Vancouver Area Network of Drug Users, Vancouver, British Columbia, CanadaAbstractObjectives—We sought to identify factors associated with harmful microinjecting practices in alongitudinal cohort of IDU.Methods—Using data from the Vancouver Injection Drug Users Study (VIDUS) betweenJanuary 2004 and December 2005, generalized estimating equations (GEE) logistic regression wasperformed to examine sociodemographic and behavioral factors associated with four harmfulmicroinjecting practices (frequent rushed injecting, frequent syringe borrowing, frequentlyinjecting with a used water capsule, frequently injecting alone).Results—In total, 620 participants were included in the present analysis. Our study included 251(40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The median age was 31.9(interquartile range: 23.4–39.3). GEE analyses found that each harmful microinjecting practicewas associated with a unique profile of sociodemographic and behavioral factors.Discussion—We observed high rates of harmful microinjecting practices among IDU. Thepresent study describes the epidemiology of harmful microinjecting practices and points to theneed for strategies that target higher risk individuals including the use of peer-driven programsand drug-specific approaches in an effort to promote safer injecting practices.Keywordsinjection drug use; harmful; Vancouver; microinjecting practicesBACKGROUNDIn addition to high rates of morbidity from cutaneous injection-related infections includingabscesses and cellulitis (Dwyer et al., 2009; Lloyd-Smith 2008; Lloyd-Smith et al., 2005;Palepu et al., 2001), individuals who inject drugs (IDU) have been recognized as a group athigh-risk for the acquisition of blood-borne viruses including Human ImmunodeficiencyVirus (HIV) and Hepatitis C Virus (HCV) (Aceijas, Stimson, Hickman, and Rhodes, 2004;Centers for Disease Control and Prevention, 2009; Spradling et al., 2010). Importantly,transmission occurs largely through the sharing of contaminated-injecting paraphernalia(Freeman, Williams, and Sanders, 1999; Hamers et al., 1997; Strathdee et al., 1998; Wood etal., 2001). In response, a range of interventions has been developed with the primary focuson the reduction of syringe sharing, such as needle exchange programs (NEPs) (Des Jarlais,Arasteh, Semaan, and Wood, 2009; Des Jarlais et al., 2000; Hurley and Jolley, 1997).Corresponding author: Dr. Thomas Kerr, BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver BC V6Z1Y6, Canada, 604-806-9116, uhri-tk@cfenet.ubc.ca.NIH Public AccessAuthor ManuscriptSubst Use Misuse. Author manuscript; available in PMC 2013 September 24.Published in final edited form as:Subst Use Misuse. 2010 July ; 45(9): 1351–1366. doi:10.3109/10826081003767643.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptHowever, it is well known that injection is a complex process that requires knowledge andtechnical proficiency. Injecting involves many steps and significant harm can result at anypoint in this process (Des Jarlais et al., 2009; Hagan and Des Jarlais, 2000). Therefore, wesought to examine a range of harmful microinjecting practices as a means of informing acomprehensive public health response.METHODSStudy SettingVancouver's Downtown Eastside (DTES), a highly impoverished neighborhood, comprisesof a 10-city block radius and is an epicenter of unstable housing, open and intense drug use,and explosive outbreaks of infectious disease (e.g., HIV and HCV). There are an estimated5,000 people who inject drugs in the DTES (Strathdee et al., 1997a). Pronounced poverty,measured in mean income, contributes to the DTES being classified as Canada's poorestpostal code (Buxton, 2007). As a result of exposure to the open drug scene in the DTES andassociated drug use, elevated levels of risk behaviors (e.g., sharing of syringes) have beenobserved (Corneil et al., 2006; Milloy et al., 2008; Small, Kerr, Charette, Schechter, andSpitall, 2006; Wood and Kerr, 2006). Further, IDU in this setting frequently contend withunstable housing environments, infectious diseases, and structural forces (e.g., policing,incarceration, urban development) that mediate the health of some of the more marginalizedindividuals living in this community. At the same time several health services have beeninitiated, including NEPs, a contact center, a street nurse program and most recently asupervised injection facility (Kerr et al., 2006).Study SampleThe first investigation