Structural constraints on the training of peer educators in hepatitis C prevention

The eastern European and central Asian (EECA) region is facing the fastest-growing HIV epidemic in the world with 160,000 (130,000–180,000) people newly acquiring HIV in 2021, an overall 48% increase in the number of new acquisitions, and a 32% rise in AIDS-related deaths over the past 10 years [1]. The World Health Organization East European region is estimated to accommodate 1.4 million people living with HIV (PWH), with the majority of new transmissions reported to occur locally and to be unrelated to cross-country migrations [2, 3]. Sadly, according to UNAIDS, in 2022 only 62% of people living in the EECA region were aware of their HIV status and 51% of PWH received HIV treatment, which resulted in an overall viral suppression rate of 48% [1]. Common (>50%) late diagnoses (with either AIDS-defining condition or CD4+ T cell count <350 cells/µl at presentation) [4] further add to the epidemiological issues and complexity of client management [5]. Although the key acquisition risk in the region has changed from unsafe injection practices to heterosexual transmission, access to opioid agonist therapy (OAT) and needle and syringe programmes is often still limited (Kazakhstan) or unavailable (Uzbekistan, Turkmenistan), which results in OAT regional coverage as low as 4%, far below the UNAIDS target of 50%. Furthermore, pre-exposure prophylaxis (PrEP) and combination prevention services are of limited availability or not formally implemented across multiple countries in the region usually due to financial barriers to access, such as lack of state funding for medicines, limited technical capacity or cost of service delivery [6]. This results in a substantially larger HIV PrEP gap (the proportion of populations at risk of acquiring HIV "very likely" to use PrEP if accessible, compared with the proportion currently using PrEP) across countries located in the EECA region (up to 45%) compared to the overall median of 17.4% estimate for the European Union [7]. Moreover, there is a high level of stigma across the countries, especially against gay men and other men who have sex with men. The growing epidemic and the suboptimal access to prevention, testing and treatment are the main reasons that challenge the 2030 targets. The humanitarian crisis related to the Russian invasion and war in Ukraine has challenged the situation even further hindering testing and treatment efforts, forcing both internal displacement (estimated 3.7 million) and external migration of locals as refugees (estimated 6.4 million, as of March 2024) [8]. On top of massive casualties, civilian and healthcare infrastructures were destroyed, forcing refugees to seek safety, protection and assistance, including continued access to medical care. Ukraine is home to ∼260,000 PWH with >130,000 on antiretroviral treatment (ART). Although significant progress was made in the response to the HIV epidemic in Ukraine before the outbreak of war resulting in a 47% reduction in HIV incidence and an 81% reduction in AIDS mortality, the war has significantly affected the HIV and tuberculosis (TB) programmes, with internal displacement resulting in diminished service capacity, difficulty in ART provision and reduction in prevention services [9]. Despite notable hardship, Ukraine managed to maintain full access to ART, increased OAT rollout by 38% (reaching >27,000 people) and doubled the number of people on PrEP, which is now available free of charge [10]. A large proportion of the studies published in this supplement focus on Ukraine and the responses given during the war, providing good examples of resilience and strength and reflecting personal experiences in the setting of mass trauma. Mass traumas are especially important from the perspective of PWH, as these may bring out stress and exacerbate mental health issues. Owczarzak et al. analyse the bioecological model of mass trauma in the context of the Russian invasion and war in Ukraine among PWH with a history of injecting substance use [11]. This study reported the results of 18 interviews with people from four Ukrainian cities in autumn 2022. The study not only outlines personal experiences but also confirms the deep impact of war on the personal and healthcare-related wellbeing of participants, the necessity to respond to the triggering situations, such as the decrease in work opportunities, incremental costs and the necessity for internal displacement. All these factors were shown to be affecting ART access, adherence and general access to healthcare. Lazarus et al. analysed the non-governmental organization (NGO) response during the war and described service provision for key populations in Ukraine, using a mixed-methods project among geographically dispersed non-governmental (n = 24) and governmental (n = 2) organizations representing several Ukrainian regions [12]. Their analysis outlines the impact of the war on NGO work, including HIV prevention and treatment in a time when humanitarian aid is critical. Following the initial shock and the terror of war, the majority of the organizations quickly resumed work, limiting the duration of cessation of services, optimizing response and reallocating work to available staff. This study provides a strong story of resilience and support emphasizing the key work of NGOs in healthcare responses during unfortunate "big events" such as war. The topic of human rights and the context of war in Ukraine is further expanded by Lohman et al. by presenting an assessment related to human rights barriers to the prevention and treatment of HIV and TB [13]. The study consisted of a series of assessments covering the period of the Russian invasion and outbreak of war aiming to examine the