Unsafe injection practices among PWID in Catalonia: the need for a syndemic approach
Background: Unsafe injection practices significantly increase the risk of HIV and hepatitis C virus (HCV) infection among people who inject drugs (PWID). We examined individual, social and structural factors associated with unsafe injection practices among PWID in Catalonia, Spain.
Methods: As part of the HIV/ STI integrated surveillance system in Catalonia, bio-behavioral surveillance among PWID in harm reduction centers started in 2008. In the last cross-sectional study (2019), anonymous questionnaires and oral fluid samples to determine HIV and HCV Ab prevalence were collected. Logistic regression models were performed to assess factors associated with recent needle and/or equipment sharing, adjusting by age, gender and migration status.
Results: Among 697 participants, the median age was 42 years; 19% were women; 45% reported being homeless; and 33.3% and 74% had HIV and HCV, respectively. Receptive syringe sharing was reported by 10.8% of the sample, and 30.2% shared other injection paraphernalia in the last 6 months. Unsafe injection practices were associated with injecting daily (adjusted odds ratio [aOR]:1.9; 95%IC 1.3, 2.7), injecting in flats where drugs can be bought (aOR:1.8; 95%IC 1.2, 2.6), hazardous alcohol use (aOR:1.6; 95%IC 1.1, 2.3), not having access to all the sterile syringes that she/he needed (aOR:3.0; 95%IC 1.7, 5.5), having a steady partner who inject drugs (aOR:3.1; 95%IC 1.7, 5.5), reporting sex work (aOR:4.1; 95%IC 2.0, 8.4), and having suffered physical violence in the last 12 months (aOR:1.8; 95%IC 1.2, 2.5).
Conclusion: Despite the availability of harm reduction services in Catalonia, HIV and HCV seroprevalence remained high. A number of individual, socio-environmental and/or structural factors were associated with unsafe injection, suggesting that interventions focused only on one level are not enough. In this sense, a syndemic approach that considers broader social and structural-level determinants will help to understanding risk and health behaviors of PWID.