into injection drug use in the DTES was the Point Project, a case-control study of 288 IDU set up in 1995 to examine risk factors for HIV infection (Patrick etal., 1997; Strathdee et al., 1997b). This study was the precursor for the Vancouver InjectionDrug Users Study (VIDUS) which is an open prospective study that has enrolled andfollowed 1,603 IDU recruited through self-referral or street outreach from Vancouver'sDTES, since May 1996. Research from VIDUS has examined a variety of aspects of druguse from individual and environmental levels. In terms of infectious disease outcomes,VIDUS has identified that nearly 30% of cohort participants are HIV positive and 90% areHCV positive (Patrick et al., 2001; Tyndall et al., 2003). Additionally, persons of Aboriginaldecent, over-represented in the DTES community, are more than two times more likely to beHIV-positive (Wood et al., 2008). Research from VIDUS has highlighted the devastatingeffects and extensiveness of drug use and infectious disease transmission in Vancouver'sDTES.The cohort has been described previously in detail (Tyndall et al., 2003; Wood et al., 2001).In brief, individuals were eligible for participation if they were 14 years of age or older, hadinjected illicit drugs at least once in the month prior to enrolment, resided in the GreaterVancouver area, and provided written informed consent. At baseline and semi-annually,participants complete an interviewer-administered questionnaire which elicits demographicdata including age, sex, and place of residence, and information regarding injection and non-injection drug use, injection practices, sexual risk behaviors, and enrolment into addictiontreatment. Participants also provide venous blood samples, which are tested for HIV andHCV antibodies. All subjects receive at $20 stipend to compensate for their time and covertransportation costs to the study office located in the heart of the DTES community. Thisstudy has been approved by the University of British Columbia's Research Ethics Board.Rachlis et al. Page 2Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptStatistical AnalysisOur analysis examined correlates between harmful microinjecting practices andsociodemographic characteristics, drug use, and other high-risk behaviors over time. We usethe term “microinjecting” in the present study to refer to a detailed examination of theinjection process at the individual level. More specifically, we use the term here to representrisks associated with individual self-injection rather than the risks associated with theinjection of small amounts of drugs. All participants who were currently injecting and had atleast one follow-up visit between January 2004 and December 2005 were eligible forinclusion in the present analysis. To begin, we explored time-invariant backgroundcharacteristics. We examined four separate harmful microinjecting practices as ourdependent variables of interest: frequent rushed injecting, frequent syringe borrowing,frequently injecting with a used water capsule, and frequently injecting alone. Whileinjecting alone may be protective in that an individual injecting outside of risky injectingnetworks may be at reduced risk of infectious disease transmission, here we consider theassociated harmful effects including risk of fatal or nonfatal overdose. For example, no onewould be available to contact emergency services in the event of an adverse reaction relatedto injecting. Responses were coded “frequent” if a participant had reported engaging in eachpractice examined 75% of the time or more. Independent variables of interest included: age(per year older), sex (female vs. male), Aboriginal ethnicity (yes/no), Downtown Eastside(DTES) residence (yes/no), homelessness (yes/no), HIV status (yes/no), years injecting (peryear), daily heroin injection (yes/no), daily cocaine injection (yes/no), syringe borrowing(yes/no), requiring help injecting (yes/no), public injecting (yes/no), incarceration (yes/no),involvement in the sex trade (yes/no), and whether police presence had affected where IDUbuy or use drugs or access clean needles (yes/no). Behavioral variables refer to the six-month period prior to the interview.We examined each harmful microinjecting practice and covariates associated during thefollow-up using generalized estimating equation (GEE) logistic regression. This approach islongitudinal in nature and accommodates changes in predictor variables over