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Declining trends in exposures to harmful policing among people who inject drugs in Vancouver, Canada Landsberg, Adina; Kerr, Thomas; Milloy, M-J; Dong, Huiru; Nguyen, Paul; Wood, Evan; Hayashi, Kanna Jul 18, 2016

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Research articleDeclining trends in exposures to harmful policing among peoplewho inject drugs in Vancouver, CanadaAdina Landsberg1,2, Thomas Kerr1,3, Michael-John Milloy1,3, Huiru Dong1, Paul Nguyen1, Evan Wood1,3 andKanna Hayashi§,1,3§Corresponding author: Kanna Hayashi, BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6 Canada. Tel: 1 604 558 6680.Fax: 1 604 806 9044. (khayashi@cfenet.ubc.ca)AbstractIntroduction: In 2006, the Vancouver Police Department (VPD) developed an organization-wide drug policy approach, whichincluded endorsing harm reduction strategies for people who inject drugs (PWID). We sought to examine rates of potentiallyharmful policing exposures and associated HIV risk behaviour among PWID in Vancouver, Canada before and after the VPD policychange.Methods: Data were derived from two prospective cohort studies of PWID. Multivariable generalized estimating equationmodels were used to examine changes in the risk of confiscation of drug use paraphernalia and physical violence by the police,as well as changes in the relationship between exposures to the two policing practices and sharing of drug use paraphernalia,before and after the policy change.Results: Among 2193 participants, including 757 (34.5%) women, the rates of experiencing police confiscation of drug useparaphernalia declined from 22.3% in 2002 to 2.8% in 2014, and the rates of reporting experiencing physical violence by thepolice also declined from 14.1% in 2004 to 2.9% in 2014. In multivariable analyses, the post-policy change period remainedindependently and negatively associated with reports of confiscation of drug use paraphernalia (adjusted odds ratio (AOR):0.25; 95% confidence interval (CI): 0.21 to 0.31) and reported physical violence by the police (AOR: 0.76; 95% CI: 0.63 to 0.91).However, experiencing both confiscation of drug use paraphernalia and physical violence by the police (AOR: 1.92; 95% CI: 1.10to 3.33) and experiencing only confiscation of drug use paraphernalia (AOR: 1.71; 95% CI: 1.34 to 2.19) remained independentlyand positively associated with sharing of drug use paraphernalia during the post-policy change period.Conclusions: In our study, two policing practices known to increase HIV risk among PWID have declined significantly since thelocal police launched an evidence-based drug policy approach. However, these practices remained independently associatedwith elevated HIV risk after the post-policy change. Although there remains a continued need to ensure that policing activitiesdo not undermine public health efforts, these findings demonstrate that a major shift towards a public health approach topolicing is possible for a municipal police force.Keywords: harm reduction; HIV/AIDS; injection drug use; drug law enforcement; Canada; epidemiology.Received 30 September 2015; Revised 3 April 2016; Accepted 24 April 2016; Published 18 July 2016Copyright: – 2016 Landsberg A et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative CommonsAttribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in anymedium, provided the original work is properly cited.IntroductionIn many settings, intensive policing is used as a commonstrategy aimed at eradicating the trafficking and use of illicitdrugs [1,2]. However, a large body of evidence demonstratesthat exposure to various policing practices increases HIVrisk behaviours and other harms among people who injectdrugs (PWID) [17]. Intensive policing practices, such as drugcrackdowns, have been shown to elicit fear among PWID,promote risk behaviours [13,5,79] (such as sharing of usedsyringes [1,2,10]) and limit access to healthcare and essentialHIV prevention services [1,7,1113]. The downstream healthconsequences of these behaviours include increased risk ofinfection, both bacterial and viral, vascular damage anddisease transmission [1,7]. Other specific policing practices,including confiscation of syringes [6,11] and arrest for