Hepatitis C prevention and true harm reduction

Harm reduction, when applied to drug use, prioritizes improving patient-centered health outcomes and reducing drug-related harm. In order for harm reduction strategies to be adopted by people who inject drugs (PWID), they need to be promoted, accessible, and accepted in that population and the community-at-large. While PWID face stigma at multiple levels, less is known about how stigma influences uptake and acceptance of harm reduction services and strategies among PWID. We aim to characterize the stigmatizing experiences PWID have had related to harm reduction and the role of stigma in influencing their acceptance and adoption of harm reduction services and strategies. A qualitative study using in-person, semi-structured interviews. We recruited hospitalized participants, age 18 and over, with a history of injection drug use. We developed an interview guide asking about various aspects of stigma and participants' experiences with naloxone, syringe service programs, fentanyl test strips, HIV and hepatitis C testing, and any other harm reduction strategies. Key themes were generated using a thematic analysis. We reached thematic saturation at 16 participants. PWID reported multi-level stigma related to harm reduction from themselves, the public, the healthcare system, and the legal and carceral systems. Themes were grouped into four main categories: internalized, interpersonal, intervention, and structural stigma. Stigma across all of these domains negatively impacted the ability of PWID to access harm reduction resources. Positive, non-stigmatizing experiences from others, such as syringe service programs and peer navigators, countered historically negative experiences and promoted greater education and comfort about using harm reduction resources among PWID. To expand the reach of harm reduction services, it is critical to develop interventions that can reduce the stigma against PWID and harm reduction.

A scoping review of harm reduction practices and possibilities among indigenous populations in Australia, Canada, and the United States.

First reduce harm: tackling HIV in Ukraine

Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff. To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge. This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles. Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services. Interviews were analyzed using thematic analysis to identify key themes. A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals. In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.

Prison health: a threat or an opportunity?

Alcohol use following liver transplantation (LT) is associated with worse outcomes. Strategies for predicting, preventing, and managing alcohol consumption among candidates and recipients of LT with alcohol-associated liver disease (ALD) have historically emphasized complete abstinence. We propose a harm reduction approach as a possible complementary and realistic strategy for managing alcohol use in the context of LT for ALD. In this article, we outline the ethical and clinical foundations for applying harm reduction across the continuum of care for LT in ALD. Although complete alcohol abstinence prevents liver damage, harm reduction promotes shared decision-making that balances liver function with realistic patient circumstances and patient autonomy. Approaches grounded in harm reduction may allow us to improve outcomes across different alcohol consumption patterns and more effectively address health disparities in certain patient groups facing additional challenges in maintaining complete abstinence. Harm reduction strategies may also help prevent psychological distress in candidates and recipients of transplant with ALD and encourage early disclosure of alcohol use that enables timely interventions. Listing procedures and waitlist management for patients with ALD that incorporate principles of harm reduction may also broaden access to life-saving care while maintaining organ utility. Based on clinical evidence, we highlight the need to examine current LT selection processes, coordinate alcohol use disorder treatment for patients with ALD, and develop comprehensive markers of posttransplant success. Finally, we discuss potential challenges and considerations when applying the harm reduction approach to nuanced scenarios of candidates and recipients of LT with ALD.

Chapter 12 - Notes on harm reduction and the opioid epidemic in the United States

Harm reduction is a grassroots, practical set of strategies to mitigate the negative consequences of drug use, and it is a movement that acknowledges that people may not stop using drugs. Clinician stigma remains a barrier to implementation of harm reduction practices, which further disempowers and jeopardizes the health of people who use drugs (PWUD). Our study objective was to understand the impact of interprofessional harm reduction trainings on health professions students' and clinicians' knowledge and stigma toward PWUD. Harm reduction outreach specialists, faculty physicians, and individuals with lived experience delivered 3 virtual, interactive trainings. We conducted pre-/post-surveys of knowledge and stigma. Stigma was evaluated using a validated instrument, the Medical Condition Regard Scale. Using SPSS Version 29, pre- and post-survey responses were compared using McNemar's test for paired knowledge/attitude categories, paired t-test for stigma scores. Our institutional IRB reviewed this study as exempt research. Of 313 participants, the majority were medical (n = 116, 37%), dental (n = 66, 22%), pharmacy (n = 17, 5%), or nursing (n = 16, 5%) students. Ninety-four participants submitted pre- and post-training surveys; 87 fully completed both surveys. Although baseline knowledge of harm reduction was high, knowledge/attitudes showed a trend toward improvement. Comfort in applying harm reduction was enhanced from pre- to post-training (68%-95%, P < .001), and respondents increasingly applied harm reduction strategies, from 62% pre-training to 86% post-training (P < .001). Participant stigma scores improved from 50 + 8 pre-training, and 53 + 8 post-training (P < .001). Harm reduction curricula developed and administered by interprofessional teachers, including those with lived experience, may reduce stigma toward PWUD, increase clinician comfort, and support consistent application of harm reduction practices in those with prior elevated baseline knowledge. Our work highlights the importance of including harm reduction training in interprofessional education.

Harm Reduction as an Essential Psychiatric Mental Health Nursing Skill.