time. Variablespotentially associated with each harmful microinjecting practice were examined in bivariateGEE analyses. We fit four individual multivariate logistic GEE models using an a priori-defined model building protocol that involved adjusting for age, gender, Aboriginalethnicity, and all other explanatory variables statistically significant at the p < .05 inbivariate analyses. In the present study, members of the Vancouver Area Network of DrugUsers (VANDU), a well-recognized drug user organization, assisted in the interpretation ofstudy findings. All statistical analyses were performed using SAS software version 8.0(SAS, Cary, NC).RESULTSIn total, 620 participants were currently injecting, had a least one follow-up visit betweenJanuary 2004 and December 2005 and were included in the present analysis.Sociodemographic characteristics of included participants reported at baseline are presentedin Table 1. The proportion of participants who reported engaging in each harmfulmicroinjecting practice on a frequent basis is presented in Figure 1 (each bar represents adifferent time period corresponding to a different follow-up visit). The proportion reportingfrequent rushed injection ranged from 23% to 31%; 7% to 9% reported frequent syringeborrowing; 39% to 47% reported frequently injecting alone; and 12% to 15% reportedfrequently using a used water capsule for injection.Longitudinal analyses are presented in Table 2 and three with bivariate results displayed inTable 2 and multivariate results displayed in Table 3. Reporting frequent rushed injectionwas associated with public injecting [adjusted odds ratio (AOR) = 4.06, 95% confidenceRachlis et al. Page 3Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptintervals (CI): 2.81–5.88], daily heroin injection (AOR = 2.12, 95% CI: 1.62–2.78), beingaffected by police presence (AOR = 1.90, 95% CI: 1.36–2.67), sex trade involvement (AOR= 1.68, 95% CI: 1.17–2.42), requiring help injecting (AOR = 1.62, 95% CI: 1.17–2.23),incarceration (AOR = 1.45, 95% CI: 1.01– 2.08), daily cocaine injection (AOR = 1.42, 95%CI: 1.08–1.87), and younger age (AOR = 1.04, 95% CI: 1.01–1.06).Frequent syringe borrowing was positively associated with daily cocaine injection (AOR =1.76, 95% CI: 1.16–2.65). Living in the DTES (AOR = 0.40, 95% CI: 0.26–0.61) andAboriginal ethnicity (AOR = 0.58, 95% CI: 0.34–0.98) were both negatively associated withfrequent syringe borrowing.Frequently reporting injecting with a used water capsule was positively associated withrequiring help injecting (AOR = 2.19, 95% CI: 1.67–2.86), being HIV-positive (AOR =1.49, 95% CI: 1.15–1.94), and daily heroin injection (AOR = 1.40, 95% CI: 1.10–1.79), butwas negatively associated with Aboriginal ethnicity (AOR = 0.56, 95% CI: 0.42–0.74).Frequently injecting alone was negatively associated with being female (AOR = 0.68, 95%CI: 0.53–0.88) and incarceration (AOR = 0.71, 95% CI: 0.53–0.96).DISCUSSIONThe present study suggests that harmful microinjecting practices are common among localIDU and are associated with different sociodemographic and behavioral factors. Among theharmful injecting practices considered, reporting frequent rushed injecting and frequentlyinjecting alone were most prevalent among local IDU.Individuals in this study who reported living in the DTES were less likely to report frequentsyringe borrowing. Notably, the NEP operating in Vancouver's DTES is one of the largest inNorth America (Strathdee et al., 1997a) and our findings suggest that although some levelsof syringe borrowing persist in our setting, syringes are available and accessible in theDTES. However, recent evidence suggests that harm reduction supplies are not equallyavailable in throughout the province of British Columbia (Buxton et al., 2008; Spittal et al.,2007) although best practice guidelines indicate that the distribution of needles and syringesshould be comparable to the distribution of other necessary injecting supplies, includingsterile water (Buxton et al., 2008). Therefore, our findings highlight the need for thewidespread distribution and availability of all injecting supplies necessary for a safe andhygienic injection, both within and outside the DTES. Further examination into geographicvariability of harm-reduction service utilization is important to inform where the expansionof services is most needed.Participants who reported public injecting, recent incarceration, as well as individuals whoreported