syringepossession [14], have also been identified as perpetuating HIVrisk among PWID. As well, previous studies have reported highrates of police-perpetrated violence among PWID [4,9,15],and such experiences have also been shown to increase fearof police and high-risk injection behaviour [4,15].In response to growing concerns regarding the negativeimpacts of high-intensity policing targeting PWID, in recentyears, police departments in some jurisdictions have soughtto develop more progressive drug policies, including thosewith a focus on or acceptance of harm reduction approaches.Although evaluation of such novel policing policies and prog-rammes is of great importance, there is a limited bodyof research on police-endorsed harm reduction strategiesand their effect on the behaviours and health of PWID. Forexample, a study conducted in Tehran, Iran, sought to examinePWID’s access to harm reduction programmes after the localgovernment implemented harm reduction strategies in 2002Landsberg A et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20729http://www.jiasociety.org/index.php/jias/article/view/20729 | http://dx.doi.org/10.7448/IAS.19.4.207291[16]; however, it did not examine their HIV serostatus or theirexposure to policing. In Kyrgyzstan in 2009, a new policy wasadopted to advise the police to not interfere with syringeexchange programmes and outreach to PWID and sex workers[17]. Although the study examined police awareness of thepolicy and related activities, it did not evaluate the effect thepolicy had on PWID.In Vancouver, Canada, a large-scale police crackdown in2003 targeting people who use drugs led to increase high-risk injection behaviours and displacement of local PWID andinvited widespread criticism from public health and humanrights experts [18,19]. Soon after, the Vancouver PoliceDepartment (VPD) launched a new drug policy approach in2006, which consists of four pillars: prevention, enforcement,harm reduction and treatment [20]. With regard to harmreduction, the VPD stated that their public safety missionaims to ‘‘ensure open and ready access to public healthharm reduction initiatives, such as needle exchange and theSupervised Injection Site’’ [20]. Although the policy documentdid not specify which policing practices should be avoided orencouraged, one would expect a reduction of harmful policingpractices that are known to increase the risk of blood-bornedisease transmission among PWID, such as confiscation ofdrug use paraphernalia and physical violence by the police[4,6,11,15]. Therefore, taking advantage of two long-runningprospective cohort studies of PWID, we sought to examinechanges in the risk of exposure to confiscation of drug useparaphernalia and physical violence by the police and theassociated HIV risk behaviours among PWID in Vancouver,Canada, before and after the policy change in 2006.MethodsStudy procedures and participantsWe pooled participants in two open prospective cohorts ofpeople who use drugs in Vancouver: the Vancouver InjectionDrug Users Study (VIDUS) and the AIDS Care Cohort to EvaluateExposure to Survival Services (ACCESS). The cohorts havebeen described in detail elsewhere [21,22]. Briefly, VIDUS is acohort of HIV-seronegative adult PWID who injected illicitdrugs in the month prior to enrolment. ACCESS is a cohortof HIV-seropositive adult drug users who used an illicit drugother than cannabis in the previous month at enrolment.Other common eligibility criteria included being aged 18 yearsor older, residing in the greater Vancouver area and providingwritten informed consent.The two studies employ harmonizeddata collection and follow-up procedures to allow for com-bined analyses. Specifically, at baseline and semi-annuallythereafter, participants answer an interviewer-administeredquestionnaire, which elicits data on demographic char-acteristics, drug-using behaviours and related exposures,and undergo HIV serologic testing or disease monitoring asappropriate. Participants received $30 CAD at study visits.Both studies have been approved by the University of BritishColumbia/Providence Healthcare Research Ethics Board.For the present analyses, participants were eligible if theycompleted at least one study visit between 1 June 2002 and30 November 2014, reported