progress in the scale-up and outcomes of human rights programmes. The paper describes an implementation learning evaluation using 25 interviews with programme implementers, community advocates and government officials, representing 14 organizations. Interview data clearly reflect the reduction of stigma in several domains, including a decrease in the proportion of PWH who faced unauthorized disclosure in the social environment (−19%), a reduction in the number of reported verbal abuses/personal threats (−13%) and improvement (+33%) in the perceived confidentiality of medical records. The war resulted in the expansion of regional coverage of legal and advocacy programmes and services, allowing a large number of the population to maintain access to key services. Ukraine is also one of few countries in the EECA region that have implemented numerous combination prevention programmes including HIV PrEP, where adherence remains challenging. In the follow-up of the study on oral daily PrEP with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) [14] in 199 people who inject drugs (PWID) in Ukraine with or without the use of text reminders, Morozova et al. analysed longitudinal reported adherence patterns coupled with the measurement of tenofovir diphosphate and emtricitabine triphosphate in dried blood spots from study participants as objective measures of adherence [15]. The study enrolled people who have been injecting drugs for longer than 20 years (37%) with a high proportion of alcohol use (67%) and >50% with moderate to severe depression. In this highly challenging group, the perceived adherence was high to moderate in >90% of the cases with 81% reporting to take more than 95% of their TDF/FTC doses. Alarmingly, data from the dried blood spot metabolite analysis revealed the reality to be divergent from patient-reported adherence with >50% of participants without detectable TDF/FTC metabolite levels. This study provides unique data confirming the divergence between perceived and measured adherence among PWID, indicating that novel telemedicine or online interventions in combination prevention of HIV can be particularly useful in marginalized or difficult-to-reach populations. Migrants from central Asia moving to central eastern countries to work are disproportionately affected by HIV and sexually transmitted infections due to high-level stigma and poor working conditions, and have lower or no access to the health system and prevention tools compared to other groups. Kovtun et al. [16] focused on human rights violations related to sexual orientation, gender identity (SOGI), and HIV in six countries in eastern Europe, Caucasus and central Asia in 2022 (Armenia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine and Uzbekistan), which have a background of a rapidly rising HIV epidemic, strict social and religious norms, high level of stigma and discrimination associated with sexual and gender minorities and HIV, and regional conflict. Using the Rights—Evidence—ACTion (REAct) tool, they analysed the data on rights violations upon complaints from gay and bisexual men who have sex with men and transgender women. The strikingly higher numbers of rights violations and violations solely based on SOGI in Ukraine compared to the Caucasus and central Asian countries suggest that despite all the achievements made in the country in the last decade in terms of harm reduction, testing, and access to ART and care, stigma and discrimination still prevails in the country. The effect of the recent war in Ukraine was also evident with more human rights violations by police and military staff, denials of private or social services, refusals of temporary accommodation services and denial of border crossings. The results of this study underscore the diversity of the region in terms of stigma, discrimination and human rights violations. Mackesy-Amiti et al. define a social intervention that aimed to reduce high-risk behaviours for HIV among Tajik migrants who inject drugs working in the Russian Federation [17]. This was a cluster-randomized controlled trial comparing the network-based, peer educator training with the general health education training. Male Tajik migrants were recruited as peer educators and trained on how to reduce personal risk for HIV acquisition and to deliver knowledge to peers. The interviews showed that the baseline percentages of binge drinking, condomless sex, and syringe and equipment sharing behaviours were considerably high, and needle cleaning behaviour and HIV testing were extremely low in both peer educators and peers. There was a significant reduction in needle-sharing behaviour following study intervention, but a modest effect on sexual behaviour. This study suggests that interventions tailored to the needs of specific groups and the inclusion of peers may be effective even in populations that are hard to reach. Stigma-associated issues were also addressed by Davis et al. who used a citizen science approach to address HIV-related stigma and increase HIV testing in adolescents and young adults in Kazakhstan [18]. These populations were called to develop digital materials, which would be assessed and rated in a contest with the aim to reduce HIV-related stigma and promote HIV self-testing. The submitted materials were judged by a board including peers of the contestants, healthcare professionals and representatives of NGOs, and highly rated submissions were awarded. Adolescents and young adults showed a high level of interest in the project both as contestants, which resulted in a high number of submissions, and as board members providing input in the development and implementation of the study, running social media procedures, creating promotional materials and providing feedback on the submission