having been affected by police presence were all more likely to report frequentrushed injection. Importantly, environmental influences such as geographic location(Freeman et al., 1999; Haw and Higgins, 1998; Maas, Fairbairn, Kerr, Li, Montaner, andWood, 2007; Rhodes, 2002; Rhodes, Singer, Bourgois, Friedman, and Strathdee, 2005) andthe social context of specific injecting environments (Celentano et al., 1991; Dovey,Fitzgerald, and Choi, 2001; Ouellet, Jimenez, Johnson, and Wiebel, 1991; Rhodes et al.,2006) are known to influence risk-taking among IDU. Public injection drug use, forexample, has been associated with high-risk injecting behaviors and risk for cutaneousinjection-related infections, injection-related vein damage, and HIV and HCV transmission(Rhodes et al., 2006; Small, Rhodes, Wood, and Kerr, 2007). Given the high rates of druguse and other illicit activity (Buxton, 2003), the DTES community has been heavily policed,and police crackdowns, common to the area, have been shown to unintentionally foster high-risk injection practices among IDU (Eby, 2006; Small et al., 2006). These crackdowns alsoRachlis et al. Page 4Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripthave the unintended effect of driving drug users away from the area further displacing themfrom health and harm reduction services (Csete and Cohen, 2003; Wood et al., 2004). A fearof interruption and increased anxiety largely attributable to police presence has previouslybeen linked with rushed injecting and may prompt unsafe disposal of injecting paraphernaliaand result in accidental syringe sharing (Miller, Strathdee, Kerr, Li, and Wood, 2006a; Smallet al., 2007). Regardless, the police have a particular responsibility to ensure that theirpresence and actions do not produce harm and others have recommended that police officersshould not intervene at the point of injection (Maher and Dixon, 1995). However, the impactof drug enforcement on drug users’ ability to protect themselves from HIV/AIDS often goesunnoticed.Interestingly, both daily heroin and daily cocaine injection were associated with reportingfrequent rushed injection. However, it may be that different drugs are injected in a hurriedfashion for different reasons. For example, previous research has suggested that rushingassociated with daily heroin use may be a result of feeling anxious due to “dope sickness”(Shannon et al., 2007) and the desire to alleviate withdrawal symptoms. In the case ofcocaine injection, rushed injection may be partially attributed to cocaine's short half-lifereflecting the desire to inject often in order to continuously feel the effects of the drug(Magura, Kang, Nwakeze, and Demsky, 1998). Rushing may be related to this need to injectfrequently but may also relate to compulsive behavior associated with the effects of the drugitself and some research has suggested that the effects of cocaine is greatest when it isadministered rapidly (Abreu, Bigelow, Fleisher, and Walsh, 2001). It is worth noting that inour setting, both daily cocaine and daily heroin have been associated with patterns of bingedrug use where an individual engages in high-intensity compulsive drug runs injecting morefrequently than normal (Miller et al., 2006b). Nevertheless, the current findings support theneed for evidence-based drug-specific interventions, given that the risk profile varies amongconsumers of different types of drugs. Incorporated, could be the expansion of peer-drivenintervention models that have been shown to be effective in reaching high-risk injectorswhile addressing critical gaps in service delivery (Broadhead et al., 1998; Wood et al.,2003). Such models could also include those that are culturally appropriate and relevant toAboriginal communities.Importantly, drug user-led organizations have been emerging globally and havedemonstrated that drug users can organize themselves and make valuable contributions totheir communities (Kerr et al., 2006). In our setting, the VANDU Injection Support Teamengages in outreach and provides referrals to local IDU. As the team is composed ofmembers of the drug-user community within the DTES, they are well positioned torecognize and understand the complex and varied patterns of use among local IDU. Thisknowledge and understanding of real drug use-related experiences faced by users can furtherbe used in the design of specific interventions and there remains an ethical imperative toinvolve IDU