a history of injection drug use atbaseline, and reported having injected drugs or smoked crackcocaine during the previous six months for each interview.Study variablesFor the examination of the trends in the risk of policingexposures, there were two primary outcomes: experiencingconfiscation of drug use paraphernalia (i.e. new syringes andpipes) by the police in the previous six months (yes vs. no) andexperiencing physical violence by the police in the previous sixmonths (yes vs. no). For the examination of the associated HIVrisk, the primary outcome was sharing drug use paraphernalia(i.e. syringes and pipes) in the previous six months (yes vs.no). In addition to syringes, we included pipes in the variabledefinition, as previous studies have shown increasing trendsin crack smoking and the associated elevated risk of HIVseroconversion among PWID in this setting [23,24].For the examination of the trends in the risk of policingexposures, the primary explanatory variable was the esti-mated calendar year of the outcome, dichotomized intobefore and after the VPD policy change in 2006. The studyquestionnaire assessed the outcomes of interest occurringin the past six months, so the calendar year was estimated asthe year of the date occurring three months prior to theinterview date. Because the reports of police confiscationof drug use paraphernalia were assessed only between June2002 and May 2006 and again between June 2009 andNovember 2014 (i.e. the question was removed for adminis-trative purposes between June 2006 and May 2009), thevariable was dichotomized as 2009 to 2014 versus 2002 to2006 for the analysis of police confiscation of drug useparaphernalia. Similarly, the reports of physical violence bythe police were assessed only between June 2004 andNovember 2014, and therefore the variable was dichotomizedas 2007 to 2014 versus 2004 to 2006 for the analysis ofphysical violence by the police. For the examination of therelationship between exposure to the two policing practicesand sharing of drug use paraphernalia, the primary explana-tory variable was exposures to the two policing practices inthe previous six months. This variable had four categories:(1) experiencing both confiscation of drug use paraphernaliaand physical violence by the police; (2) experiencing onlyconfiscation of drug use paraphernalia by the police; (3)experiencing only physical violence by the police; and (4)experiencing neither of them.Based on existing literature [4,6,15,25], we consideredsecondary explanatory variables that might confound therelationships between the primary explanatory variables andthe outcomes. These included: age (in years); gender (malevs. female); ancestry (Caucasian vs. other); homelessness(yes vs. no); Downtown Eastside residence (yes vs. no); heroininjection (]daily vs. Bdaily); cocaine injection (]dailyvs. Bdaily); crack smoking (]daily vs. Bdaily); injection ofdrugs in public (yes vs. no); drug dealing (yes vs. no); sexwork involvement (yes vs. no); incarceration (yes vs. no); andHIV serostatus (positive vs. negative). Behavioural variablesreferred to the previous six months unless otherwise indicatedand were treated as time-varying variables.Statistical analysesFirst, we examined the baseline sample characteristics strati-fied by reports of policing exposures in the previous sixmonths, using the Pearson’s chi-square test (for categoricalLandsberg A et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20729http://www.jiasociety.org/index.php/jias/article/view/20729 | http://dx.doi.org/10.7448/IAS.19.4.207292variables) and Wilcoxon rank-sum test (for continuous vari-ables). We also plotted the proportions of participantsreporting confiscation of drug use paraphernalia and physicalviolence by the police in the previous six months overthe calendar year. Because our questionnaire asked aboutpolice confiscation of drug use paraphernalia during the pastmonth between 2006 and 2014, we added the past monthdata to the plot.Because the present analyses included serial measures foreach participant, we used generalized estimating equations(GEE) with logit link, which provided standard errors adjustedby multiple observations per person using an exchangeablecorrelation structure. As a first