system. Inclusion of the community stimulated collaboration among adolescents and young adults, and increased knowledge of HIV-related stigma and the importance of HIV testing. Lastly, a study also from Kazakhstan on adherence to ART among PWH in association with mental health and cognitive disorders was presented by Mergenova et al. [19]. The size of the HIV epidemic in this country is increasing with the majority of acquisitions reported among people who inject psychoactive substances. The authors performed a cross-sectional questionnaire-based analysis of 230 PWH on stable (>6 months) ART, with the assessment of self-reported ART adherence in addition to depression, anxiety, post-traumatic stress disorder (PTSD) symptoms, and cognitive and memory assessments. Notably, a third of the patients reported a history of mental illness, while only 25% reported injection drug use and 17% hazardous alcohol drinking. Moreover, mild depression or anxiety was reported in 20−32%, while in 6−10%, these mood disorders were at least moderate including PTSD symptoms observed in 7% of cases. Not surprisingly, these symptoms were associated with lower adherence—missing ART was more likely among participants with mild or moderate depressive symptoms, mild or moderate anxiety symptoms, PTSD symptoms or forgetfulness. On the contrary, better cognitive function was associated with better adherence to therapy. This study emphasizes the need for precise and regular assessment of not only ART but also mental health and cognitive function for better care of PWH in order to tailor specific responses and to provide mental health support for improving treatment adherence and maintaining optimal viral suppression rates. The long history of neglecting HIV in EECA resulted in rapid increases of transmissions. The high number of PWID and migrants who are disproportionately affected by HIV and the unique characteristics of each country with different cultures, beliefs and structures challenge the long-term efforts to address the epidemic. This supplement on the HIV epidemic in eastern Europe and central Asia presents a story of resilience, continued efforts to improve human rights, and innovative approaches to combination prevention, and summarizes key challenges related to stigma and other societal issues. While continuing these efforts, further international support, commitment and collaboration will be vital to achieve the new goals for 2030 to end AIDS in the region. The authors declare no competing interests. MP and DG jointly drafted and revised the editorial. All the authors read and approved the final version. We would like to express our sincere thanks to all the authors who prepared, submitted and revised manuscripts in response to this supplement request. We are grateful to all the research participants who volunteered to take part in studies in this supplement. We are also thankful to our co-Guest Editor, Dr Andriy Klepikov, Executive Director of the Alliance for Public Health, for his valuable role in the conceptualization and development of this supplement. The authors alone are responsible for the views expressed in this supplement and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Background: Student groups are prone to drug abuse. The prevalence of drugs in the past year among high school students in Surabaya, Indonesia occupies the highest provincial capital (9.4%). The purpose of this study analyzed the relationship between knowledge about drugs, attitudes about peer education, gender, class, and students’ intention to participate in peer education programs in HEY (Health Educator for Youth) activities.Design and methods: A cross-sectional study was conducted with student participants (12-18 years) in six high schools in Surabaya, Indonesia (n=167). This study used an online survey to assess knowledge of drugs and students’ attitudes about HEY peer education activities.Results: More than half of the students have insufficient knowledge about drugs and have negative attitudes about peer education in HEY activities. This study also showed that students’ intention to participate in peer education was not influenced by the level of knowledge, student attitudes, and gender. The results of statistical tests showed that there was a relationship between class and student participation in peer education activities. This showed that the student’s factor regarding participation in peer education was a class category where the lower class is more motivated to participate.Conclusion: Most students have less knowledge about drugs and a negative attitude about peer education. However, the intention to participate in peer education activities is more thus it is necessary to improve the quality of peer educators through activities that are performed regularly by various relevant stakeholders.Significance for public healthDrug abuse among high school students has reached an increasingly concerning number. This study aims to discover how well students’ knowledge regarding to drugs and their attitudes towards peer education activities in order to prevent drug abuse. Findings of the research indicate that many students' knowledge remain lacking and students' attitudes about peer education remain negative. Good knowledge about drugs is very important so that students do not fall into drug abuse. One of the factors related to students' intention to participate in peer education is class; students at lower-level classes had more free time to take part in peer education. Students who have the intention to participate in more peer education so that peer educator quality improvement and support from schools and related stakeholders are needed to create conditions for peer education that can work optimally in order to prevent drug abuse.