populations in research (Kleinig and Einstein, 2006). In our setting, there hasbeen much discussion on the need for effective and appropriate policies that encourage theprovision of information and materials (Fast, Small, Wood, and Kerr, 2008; Wood et al.,2008) that serve to reduce harm, including those that can be incorporated into existing harmreduction programs such as the local supervised injecting facility. In addition to mobilizinglocal IDU as vital social agents of change, there remains an equally important need foradequate knowledge translation activities that serve to inform both policy makers as well asthe broader community on the nature and effects of local evidence-based harm reductionprograms currently in operation. VANDU performs a critical education function byexposing outsiders to the realities of daily life for drug users in Vancouver's DTES (Kerr etal., 2006). Findings from the present study have the potential to benefit both participants, aswell as nonparticipants, in the community if the reported findings inform or are incorporatedinto public policy.Rachlis et al. Page 5Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptThere are limitations of this study. First, VIDUS is not a random sample and therefore,findings from this analysis may not generalize to the wider population of IDU. Importantly,elevated levels of HIV and related risk behavior among IDU in our setting and others, maybe influenced by poor living conditions (Rhodes et al., 2005; Song, Safaeian, Strathdee,Vlahov, and Celentano, 2000) and evidence points to disproportionate levels of drug use andinjection among the urban poor (Galea, Nandi, and Vlahov, 2004). A lack of socioeconomicresources (Song et al., 2000) and the treatment of drug users as “criminals” continues toexacerbate social marginalization (***Csete, 2007) and stigmatizing practices against IDU—whether at the level of the individuals, community, institutions, or policies—often impedethe development and delivery of effective public health interventions (Friedman and Reid,2002; Kerr et al., 2006; Rhodes et al., 2005). However it is important to recognize thatpeople who inject drugs are not, in themselves, a homogenous population and although wefocused predominately on individual-level behaviors in the present study, we recognize thatsuch behaviors are shaped by an individual's social, political, economic, and physicalenvironments (Rhodes et al., 2005). While recent analyses indicate that the VIDUS cohort isrepresentative of IDU in the DTES community (Tyndall et al., 2001), findings from thepresent study should be generalized and interpreted with caution. Second, because our studyrelied on self-report data regarding drug use and injecting practices, our analysis could besubject to social desirability responding bias. Participants may have under-reported harmfulmicroinjecting practices, which would make our estimates conservative. However, it hasbeen suggested that self-report among IDU is generally valid (Darke, 1998). Third,unmeasured factors predictive of high-risk activity among IDU including anxiety levelsrelated to police presence and social network dynamics may have also contributed to theobserved findings.CONCLUSIONSIn the present study, we found high rates of unsafe injecting practices among IDU inVancouver. In particular, frequent rushed injecting and frequently injecting alone werehighly prevalent. However, we did not find a consistent set of sociodemographic orbehavioral factors that predicted the harmful microinjecting practices examined. Instead wefound that each harmful microinjecting practice was associated with a unique profile ofsociodemographic and behavioral factors, which may reflect, in part, the heterogeneity ofIDU both in our setting. While there are a variety of harm reduction programs in placelocally, our study suggests that harmful injecting practices persist in the community andnovel responses to these problems are needed. In addition to evidence-based drug-specificinterventions that are culturally appropriate, other approaches should consider involvingdrug user-led outreach efforts and the increased participation of IDU in research anddecision-making processes.AcknowledgmentsWe would particularly like to thank the VIDUS participants for their willingness to be included in the study, as wellas current and past VIDUS investigators and staff. We would specifically like to thank Deborah Graham, TriciaCollingham, Caitlin Johnston, Steve Kain, and Calvin Lai for their research and administrative assistance. Inaddition, we would like to thank the members of the VANDU Injecting Support Team for their input ininterpretation of the study findings. The study was supported by grants from the US National Institutes of Health(R01 DA011591) and the Canadian Institutes of Health Research (HHP-67262), including a CIHR community-based research grant (CBR-79873). 