step, we fitted univariableGEE models to examine the unadjusted associations betweenthe explanatory variables and the outcomes. To determinewhether the calendar year after the VPD policy changewas associated with decreased risk of exposures to thetwo policing practices after adjustment for potential con-founders, we used an a priori-defined statistical protocol[26] to construct multivariable GEE models. Briefly, we firstbuilt the full multivariable GEE models for each of the twooutcomes, which included all explanatory variables associatedwith the outcome at pB0.05 in the univariable models. Then,we fit a series of reduced models comparing the coefficientvalue associated with the primary explanatory variable in thefull model to its corresponding value in each of the reducedmodels and dropped the secondary explanatory variablesassociated with the smallest relative change. We continuedthis iterative process until the minimum change exceeded 5%.Next, to identify changes in the relationship betweenexposures to the two policing practices and sharing of druguse paraphernalia before and after the VPD policy change, wefirst used data from throughout the study period to build amultivariable GEE model, employing the same statisticalprotocol described above. Then, we divided the study periodinto two sub-periods (June 2004 to May 2006 and June 2009to November 2014) based on the timing of the VPD policychange, as well as the availability of the required data, andfit a multivariable model for each of the two periods. Thetwo models included the same set of primary and secondaryexplanatory variables, allowing us to compare the effectestimates for the primary explanatory variable between thetwo periods.We also used descriptive statistics to examine the following:the proportion of participants who reported that drug useparaphernalia were returned to them after having been con-fiscated by the police; types of physical violence by the policethat participants reported experiencing; and what participantsreported doing immediately before experiencing physicalviolence by the police. The analysis was restricted to a period ofJune 2009 and November 2014 because these sub-questionswere added to the questionnaire in June 2009. All p-valueswere two-sided. All statistical analyses were performed usingthe SAS software version 9.4 (SAS Institute, Cary, NC).ResultsSample characteristicsIn total, 2193 participants were eligible for the presentanalyses, including 757 (34.5%) women. Of these, medianage at baseline was 40 years (interquartile range (IQR): 32to 46), and 60.0% self-reported having Caucasian ancestry.A total of 19,027 interviews were conducted, with a medianof 7 (IQR: 3 to 13) interviews per person. A total of 179participants were not asked about police confiscation ofdrug use paraphernalia, whereas 109 participants were notasked about police physical violence. As shown in Table 1, 242(12.0%) of 2014 participants reported experiencing policeconfiscation of drug use paraphernalia, 186 (8.9%) of 2084participants reported experiencing physical violence by thepolice, and 1279 (58.3%) of 2193 participants reported havingshared drug use paraphernalia during the previous six monthsat their respective baseline periods. For the analyses of policeconfiscation of drug use paraphernalia, 1698 (84.3%) of2014 participants were followed during both periods (2002to 2006 and 2009 to 2014), and the baseline rate of reportingpolice confiscation (12.2%) was not statistically different fromthat (11.1%) among those followed in either period only(p0.576). Similarly, for the analyses of police violence, 1780(85.4%) of 2084 participants were followed during bothperiods (2004 to 2006 and 2007 to 2014), and the baselinerate of reporting police violence (8.9%) was essentially thesame as that (8.9%) among those followed in either periodonly (p0.977).Trends in police confiscation of drug use paraphernalia andphysical violenceIn total, 528 (26.2%) of 2014 participants reported experien-cing police confiscation of drug use paraphernalia at leastonce, and 472 (22.6%) of 2084 participants reported experi-encing physical violence by the police at least once duringtheir respective study periods. After June 2009, there were277 reports of police