The “Peer educator for Healthy Relationships” program aims to improve the understanding of students of SMK Negeri 1 Malang regarding reproductive health and interpersonal relationships through peer educator training in love, sex, and dating education. The methods used involved seminars, peer educator selection, focus group discussions (FGDs), and roleplay to prepare students as agents of change. This study used a qualitative approach with descriptive analysis. Results showed an increase in student understanding from 65% to 85% based on a comparison of pre-test and post-test results. The program succeeded in creating an open atmosphere for students in discussing adolescent issues, as well as equipping them with effective communication skills. The conclusion of this study confirms that participation-based sexual education through peer educators is an effective strategy in promoting positive behavior change in adolescents. The program significantly improved students' understanding of reproductive health and interpersonal relationships, thus strengthening the role of peer educators in providing effective education to their peers. The program contributes to the reduction of adolescent risk behaviors and supports the sustainability of health education in schools.

Primary health care for people who inject drugs in low and middle income countries

Background: More than half of adolescents in low- and middle-income countries feel unprepared for menarche due to a lack of menstrual knowledge, which leads to poor menstrual hygiene practices that increase reproductive health risks. This problem worsens in boarding schools, where restrictions like bans on mobile phones, limited contact with parents, and the absence of formal health programs severely limit access to accurate menstrual health information. Peer education leverages adolescents' natural dependence on peers for sensitive issues and is especially vital in environments with limited information, such as boarding schools. This study aimed to evaluate the effectiveness of peer education in enhancing Menstrual Hygiene Management (MHM) knowledge and attitudes among female students in a boarding school and to explore their experiences with this intervention.Method: An explanatory sequential mixed-methods design was employed. The quantitative phase involved a One Group Pre-test Post-test design with 31 purposively selected students to assess changes in knowledge and attitude following the peer education intervention. Five trained peer educators conducted 120-minute sessions using standardized modules. Quantitative data were analyzed using paired t-tests and N-gain scores. The qualitative phase adopted a phenomenological approach with in-depth interviews involving six primary informants (students) and five supporting informants (peer educators) to explore the intervention experiences and the mechanisms behind observed changes. Qualitative data were analyzed thematically with source triangulation to enhance credibility.Result: Mean knowledge scores increased significantly from 30.10 to 72.04 (p&lt;0.001, N-gain=0.612, moderate effectiveness), with the largest improvement in pad disposal knowledge (90.3 percentage points). Mean attitude scores rose from 54.41 to 80.72 (p&lt;0.001, N-gain=0.586, moderate effectiveness). Qualitative findings showed that students gained evidence-based knowledge, corrected menstrual myths, and expressed readiness to adopt proper hygiene practices. However, deeply rooted cultural beliefs remained resistant after a single session. The findings confirmed that knowledge improvements do not automatically lead to uniform behavioral change. Boarding schools should implement multiple-session peer education programs with spaced repetition, invest in peer educator training, establish student-led health clubs, and incorporate a formal MHM curriculum before menarche.

