Perspectives of HIV-positive and -negative people who use drugs regarding the criminalization of HIV non-disclosure in Canada: a qualitative study

AbstractBackgroundWhile previous research has identified how criminalization of HIV non-disclosure can have deleterious effects on those living with HIV, the perspectives of people who use drugs – a population disproportionately affected by HIV– should be more meaningfully considered in these discussions.MethodsUsing constant comparative techniques, data from 60 interviews with men and women living with and without HIV and who use drugs in Vancouver were analyzed to explore their perceptions about Canada’s HIV non-disclosure legal framework.ResultsParticipants’ perspectives on the framework involved three themes: understandings of HIV risk; HIV-related stigma; and their own experiences with HIV. While several participants favored the punitive character of the legal framework, these arguments were premised on misinformed and stigmatized assumptions regarding HIV.ConclusionsThe paper concludes by discussing the challenges and opportunities for resisting HIV stigma and misconceptions about HIV within the context of personal accounts that, at times, support criminalization of non-disclosure.</jats:sec

Implementation opportunities and challenges identified by key stakeholders in scaling up HIV Treatment as Prevention in British Columbia, Canada: a qualitative study

Abstract Background The province of British Columbia (BC), Canada, was among the first jurisdictions to scale up HIV Treatment as Prevention (TasP) to the population level, including funding and policy commitments that enhanced HIV testing efforts (e.g., expansion of routine, opt-out testing), while also making antiretroviral therapy universally available to all people living with HIV. As such, BC represents a critical context within which to identify factors that influenced the scalability of TasP (e.g., acceptability, adoption, fidelity, equitable reach, sustainability), including key opportunities and challenges. Methods We draw on in-depth, semi-structured interviews with 10 key stakeholders, comprised policymakers at the local and provincial levels and representatives from community-based organizations. Using the Consolidated Framework for Implementation Research (CFIR) to guide data collection, coding, and analysis, we identified key factors that influenced practice transformation and scale up. Results Key factors that contributed to the successful scale up of TasP included: (i) opportunities that enhanced stakeholder buy-in based on features of the intervention characteristics, including with regard to assessments about the quality and strength of evidence supporting TasP; (ii) an inner setting implementation climate that was, in part, shaped by the large and highly symbolic government investments into TasP; (iii) features of the outer setting such as external policies (e.g., harm reduction) that cultivated opportunities to implement new “systems-level” approaches to HIV intervention; (iv) the personal attributes of some “middle-level” influencers, including a team that was comprised of some highly motivated and social justice-oriented individuals (e.g., folks who were deeply committed to serving marginalized populations); and (v) the capacity to develop various implementation processes that could maintain “nimble and evidence-informed” adaptations across a highly decentralized service delivery system, while also creating opportunities to adapt features of TasP programming based on “real time” program data. Conclusion Constructs across all five domains of CFIR (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) were identified to influence the success of TasP in BC. Our findings provide important insights into how BC can successfully implement and scale up other systems-level interventions that have demonstrated efficacy, while also offering insights for other jurisdictions that are currently or planning to scale up TasP. </jats:sec

Using alone at home: what's missing in housing-based responses to the overdose crisis?

BACKGROUND: Against the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis. HARM REDUCTION AND OVERDOSE PREVENTION IN HOUSING: In response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts. CONCLUSION: Emerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings

Using alone at home: What’s missing in housing-based responses to the overdose crisis?

Abstract Background Against the backdrop of North America’s overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis. Harm reduction and overdose prevention in housing In response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts. Conclusion Emerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings

Using alone at home: What’s missing in housing-based responses to the overdose crisis?

BackgroundAgainst the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis.Harm reduction and overdose prevention in housingIn response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts.ConclusionEmerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings

Housing-based syringe services programs to improve access to safer injecting equipment for people who inject drugs in Vancouver, Canada: a spatially oriented qualitative study

Abstract Background Housing environments shape injection drug-related risks and harms and thus represent a critical implementation setting for syringe services programs (SSPs). As critical harm reduction measures, SSPs provide safe injecting equipment to people who inject drugs (PWID). Vancouver, Canada, has well-established syringe distribution programs through which PWID have low-threshold access to unlimited syringes and related injecting equipment, including through non-profit operated supportive housing and single-room occupancy hotels. This study examines the role of housing-based SSPs in distributing injecting equipment to PWID in Vancouver. Methods Between January and March 2020, semi-structured, in-depth interviews were conducted in Vancouver with 26 PWID. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using inductive and deductive approaches. Results Many participants accessed SSPs in housing facilities and expressed preference for these programs over those offered at other locations and through other health and social services. Three major themes emerged to explain this preference. First, most participants injected in the buildings where they resided, and housing-based SSPs made injecting equipment available when and where it was most needed. Second, many participants preferred to avoid carrying syringes outside of the places where they inject due to fears that syringe possession may lead to criminal charges or confiscation of syringes and/or illicit drugs by police. Third, for some participants, anti-drug user stigma and concerns over unwillingly disclosing their drug use hindered access to SSPs outside of housing settings. Programs operated within housing facilities often offered greater client anonymity along with more supportive and less stigmatizing environments, particularly in the presence of peer staff. Conclusion The current study advances understanding of access to injecting equipment in a setting with city-wide syringe distribution programs. Our findings underscore the benefits of housing-based SSPs and encourage the expansion of such services to maximize access to harm reduction supports for PWID

Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study

Abstract Background In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges. Methods We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research. Results While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants’ emphasis that knowing the composition of one’s drugs is a “right to know”, particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men. Conclusions The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions

Acceptability of long-acting antiretroviral therapy among people living with HIV who use drugs in Vancouver, Canada: A qualitative study.

BackgroundPeople living with HIV (PLHIV) who use drugs face overlapping social-structural inequities that contribute to suboptimal adherence to antiretroviral therapy (ART). Recent research suggests that long-acting antiretroviral therapy (LA-ART) can offer an important alternative to daily oral ART by mitigating adherence barriers, but this work has largely excluded PLHIV who use drugs. We, therefore, explored the acceptability of injectable and transdermal LA-ART among PLHIV who use drugs in Canada, which has no-cost universal access to oral ART. Greater understanding of PLHIV who use drugs' perspectives on LA-ART will be essential to fully leverage treatment advances and maximize its individual- and population-level benefits.MethodsFrom February 2019 to February 2020, we conducted in-depth interviews with 33 PLHIV who use drugs in Vancouver, Canada with suboptimal ART adherence (i.e., ≦  50%). Participants were recruited for interviews through a prospective cohort study. Interviews were audio-recorded, transcribed, and analyzed using inductive and deductive approaches.ResultsOur analysis identified key factors shaping LA-ART acceptability. First, LA-ART enthusiasm was highest among participants who were less satisfied with oral ART regimens due to pill burden or adverse side effects for oral ART and participants who struggled with daily adherence due substance use and social-structural factors (e.g., homelessness, incarceration). Moreover, participants who had physicians they trusted identified their physicians as credible sources of information on LA-ART, and indicated a desire for informed and shared decision-making regarding treatment changes. Finally, participants emphasized that there is no one-size-fits-all treatment approach for PLHIV who use drugs and highlighted the importance of access to a full range of available treatment options, including LA-ART.ConclusionsThere is potential for high LA-ART uptake among PLHIV who use drugs, particularly those who experience adherence barriers due to their substance use and structural vulnerability. While our findings are limited by the specific population and setting, they nevertheless underscore the need for efforts to ensure universal and equitable access to LA-ART