confiscation of drug use paraphernalia,and the paraphernalia were reportedly returned to partici-pants only on three (1.1%) occasions. There were 283 reportsof physical violence by the police after June 2009. Of these,the most commonly reported types of physical violenceexperienced included the following: bruises (41.0%), scratches(20.5%) and broken bones (6.7%). Prior to experiencingphysical violence by the police, participants most commonlyreported engaging in the following activities: nothing (30.7%),selling drugs (8.1%) and criminal activity (7.1%).As shown in Figure 1, the rates of experiencing policeconfiscation of drug use paraphernalia declined from 22.3%in 2002 to 2.8% in 2014, and the rates of experiencingphysical violence by the police also declined from 14.1% in2004 to 2.9% in 2014.Table 2 presents the results of univariable and multi-variable GEE analyses of changes in the risk of experiencingthe two policing practices before and after the VPD policychange. As shown, in the final multivariable models, the post-policy change period remained independently and negativelyassociated with reports of confiscation of drug use para-phernalia (adjusted odds ratio (AOR): 0.25; 95% confidenceinterval (CI): 0.21 to 0.31) and physical violence by the police(AOR: 0.76; 95% CI: 0.63 to 0.91).Changes in the association with HIV risk behaviourTable 3 shows the results of multivariable GEE analyses of therelationship between exposures to policing and sharing ofLandsberg A et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20729http://www.jiasociety.org/index.php/jias/article/view/20729 | http://dx.doi.org/10.7448/IAS.19.4.207293drug use paraphernalia, stratified by two sub-periods. Asshown, in 2004 to 2006, experiencing confiscation of druguse paraphernalia but not physical violence by the policeremained independently and positively associated withsharing of drug use paraphernalia (AOR: 1.37; 95% CI: 1.02to 1.85). In 2009 to 2014, experiencing both confiscation ofdrug use paraphernalia and physical violence by the police(AOR: 1.92; 95% CI: 1.10 to 3.33) and experiencing confisca-tion of drug use paraphernalia but not physical violence bythe police (AOR: 1.71; 95% CI: 1.34 to 2.19) remainedindependently and positively associated with sharing of druguse paraphernalia.Table 1. Baseline sample characteristics stratified by reports of confiscation of drug use paraphernalia and physical violence by thepolice in the previous six months among PWID in Vancouver, Canada (n2193)Police confiscation of druguse paraphernaliaa,b Police physical violencea,cCharacteristicTotal,n (%)Yesn (%)242 (12.0)Non (%)1772 (88.0) pYesn (%)186 (8.9)Non (%)1898 (91.1) pDemographicAge (median, IQR) 40 (32 to 46) 36 (28 to 43) 42 (34 to 47) B0.001 37 (31 to 43) 41 (34 to 47) B0.001Male gender 1436 (65.5) 154 (63.6) 1158 (65.4) 0.600 134 (72.0) 1234 (65.0) 0.054Caucasian ancestry 1316 (60.0) 129 (53.3) 1076 (60.7) 0.027 123 (66.1) 1126 (59.3) 0.071Homelessa 682 (31.1) 93 (38.4) 436 (24.6) B0.001 102 (54.8) 554 (29.2) B0.001DTES residencea 1391 (63.4) 163 (67.4) 1065 (60.1) 0.030 124 (66.7) 1229 (64.8) 0.602]Daily injection heroin usea 640 (29.2) 121 (50.0) 402 (22.7) B0.001 78 (41.9) 524 (27.6) B0.001]Daily injection cocaine usea 337 (15.4) 64 (26.5) 241 (13.6) B0.001 39 (21.0) 250 (13.2) 0.003]Daily crack smokinga 892 (40.7) 159 (65.7) 605 (34.1) B0.001 98 (52.7) 742 (39.1) B0.001Injected drugs in publica 882 (40.2) 153 (63.2) 559 (31.5) B0.001 104 (55.9) 655 (34.5) B0.001Drug dealinga 649 (29.6) 119 (49.2) 395 (22.3) B0.001 97 (52.2) 498 (26.2) B0.001Sex worka 371 (16.9) 55 (22.7) 263 (14.8) 0.002 27 (14.5) 295 (15.5) 0.700Incarcerationa 370 (16.9) 85 (35.1) 201 (11.3) B0.001 71 (38.2) 260 (13.7) B0.001HIV positivea 831 (37.9) 62 (25.6) 720 (40.6) B0.001 68 (36.6) 731 (38.5) 0.593Sharing of drug use paraphernaliaa 1279 (58.3) 181 (74.8) 864 (48.8) B0.001 125 (67.2) 1031 (54.3) 0.001PWID: people who inject drugs; IQR: interquartile range; DTES: Downtown Eastside; HIV: human immunodeficiency virus; adenotes activities inthe previous six months; bfor this analysis, n2014; cfor this analysis, n2084.Figure 1. Rates of reporting confiscation of drug user paraphernalia and physical violence by the police among PWID in