Trends in sources and sharing of needles among people who inject drugs, San Francisco, 2005–2012

BackgroundIn 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at “Peer Support” (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico.MethodsSecondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement “going to rehabilitation puts me at risk of violence”. Logistic regression was used to examine factors associated with perceived risk of violence.ResultsOf 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level.ConclusionThe perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs’ concerns about violence.Electronic supplementary materialThe online version of this article (doi:10.1186/s13011-015-0044-z) contains supplementary material, which is available to authorized users.

Commentary on Hancock et al. (2020): Low dead space syringes are just one component of an integrated package of care needed to tackle HCV and social exclusion among people who inject drugs.

Individual and network factors associated with HCV treatment uptake among people who inject drugs

We aimed to determine the rate of GBV-C viremia, seropositivity, and genotypes among people who inject drugs (PWID) and healthy volunteers in Estonia and to evaluate associations between GBV-C and sociodemographic factors, intravenous drug use, co-infections. The study included 345 Caucasian PWID and 118 healthy volunteers. The presence of GBV-C RNA (viremia) was determined by reverse transcriptase-nested PCR in 5' long terminal repeat. PCR products were sequenced and genotyped by phylogenetic analysis. GBV-C seropositivity was determined by ELISA. One third of PWID (114/345) and 6% (7/118) of healthy volunteers (OR = 7.8, 95% CI = 3.5-20.5, P < 0.001) were GBV-C viremic. In PWID group, 79% of sequences belonged to subtype 2a, 19% to subtype 2b, and two remained unclassified. In healthy volunteers, six out of seven sequences belonged to subtype 2a and one to subtype 2b. We found HIV+ PWID to have two times increased odds of being GBV-C viremic compared to HIV- PWID (62% vs. 38%; OR = 2.13, 95% CI = 1.34-3.36, P = 0.001). In addition, odds of being GBV-C viremic decreased with increasing age (OR = 0.94, 95% CI = 0.90-0.98, P = 0.001). HIV positivity remained associated with GBV-C viremia in multivariate analysis after adjustment for age (OR = 2.23, 95% CI = 1.39-3.58, P = 0.001). GBV-C seropositivity was similar among PWID and healthy volunteers (2.3% vs. 1.7%, respectively; OR = 1.4, 95% CI =0.3-13.5, P = 1). In an Eastern European country we demonstrated that GBV-C viremia is common among PWID, but uncommon among healthy volunteers, and GBV-C seropositivity is infrequent among both groups. Similarly to other European countries and USA, GBV-C 2a is the most common genotype in Estonia. J. Med. Virol. 89:632-638, 2017. © 2016 Wiley Periodicals, Inc.