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Social and structural violence andpower relations in mitigating HIV risk of drug-using women in survival sex work. Social Scienceand Medicine. 2007; 66:911–921. [PubMed: 18155336]Small W, Rhodes T, Wood E, Kerr T. Public injection settings in Vancouver: physical environment,social context and risk. International Journal of Drug Policy. 2007; 18:27–36. [PubMed:17689341]Small W, Kerr T, Charette J, Schechter MT, Spittal PM. Impacts of an intensified police activity oninjection drug users: evidence from an ethnographic investigation. International Journal of DrugPolicy. 2006; 17:85–95.Song JY, Safaeian M, Strathdee SA, Vlahov D, Celentano DD. The prevalence of homelessnessamong injection drug users with and without HIV infection. Journal of Urban Health. 2000;77:678–687. [PubMed: 11194310]Spittal PM, Craib KJ, Teegee M, Baylis C, Christian WM, Moniruzzaman AK, et al. The Cedarproject: prevalence and correlates of HIV infection among young Aboriginal people who use drugsin two Canadian cities. International Journal of Circumpolar Health. 2007; 66:226–240. [PubMed:17655063]Spradling PR, Richardson JT, Buchacz K, Moorman AC, Finelli L, Bell BP, Brooks JT. the HIVOutpatient Study Investigators. Trends in hepatitis C virus infection among patients in the HIVoutpatient study, 1996–2007. Journal of the Acquired Immune Deficiency Syndromes. 2010;53:388–396.Strathdee SA, van Ameijden EJ, Mesquita F, Wodak A, Rana S, Vlahov D. Can HIV epidemics amonginjection drug users be prevented? AIDS. 1998; 12:s71–s79. [PubMed: 9632987]Strathdee SA, Patrick DM, Currie SL, Cornelisse PGA, Rekart M, Montaner JSG, et al. Needleexchange is not enough: lessons from the Vancouver injecting drug users study. AIDS. 1997a;11:F59–F65. [PubMed: 9223727]Strathdee SA, Patrick DM, Archibald CP, Ofner M, Cornelisse PG, Rekart M, et al. Socialdeterminants predict needle-sharing behaviour among injection drug users in Vancouver, Canada.Addiction. 1997b; 92:1339–1347. [PubMed: 9489050]Tyndall MW, Currie P, Spittal P, Li K, Wood E, O’Shaughnessy MV, Schechter MT. Intensiveinjection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS. 2003;17:887–893. [PubMed: 12660536]Tyndall MW, Craib KJP, Currie S, Li K, O’Shaughnessy MV, Schechter MT. Impact of HIV infectionon mortality in a cohort of injection drug users. Journal of the Acquired Immune DeficiencySyndrome. 2001; 28:351–357.Wood AR, Wood E, Lai C, Tyndall MW, Montaner JSG, Kerr T. Nurse-delivered safer injectioneducation among a cohort of injection drug users: evidence from the evaluation of Vancouver’ssupervised injection facility. International Journal of Drug Policy. 2008; 19:183–188. [PubMed:18367389]Wood E, Montaner JS, Li K, Zhang R, Barney L, Strathdee SA, et al. Burden of HIV infection amongaboriginal injection drug users in Vancouver, British Columbia. American Journal of PublicHealth. 2008; 98:515–519. [PubMed: 18235063]Wood E, Tyndall MW, Spittal PM, Li K, Kerr T, Hogg RS, et al. Unsafe injection practices in a cohortof injection drug users in Vancouver: could safer injecting rooms help? Canadian MedicalAssociation Journal. 2001; 165:405–410. [PubMed: 11531048]Wood E, Kerr T. What do you do when you hit rock bottom? Responding to drugs in the city ofVancouver. International Journal of Drug Policy. 2006; 17:55–60.Wood E, Kerr T, Spittal PM, Small W, Tyndall MW, O’Shaughnessy MV, et al. An evaluation of apeer-run ‘unsanctioned’ syringe exchange program. Journal of Urban Health. 2003; 80:455–464.[PubMed: 12930883]Rachlis et al. Page 9Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptWood E, Spittal PM, Li K, Ken T, Miller CL, Nogg RS, Montaner JS, Schechter MT. Inability toaccess addiction treatment and risk of HIV-infection among injection drug users. Journal ofAcquired Immune Deficiency Syndromes. 