Vancouver, Canada(n2193).Landsberg A et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20729http://www.jiasociety.org/index.php/jias/article/view/20729 | http://dx.doi.org/10.7448/IAS.19.4.207294DiscussionWe found that approximately one-quarter of participantsexperienced confiscation of drug use paraphernalia or physicalviolence by the police, respectively, at least once during the12-year study period. Post-VPD policy change, there was asignificant decline in the prevalence of experiencing policeconfiscation of drug use paraphernalia, as well as physicalviolence by the police, after extensive confounder adjustment.However, experiencing both confiscation of drug use para-phernalia and physical violence by the police, and experien-cing confiscation of drug use paraphernalia but not physicalviolence by the police, remained independently and positivelyassociated with sharing of drug use paraphernalia duringthe post-policy change period. Additionally, the effect size ofthe association between exposure to harmful policing andsharing of drug use paraphernalia appears to have increasedafter the VPD policy change.Although the overall declining trends in exposure to harmfulpolicing observed among our sample of PWID are encouraging,the persistent and seemingly stronger association betweenexposure to harmful policing and HIV risk behaviour duringthe post-VPD policy change period is concerning. In Vancouver,there has been a general decline in the rates of sharingof syringes and crack pipes during the last decade [27,28].This decrease in HIV risk behaviour has coincided with greaterand easier access to sterile drug use paraphernalia, as a resultof decentralization of needle exchange programmes (NEPs)that led to widespread syringe distribution [27,29], and thelaunch and scale-up of crack pipe distribution programmesbeginning in 2004 [30]. Now that there is greater coverageTable 2. Univariable and multivariable GEE analyses of factors associated with confiscation of drug use paraphernalia and physicalviolence by the police before and after the VPD policy change among PWID in Vancouver, Canada (n2193)Police confiscation of drug useparaphernaliaa,b Physical violence by the policea,cCharacteristicUnadjusted OR(95% CI)Adjusted OR(95% CI)Unadjusted OR(95% CI)Adjusted OR(95% CI)Calendar year(2009 to 2014 vs. 2002 to 2006)(2007 to 2014 vs. 2004 to 2006)0.18 (0.15 to 0.21) 0.25 (0.21 to 0.31)0.56 (0.48 to 0.65) 0.76 (0.63 to 0.91)Gender(Male vs. female) 0.93 (0.76 to 1.14) 2.01 (1.59 to 2.54) 2.15 (1.68 to 2.75)Age(Per 10-year increase) 0.43 (0.39 to 0.47) 0.72 (0.65 to 0.80) 0.56 (0.51 to 0.62) 0.68 (0.60 to 0.76)Ancestry(Caucasian vs. other) 0.81 (0.67 to 0.99) 1.26 (1.02 to 1.56)Homelessnessa(Yes vs. no) 2.46 (2.08 to 2.89) 2.22 (1.88 to 2.63) 2.43 (2.05 to 2.88) 1.64 (1.37 to 1.96)DTES residencea(Yes vs. no) 1.13 (0.95 to 1.34) 1.37 (1.14 to 1.64)Heroin injectiona(]Daily vs. Bdaily) 3.02 (2.56 to 3.56) 1.89 (1.58 to 2.25)Cocaine injectiona(]Daily vs. Bdaily) 2.16 (1.79 to 2.61) 1.70 (1.37 to 2.12) 1.42 (1.13 to 1.79)Crack smokinga(]Daily vs. Bdaily) 4.08 (3.48 to 4.80) 2.78 (2.36 to 3.27) 1.53 (1.31 to 1.80)Injected drugs in publica(Yes vs. no) 3.82 (3.27 to 4.46) 2.49 (2.11 to 2.94)Drug dealinga(Yes vs. no) 2.67 (2.29 to 3.12) 2.71 (2.33 to 3.16)Sex worka(Yes vs. no) 2.20 (1.79 to 2.71) 1.16 (0.91 to 1.48)Incarcerationa(Yes vs. no) 4.81 (4.05 to 5.71) 4.74 (3.94 to 5.71) 3.31 (2.70 to 4.05)HIV serostatusa(Positive vs. negative) 0.61 (0.49 to 0.77) 0.67 (0.54 to 0.82) 0.82 (0.67 to 1.02)GEE: generalized estimating equations; VPD: Vancouver Police Department; PWID: people who inject drugs; OR: odds ratio; CI: confidenceinterval; DTES: Downtown Eastside. aDenotes activities in the previous six months; bfor this analysis, n2014; cfor this analysis, n2084.Landsberg A et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20729http://www.jiasociety.org/index.php/jias/article/view/20729 | http://dx.doi.org/10.7448/IAS.19.4.207295of NEPs and crack pipe distribution programmes in thissetting, it may be that competing risks of sharing drug useparaphernalia (e.g. requiring many sterile syringes due tohigh-intensity drug use) have decreased in recent years and,consequently, exposure to harmful police activities may havehad