This commentary aims to reveal how a steering committee has effectively responded to advancing accessibility to harm reduction resources, hepatitis C virus (HCV) policy and health strategies within adult prison settings in New South Wales (NSW). By reviewing the audit approach taken by the of the Justice Health and Forensic Mental Health Network and Corrective Services New South Wales Harm Reduction Reference Group (JHFMHN/CSNSW HRRG), this commentary emphasizes the committee's success in identifying contemporary harm reduction issues that affect people in custodial settings. This commentary is a compilation of data gathered through the 2018 JHFMHN/CSNSW HRRG audit and corresponding program materials. Conclusions regarding the effectiveness of the working group's audit were drawn by critically appraising the JHFMHN/CSNSW HRRG's Final Audit Report (JHFMHN and CSNSW, 2018) with reference to current harm reduction literature. The HRRG has provided leadership, professional representation and strategic advice on the development, implementation, monitoring and evaluation of best practice harm reduction strategies in prison settings. The HRRG developed and maintained networks and information exchange between the state-wide HCV health network, corrections services and the NSW harm reduction sector at large. Public health partnerships and advocacy that involve all key players, such as the HRRG, will continue to be crucial to remove barriers to enhancing HCV harm reduction measures especially in NSW prison settings. Strategies such as primary prevention and treatment can mitigate the spread of HCV in the custodial system. This audit of access to harm reduction resources was conducted on behalf of the diverse group of professionals, scholars and stakeholders comprising the HRRG. This audit and other advocacy efforts of this committee can facilitate future access to quality healthcare and the necessary policies required to support a healthier prison population at large. Collaborating with health authorities, researchers and social service workers can enable prison health-care systems to be guided by wider health workforce programs and public health standards. This collaboration can reduce the professional isolation of custodial health-care staff and promote a balanced approach to harm reduction policies by ensuring an equitable focus on both health and security imperatives.

The meaning of the term "harm reduction" has changed over the decades of its existence but it is now increasingly being aligned with public health approaches. An agreed meaning for the term would be helpful and should be sought. Antecedents are easy to find. Emphasis on small achievable steps is an important element; neither inherently supportive of prohibition nor of legalization, harm reduction is essentially pragmatic and tends to favour regulatory approaches. HIV has focused attention on harm reduction but even in the illicit drug field, a strong tradition of research and policy with an identical philosophical framework can be traced back well before the AIDS era. Harm reduction primary prevention educational approaches are more open, honest and respectful of responsible decision making processes. With current illicit drug users, harm reduction emphasizes the need to understand existing individual control mechanisms. The concept can be well understood if contrasted with prevailing approaches to drugs which generally emphasize punishment, lack of regulation and often augment harm.

At a two-day private meeting in Tokyo in June 2005, some of Japan's most senior politicians and powerbrokers met to consider the steadily expanding HIV/AIDS epidemic. AIDS has recently become a matter of increasing concern in Japan following an HIV epidemic in several major Japanese cities among Japanese men having sex with men at sex-on-premises venues. The Japanese elites at the Tokyo meeting were shocked to learn that the United States has by far the highest annual AIDS incidence among OECD countries at 15/100,000 [1]. Spain, with an annual AIDS incidence of 3.3/100,000, has the second highest rate among industrialized countries, while Australia was well down the ranking with an incidence only one tenth that of the United States at 1.5/100,000 [1].

Homeless people (HP) are defined as a heterogeneous group that lives in extreme poverty, with weakened or severed family ties, lacking access to conventional housing, and using public spaces as residence. In terms of health, mental health conditions are prominent as a primary treatment demand, with care aimed at addressing needs arising from the use of alcohol and other drugs being a priority in serving HP. In this context, mobile street clinics (MSC) provide health services directly in street environments, focusing on individuals who use alcohol and other substances through harm reduction approaches. Harm reduction is defined as a set of practices aimed at minimizing the adverse health effects of alcohol and drug use without necessarily eliminating usage. Moreover, it represents an ethical and political direction in care, confronting the logic of criminalization and compulsory abstinence, enhancing access to health care for alcohol and other drug users through strategies that foster autonomy development. In the current study, we conducted an integrative review assessing the facilitators and barriers for HP access to mental health services. Preliminary results indicated that MSC, the connection between healthcare workers and the HP they serve, and the implementation of local street-based actions were the main facilitators of access for individuals who engage in harmful use of alcohol and other drugs to mental health services. Conversely, stigma, services’ lack of adjustment to the lifestyles of homeless people, and excessive bureaucracy were identified as the principal barriers of access. MSC, through their harm reduction activities, have emerged as a potential care technology to facilitate access to health services for homeless people. This research aims to present harm reduction as an ethical and political direction of care through the actions of mobile street clinics, as a way to facilitate access to health services for the homeless people. Key messages • Homeless people require mental health care tailored to the use of alcohol and other drugs, and harm reduction strategies implemented through mobile street clinics prove to be an effective form of care. • Mobile street clinics and harm reduction are important care technologies that enhance access to health services for the homeless population.

Inequities with access to naloxone and fentanyl test strips (FTS) due to cost and stigma have reinforced the necessity of community-based distribution of lifesaving harm reduction supplies. In Wichita and Sedgwick County, the epicenter of the opioid epidemic in Kansas, Safe Streets Wichita, a grassroots prevention and harm reduction coalition, started Project Wichita Overdose Recovery Kit Expedited Delivery (WORKED), a free volunteer-led intramuscular naloxone and FTS program. To assess the lessons learned from those involved with Project WORKED, interviews with 12 key stakeholders were conducted. These interviews focused on reflection, constructive criticism, and feedback. Individuals interviewed for this study included volunteers, former/current employees, and naloxone and FTS kit recipients, with special considerations for those with lived experiences of substance-related harms. Based on a reflexive thematic analysis, findings highlight the importance of meaningfully engaging community members most affected by substance-related harms, emphasizing a strengths-based perspective of harm reduction, and being cognizant of the barriers that undermine harm reduction supply distribution efforts and harm reduction in general. These findings help serve as the foundation by which interviewees envision a more holistic and comprehensive approach to harm reduction. Findings will be used to inform the fidelity, efficiency, accessibility, and longevity of community-based naloxone and FTS distribution and the implementation of harm reduction strategies in general across the state of Kansas

Peer Reviewed