2004; 36:750–754. [PubMed: 15167295]Rachlis et al. Page 10Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 1.Proportion reporting four harmful microinjecting practices between January 2004 andDecember 2005 (n=620).Note: Each bar corresponds to a different follow-up visit between January 2004 andDecember 2005.Rachlis et al. Page 11Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptRachlis et al. Page 12Table 1Sociodemographic characteristics of included participants at baseline (n = 620).Characteristic n (%)Age  Median (IQR)* 31.9 (25.4–39.3)Years Injecting  Median (IQR)* 16.8 (10.2–27.3)Gender  Male 369 (59.5)  Female 251 (40.5)Aboriginal ethnicity  No 414 (67.3)  Yes 203 (32.7)Downtown Eastside (DTES) residence**  No 233 (37.6)  Yes 387 (64.2)HIV-positive  No 401 (68.8)  Yes 182 (31.2)Homeless**  No 541 (87.3)  Yes 79 (12.7)Sex trade involvement**  No 496 (80.0)  Yes 124 (20.0)*IQR: Interquartile Range.**Activities referring to previous six months.Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptRachlis et al. Page 13Table 2Sociodemographic and behavioral factors associated with four harmful microinjecting practices in bivariateGEE analyses.Frequent rushedinjectionFrequent syringeborrowingFrequentlyinjecting aloneFrequentlyinjecting with usedwaterAge (year older) 1.07 (2.05–1.09)** 1.03 (1.01–1.06)* 1.00 (0.98–1.01) 1.01 (1.00–1.03)Years injecting (per year) 0.95 (0.93–0.96)** 0.99 (0.97–1.02) 0.99 (0.98–1.01) 0.99 (0.99–1.01)Female gender (yes vs. no) 1.45 (1.09–1.94)* 0.82 (0.52–1.29) 0.68 (0.53–0.87)* 0.83 (0.65–1.06)Aboriginal ethnicity (yes vs. no) 1.40 (1.04–1.89)* 0.53 (0.32–0.89)* 0.81 (0.63–1.04) 0.56 (0.43–0.72)**Downtown Eastside (DTES) residence (yes vs. no) 1.18 (0.91–1.53) 0.42 (0.28–0.64)** 1.07 (0.84–1.36) 1.08 (0.85–1.37)HIV-positive (yes vs. no) 0.99 (0.73–1.36) 0.95 (0.58–1.56) 0.97 (0.75–1.26) 1.30 (1.00–1.68)*Homeless (yes vs. no) 2.81 (2.05–3.86)** 1.26 (0.76–2.09) 0.81 (0.61–1.08) 1.21 (0.90–1.62)Daily heroin use (yes vs. no) 2.86 (2.22–3.70)** 1.60 (1.08–2.36)* 0.89 (0.71–1.11) 1.53 (1.21–1.93)**Daily cocaine use (yes vs. no) 1.64 (1.30–2.06)** 1.60 (1.09–2.34)* 0.85 (0.68–1.06) 1.28 (1.01–1.62)*Public injecting (yes vs. no) 5.75 (4.18–7.91)** 1.53 (0.93–2.53) 0.89 (0.66–1.21) 0.82 (0.59–1.13)Help injecting (yes vs. no) 1.94 (1.46–2.57)** 1.34 (0.87–2.07) 0.76 (0.60–0.97)* 2.28 (1.76–2.96)**Sex trade (yes vs. no) 2.17 (1.60–2.93)** 1.06 (0.63–1.79) 1.08 (0.83–1.41) 1.21 (0.91–1.63)Incarceration (yes vs. no) 2.06 (1.49–2.85)** 1.90 (1.19–3.05)* 0.75 (0.56–1.00)* 1.35 (1.00–1.83)*Police presence (yes vs. no) 3.66 (2.83–4.74)** 1.09 (0.72–1.66) 0.89 (0.70–1.15) 1.62 (1.25–2.10)***p < 0.05.**p < 0.001.All variables refer to the last six months. Daily heroin and daily cocaine use refers to injecting at least once daily. Police presence refers to whetherpolice presence had affected where IDU buy or use drugs or access clean needles.Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptRachlis et al. Page 14Table 3Sociodemographic and behavioral factors associated with four harmful microinjecting practices in multivariateGEE analyses.Frequent rushedinjectionFrequent syringeborrowingFrequentlyinjecting aloneFrequentlyinjecting with usedwaterAge (year older) 1.04 (1.01–1.06) 1.03 (1.00–1.06) 1.01 (0.99–1.02) 1.01 (1.00–1.02)Years injecting (per year) 0.99 (0.97–1.01) — — —Female gender (yes vs. no) 0.88 (0.62–1.26) 0.86 (0.52–1.42) 0.68 (0.53–0.88)* 0.79 (0.60–1.04)Aboriginal ethnicity (yes vs. no) 1.24 (0.90–1.69) 0.58 (0.34–0.98)* 0.86 (0.66–1.12) 0.56 (0.42–0.74)**Downtown Eastside (DTES) residence (yes vs. no) — 0.40 (0.26–0.61)** — —HIV-positive (yes vs. no) — — — 1.49 (1.15–1.94)*Homeless (yes vs. no) 1.45 (0.99–2.11) — — —Daily heroin use (yes vs. no) 2.12 (1.62–2.78)** 1.41 (0.94–2.11) — 1.40 (1.10–1.79)**Daily cocaine use (yes vs. no) 1.42 (1.08–1.87)* 1.76 (1.16–2.65)** — 1.08 (0.85–1.38)Public injecting (yes vs. no) 4.06 (2.81–5.88)** — — —Help injecting (yes vs. no) 1.62 (1.17–2.23)* — 0.79 (0.62–1.00) 2.19 (1.67–2.86)**Sex trade (yes vs. no) 1.68 (1.17–2.42)* — — —Incarceration (yes vs. no) 1.45 (1.01–2.08)* 1.61 (0.97–2.67) 0.71 (0.53–0.96)* 1.15 (0.84–1.58)Police presence (yes vs. no) 1.90 (1.36–2.67)** — — 1.26 (0.99–1.60)*p < 0.05.**p < 0.001.All variables refer to the last six months. Daily heroin and daily cocaine use refers to injecting at least once daily. Police presence refers to whetherpolice presence had affected where IDU buy or use drugs or access clean needles.Subst Use Misuse. Author manuscript; available in PMC 2013 September 24.

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