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Exploring the Risk Environment: Challenges and Opportunities in Reducing Harm among People who Inject Drugs Thomas Kerr, PhD Director, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, Professor, Department of Medicine,
Exploring the Risk Environment: Challenges and Opportunities in Reducing Harm among People who Inject Drugs
Thomas Kerr, PhD
Director, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, Professor, Department of Medicine, University of British Columbia Associate Scientist, Ontario HIV Treatment Network
Individual
Individual
Social
Structural
Environmental
environment
mix-methods study
trained as peer researchers
all stages of the project
Thai AIDS Treatment Action Group Mitsampan Harm Reduction Center Chulalongkorn University Summer 2008, Bangkok, Thailand
10
PWID in Bangkok, 2011 (n=435) * Refers to the previous 6 months.
13% 14% 28% 45%
Ever beaten and drug tested* by police Drug tested* by police only Ever beaten by police only None of the two events
11 Hayashi et al,. AIDS Behav, 2013
Policing exposures and syringe sharing
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reporting avoiding HIV testing.
drugs was significantly associated with HIV test avoidance (OR: 2.06; 95% CI: 1.10–3.84).
Drug enforcement policing:
These days they just take it and shoot it up right away. They don’t look at what they have got or think about how strong it may be. IDU Respondent #25. People are at a higher risk because they are being forced to go into areas that they don’t know. Usually there are no services provided in those areas where they can get clean works, or be observed or helped by someone. Service Provider Respondent # 8.
Journal of Infectious Diseases, 2011
Factors influencing inmates’ ability to access and adhere to HAART: Short term interruptions in treatment during intake and transfers Delays in obtaining medications through institutional healthcare High levels of HIV discrimination and stigma Problems ensuring continuity of treatment post-release
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Changes in policies to :
incarcerated most likely to leave AMA
(Ti et al., PloS One, 2015)
Why AMA?
security guards, lack of access to syringes
I think they pretty much have zero tolerance in [the hospital]. I was worried about getting kicked out and then not getting the proper health care that I needed to get better. [.] I’d turn the tap on so, if they came in my room to check to see if I was okay, then they’d hear the water running so they’d figure oh she’s just in the bathroom. [Participant #25, Caucasian Female, 44 years old]
McNeil et al, Soc Sci Med, 2014)
[Security guards] yell and scream at you. When there’s nobody around, [they say], “You fucking junkie.”…They search you, destroy your property, cause a scene, and make sure everybody there knows that you’re a drug addict. [.] They use their authority to pull power trips more or less. It’s not
years old]
(McNeil et al, Soc Sci Med, 2014)
Overdose prevention assumes rationality and personal autonomy, emphasizes the self- regulating subject
Social-structural factors: extreme poverty, shifting quality and illegal status of heroin, risky income generating activities Individual factors: entrenched injecting routines, perceived invincibility, ambivalence towards death
Common reasons:
hospital
related risks
being kicked out because they were using drugs
Social Assistance in B.C.: Institutional Design
alcohol use
admissions
interruption
access barriers
medical advice
Provincial Government Cheque Issue
The impact of alternative social assistance disbursement on drug-related harm (TASA): a randomized controlled trial
PI: Lindsey Richardson, DPhil Assistant Professor, Department of Sociology, University of British Columbia Research Scientist, B.C. Centre for Excellence in HIV/AIDS
Which social assistance disbursement schedule most effectively mitigates escalations in drug-related harm coinciding with government cheque issue?
Richardson et al. (2016) BMC Public Health
TASA: Changing payment timing and frequency
Social Assistance Payment
Shelter Allowance Support Allowance
Direct deposit
Staggered Arm Staggered & Split Arm
during the first two weeks of the month to avoid cheque issue week
unacceptably long period between payments
day during the week after cheque issue week, second two weeks later
Gradual transition to new date to avoid unacceptably long period between payments
Direct to landlord
Control Arm
theft, squeegeeing, binning, panhandling
– 391 (57%) reported prohibited income generation – Prohibited income generation negatively associated with viral suppression (Adjusted Odds Ratio = 0.74, 95% Confidence Interval: 0.56 – 0.97)
29% 37% 44% 63% 0% 10% 20% 30% 40% 50% 60% 70% Binning Panhandling Drug dealing Sex work
Willing to give‐up if had other employment op ons
Increasing low-threshold employment access
Aim:
increase access to low-threshold jobs for PWUD Intervention:
work that PWUD undertake according to availability and preference Outcomes:
generation, drug use and related risk, clinical outcomes
“…medical cannabis laws were associated with a 24.8% lower annual rate of opioid analgesic
JAMA Internal Medicine, 2014
Figure 1. Frequencies of crack cocaine (Panel A) and cannabis use (Panel B) in each of the intentional cannabis use periods. (Socias et al, under rev
environment
environmental level exist
and evaluate alternative regulatory approaches