BackgroundThe age-adjusted rate of drug overdose deaths in the United States tripled from 1999 to 2016. Public health surveillance data indicate that an increasing proportion of infections due to bacterial and fungal pathogens is associated with injection drug use (IDU). We describe healthcare encounters (HCEs) of PWID as potential opportunities to prevent infections related to IDU by identifying risks and treating SUD, including with medication-assisted treatment (MAT) for opioid use disorder.MethodsAt six hospitals in western New York, we abstracted medical records from hospital admissions and emergency department (ED) visits for PWID (i.e., IDU in the preceding year) who had positive cultures for Staphylococcus aureus (any clinical specimen, April–July 2017), group A Streptococcus (invasive specimens, all of 2017) or Candida spp. (blood specimens, all of 2017). We reviewed hospital admission and ED records for 1 year preceding the positive culture to identify visits during which opportunities to prevent infection and treat SUD by addressing SUD and IDU were missed.ResultsWe identified 99 PWID with positive cultures. The median age was 33 years (range 19–68) and 61 were female. Sixty-nine had a skin and soft-tissue infection, 44 had a bloodstream infection, and 20 had both. Thirty-one PWID left against medical advice during a hospital admission or an ED visit. Seventy-nine PWID were hospitalized, of whom 4 died. Ninety-five used opioids and 71 used cocaine in the preceding year. Seventy-five PWID had an HCE in the 12 months prior to the index visit, with a median of two HCE per person (interquartile range 1–4); 53 of PWID had a previous HCE for infection and 28 for opioid overdose. SUD was documented during a prior HCE at the same hospital for 61 PWID, but only 10 (16%) were offered MAT during any prior HCE and for 24 (39%) there was no documentation that any form of treatment for SUD was offered.ConclusionIn this cohort, PWID frequently had one or more healthcare encounters documented at the same hospital in the year prior to a serious bacterial or fungal infection. These prior HCEs were often for infections or overdose that signaled the need for MAT, demonstrating that there are critical missed opportunities to identify risks, prevent infection, and treat SUD.DisclosuresAll Authors: No reported Disclosures.

BackgroundOpioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID.MethodsAs a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns.ResultsDespite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators.ConclusionThese results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Incidence of HIV-associated non-AIDS (HANA) related comorbidities is increasing in HIV-infected individuals. Our objective was to estimate the risk of HANA comorbidity associated with history of injection drug use (IDU) correctly accounting for higher death rates among people who inject drugs (PWID). We followed HIV-infected persons aged 25-59 years who enrolled in the Johns Hopkins HIV Clinical Cohort between 1995 and May 2014, from enrollment until HANA comorbidity diagnosis, death, age 60, or administrative censoring. We compared cumulative incidence ('risk'), by age, of validated diagnoses of HANA comorbidities among HIV-infected PWID and non-IDU; specifically, we considered end-stage renal disease (ESRD), end-stage liver disease (ESLD), myocardial infarction, stroke, and non-AIDS-defining cancer. We used competing risk methods appropriate to account for death, standardized to the marginal distribution of baseline covariates, and adjusted for potential differential loss-to-clinic. Of 5490 patients included in this analysis, 37% reported IDU as an HIV transmission risk. By age 55 years, PWID had higher risk of ESLD [risk difference = 6.8, 95% confidence interval (CI): -1.9, 15.5] and ESRD (risk difference = 11.1, 95% CI: 1.2, 21.0) than did non-IDU. Risk of myocardial infarction and stroke were similar among PWID and non-IDU. Risk of non-AIDS-defining cancer was lower among PWID than among non-IDU (risk difference at 55 years: -4.9, 95% CI: -11.2, 1.3). Not all HANA comorbidities occur with higher incidence in PWID compared with non-IDU. However, higher incidence of ESRD and ESLD among PWIDs highlights the importance of recognition and management of markers of these comorbidities in early stages among PWID.

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.

Past efforts to address endemic rates of sexually transmissible infections amongst young Aboriginal people living in remote/very remote Australian communities have had limited success. Peer education has been used in youth sexual health promotion but has received limited evaluation and has not been tested in remote Aboriginal settings. The Young Deadly Free youth peer education programme trained Aboriginal young people in 15 remote/very remote communities as peer educators to deliver sexual health education to other young people. Semi-structured interviews were conducted with the project team and regional coordinators to understand the barriers and enablers to implementing peer education in remote communities. Programme credibility, the offer of financial gratuities, and the recruitment of peer educators with prior sexual health knowledge and/or group facilitation experience were identified as programme enablers. Implementation challenges included programme rigidity, cultural sensitivities, and retention and expectations of peer educators. Seven implications for policy and practice are identified to increase the efficacy and long term-impacts of youth peer education. Peer education for youth sexual health promotion in remote communities can be effective if young peer educators are supported appropriately and the peer education programme is part of a comprehensive sexual health promotion strategy.