a greater effect on this behaviour among PWID.Our findings suggest that between the two policingpractices examined in this study, exposure to confiscationof drug use paraphernalia by the police appears to be themajor factor associated with elevated HIV risk behaviourthroughout the study period. The result that experiencingboth types of policing practices was not independentlyassociated with HIV risk behaviour during the 2004 to 2006period may be due to the statistical power or may suggestthat that may be the case. Of the individuals who experiencedconfiscation of drug use paraphernalia after June 2009 inour study, only about 1% reported having their paraphernaliareturned to them by the police. Thus, sharing of drug useparaphernalia may be a direct consequence of confiscation.On the contrary, physical violence by the police has beenshown to provoke fear in PWID [4,15] and increase apprehen-sion of being stopped by the police [10], thus making PWIDmore reluctant to carry sterile drug paraphernalia and there-fore indirectly impacting their HIV risk behaviours.We also found that one-third of the participants whoreported experiencing physical violence by the police after2009 reported engaging in nothing prior to experiencing theviolence. This finding is concerning, as it has been suggestedthat many PWID were exposed to unjustified, discriminatoryabuse by the police during the police crackdown of 2003 inVancouver [19]. Such human rights concerns have also beenraised in many countries, including Thailand, Kazakhstanand China [15,31,32]. In Thailand, police have used visibletrack marks on the arms of PWID as an ostensible excuse tophysically abuse or arrest them [33]. In our study, however,further in-depth investigation is needed to determine thecontext of police violence before any major inferences aremade.In addition to the VPD policy change in 2006, there hasbeen a gradual scale-up of harm reduction services in thissetting during the study period, which may have furtherpromoted changes in policing practices [27,34]. Although wecannot make a causal conjecture from this observationalstudy, we found that both of the harmful policing activities ofinterest have markedly decreased since 2006, suggesting thatthe VPD policy change may have served to positively changepolicing practices in this setting. These findings demonstratethat a significant shift of police attitudes towards harmreduction policies is possible. However, it remains importantto explore potential reasons why these harmful behavioursstill persist. Previous studies have demonstrated that policein some settings are misinformed of the law [17,35,36],Table 3. Multivariable GEE analyses of the relationship between exposures to policing and sharing of drug use paraphernalia amongPWID in Vancouver, Canada (n2193)2004 to 2006b 2009 to 2014cCharacteristicAOR(95% CI)AOR(95% CI)Exposures to policinga(Both confiscation of drug use paraphernalia and physical violence by the police vs. neither)(Confiscation of drug use paraphernalia but not physical violence by the police vs. neither)(Physical violence but not confiscation of drug use paraphernalia by the police vs. neither)0.96 (0.57 to 1.60)1.37 (1.02 to 1.85)1.03 (0.66 to 1.62)1.92 (1.10 to 3.33)1.71 (1.34 to 2.19)1.13 (0.85 to 1.50)Age(Per 10-year increase) 1.10 (0.99 to 1.22) 0.81 (0.74 to 0.88)Homelessnessa(Yes vs. no) 1.29 (1.00 to 1.67) 1.34 (1.18 to 1.52)Heroin injectiona(]Daily vs. Bdaily) 0.74 (0.60 to 0.92) 0.94 (0.81 to 1.08)Crack smokinga(]Daily vs. Bdaily) 2.14 (1.76 to 2.60) 1.98 (1.76 to 2.22)Injected drugs in publica(Yes vs. no) 1.70 (1.33 to 2.16) 1.70 (1.51 to 1.91)Drug dealinga(Yes vs. no) 1.47 (1.18 to 1.83) 1.33 (1.17 to 1.50)Sex worka(Yes vs. no) 1.35 (1.04 to 1.75) 1.43 (1.20 to 1.70)Incarcerationa(Yes vs. no) 1.75 (1.32 to 2.32) 1.10 (0.93 to 1.31)GEE: generalized estimating equations; PWID: people who inject drugs; AOR: adjusted odds ratio; CI: confidence interval.aDenotes activities in the previous six months; bfor this analysis, n1012; cfor this analysis, n1494.Landsberg A et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20729http://www.jiasociety.org/index.php/jias/article/view/20729 | http://dx.doi.org/10.7448/IAS.19.4.207296whereas others are aware of the specific laws but continue tooppose them because progressive harm reduction policiesmay not align with their personal beliefs [35]. As we can onlyspeculate about the reasons for the scarce yet persistentoccurrence of these policing actions, in order to refineharm reduction training and implementation, the policeshould be further consulted [36]. In addition, the presentharm reduction programmes in Vancouver must continueto be sustained, as police partnership with public healthservices, such as supervised injection facilities, has beenshown to benefit PWID, increase public order and increasepublic support of these important facilities [37].This study has several limitations. First, because the VIDUSand ACCESS are not random samples, the generalizability maybe limited. Second, the self-reported data may be affectedby response bias and socially desirable responding. However,previous research has shown that reported behaviours byPWID are generally truthful and reliable [38,39]. Third,the observational research study design may have excludedunmeasured confounding variables from consideration,although we did extensively adjust for potential confoundingvariables. Fourth, our questionnaire did not differentiatebetween the confiscation of syringes and pipes, and there-fore the analyses could not be stratified to consider syringesand pipes separately as well as in combination. Last, futureresearch should focus on the internal process within the policedepartment and examine how the VPD policy change has beentranslated into street-level policing practices.ConclusionsWe found a significant decrease in the proportion of PWIDexposed to confiscation of drug use paraphernalia and physicalviolence by the police during the time period after the VPDdrug policy change, compared to the time period beforethe drug policy change. Although it is encouraging that there isa significantly lower prevalence of exposure to these harmfulpolicing methods, it is noteworthy that those who wereexposed to these policing practices after the policy changewere even more likely to engage in HIV risk behaviours. Thesefindings suggest that overall the VPDmay have been successfulat adhering to the spirit of their drug policy; however, morecould be done to protect PWID from harmful policing andassociated HIV risk behaviours. Therefore, there is a need forfurther police engagement with harm reduction services toensure that public health efforts have the greatest favourableimpact on PWID and the public at large.Authors’ affiliations1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, BC, Canada; 2Faculty of Health Sciences, McMaster University,Hamilton, ON, Canada; 3Department of Medicine, St. Paul’s Hospital, Universityof British Columbia, Vancouver, BC, CanadaCompeting interestsThe authors declare no competing interests.Authors’ contributionsEW, TK, KH and MJM designed and managed the cohort studies that thepresent study was drawn from. AL and KH designed the present study. PN andHD conducted the statistical analyses. AL drafted the first manuscript andincorporated suggestions from all co-authors. All authors made significantcontributions to the conception of the analyses, interpretation of the data anddrafting of the manuscript. All authors have read and approved the finalversion of the article.AcknowledgementsThe authors thank the study participants for their contribution to the research,as well as current and past researchers and staff. The study was supported bythe US National Institutes of Health (NIH) (U01DA038886 and R01DA021525).This research was undertaken in part thanks to funding from the CanadaResearch Chairs programme through a Tier 1 Canada Research Chair in InnerCity Medicine, which supports Dr. Evan Wood. Dr. Kanna Hayashi is supportedby the Canadian Institutes of Health Research New Investigator Award (MSH-141971). Dr. M-J Milloy is supported in part by the NIH (R01-DA021525).References1. Kerr T, Small W,Wood E. The public health and social impacts of drug marketenforcement: a review of the evidence. Int J Drug Policy. 2005;16(4):21020.2. Csete J. Do not cross: policing and HIV risk faced by people who use drugs.Toronto: Canadian HIV/AIDS Legal Network; 2007.3. 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