Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: An exploratory qualitative study.

BACKGROUND: Countries in Sub-Saharan Africa (SSA) have seen rapid increases in injection drug use since 2008. In Uganda, the Global Sate of Harm report and studies conducted by Makerere University Crane Surveys have estimated HIV prevalence among people who inject drugs (PWID) at approximately 17%. The objective of the research was to document injection and other drug-related risks among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention interventions.
METHODS: Between August and September 2018, we conducted qualitative interviews among male and female people who use drugs. Interview topics included the availability and accessibility of clean syringes, injection risks, overdose, sexual-risk behaviors, and the availability and accessibility of harm reduction and drug treatment services.
RESULTS: Participants reported several injection-related risks including sharing and reusing syringes, pooling and mixing drugs in the same container, measuring drugs using syringes, getting prefilled injections from dealers, being injected by other people who inject drugs, and using contaminated water or blood to dilute drugs. Participants reported a scarcity of harm reduction services, although a few appear to have participated in the syringe exchange pilot conducted by the Uganda Harm Reduction Network (UHRN). Even fewer reported knowing organizations that helped people who use drugs abstain from or reduce their use. Medication assisted therapy (MAT) and naloxone to reverse overdoses are not currently available.
CONCLUSIONS: Comprehensive prevention and treatment services are needed in Uganda and should include expanded syringe exchange programs, social network HIV testing, HCV testing, provision of naloxone and MAT, and linkage to and retention in HIV care.

Introduction

HIV prevalence in Uganda is among the highest in the world, with national prevalence estimated at 6.2% [1] and prevalence among high risk populations such as fisherfolk and female sex workers at 30% [2] and 33% [3] respectively. While Uganda has been the site of abundant HIV prevention and research efforts, it is one of only two countries in Sub-Saharan Africa (SSA) in which HIV incidence is increasing, particularly in the general population [4]. There is some indication that unaddressed factors including injection and non-injection drug use may be impairing Uganda’s HIV prevention efforts [5, 6]. Countries in SSA have seen rapid increases in injection drug use since 2008 including heroin and cocaine [7-10], and these drugs are also present and increasingly used in Uganda [11-13]. Heroin and cocaine injection are highly prevalent in the coastal areas of Tanzania and Kenya which have long acted as trans-shipment points but have increasingly opened local markets. A recent review of studies found a substantial proportion of heroin users who inject in Kenya and Tanzania [14] and that these groups may have high HIV prevalence rates. In Kenya, of 101 current injectors, 52.5% were found to be HIV positive, attributed mainly to sharing injection equipment compared to 13.5% of heroin users who had not injected [14]. In Uganda, the Global Sate of Harm report and studies conducted by Makerere University Crane Surveys have estimated HIV prevalence among people who inject drugs (PWID) at approximately 17% [1, 11]. In 2018, the Kampala Place Study estimated over 18,000 people who inject drugs (PWID) in Uganda [15]. A high number of women who use injection and non-injection drugs report selling sex (79%) and may have significantly higher rates of HIV infection [16]. There is no reliable data on the prevalence of HCV as PWID are not tested for this in Uganda or other SSA countries [12]

Despite the effectiveness of existing HIV prevention efforts for people who inject drugs, such efforts are inadequate or non-existent in many SSA countries [14, 17]. Uganda has recently piloted a syringe exchange program [18] and has pledged to devote more resources to prevent HIV among PWID including providing medication assisted therapy (MAT) such as buprenorphine to help drug users abstain from more harmful opioids like street heroin, or injection risks; the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund key population investment fund have pledged money and resources to begin MAT by this year in three centers in Kampala. Tanzania and Kenya recently opened methadone clinics in 2016 and 2018, respectively [19]. These efforts are likely insufficient to combat HIV in PWID in East Africa and have been hampered by addictophobia on the part of providers, stigma of people living with HIV (PLH) and PWID and a lack of political will [20]. Most researchers argue that a combination of approaches are needed including provision of clean syringes through syringe exchange programs (SEPs), frequent HIV testing and linkage to HIV care, antiretroviral therapy initiation after infection to reduce risk of onward transmission through viral suppression, medication assisted therapy, psychosocial support and pre- and post-exposure prophylaxis [20-22]. In addition, modelling projections suggest that very high coverage of ART, SEPs, and MAT in combination are necessary to reduce HIV incidence of PWID by more than 50%; very high intensity and coverage of single interventions is necessary to achieve similar effects, otherwise single interventions are unlikely to be effective [21]. Very few countries provide all these harm reduction services and services are often fragmented and rarely offered in one place. For example, many studies have shown that the integration of substance abuse treatment in HIV care can improve adherence to ART, but such programs are still rare [23-25]. At present, only HIV testing and linkage to care is consistently provided to drug users and only in Kampala through the Uganda Harm Reduction Network (UHRN) outreach to drug hotspots and peer navigation to government HIV clinics in which ART is provided free of charge. However, efforts are underway to increase harm reduction centers to the rest of the country that include MAT, syringe exchange and PrEP.

The current study presents results from qualitative interviews with 30 people in Kampala, Uganda who use injection and non-injection drugs to determine their behavioral risks for HIV and the availability and accessibility of resources to reduce the harms associated with injection such as clean syringes, non-pharmaceutical drug treatment such as counseling or 12-step programs (as MAT was not available at the time of study), condoms and HIV testing.

Methods

We conducted 30 in-depth interviews with people who used illicit drugs from drug-use hotspots in Kampala, Uganda. Interviews assessed the physical and social context in which drugs were consumed that increased or decreased injection- and drug-related sexual risk. Interviews also explored participants’ access to syringes, experiences with HIV prevention programs, HIV testing services, HIV treatment, and any substance abuse prevention or treatment services. This study was approved by Institutional Review Boards at the Medical College of Wisconsin, Makerere University School of Public Health, and the Uganda National Council for Science and Technology.

Eligibility criteria and interview sampling characteristics

Eligibility requirements included being 18 or older, having used an illicit drug in the last 30 days, and being able to provide informed consent in English or Luganda. Drug use was kept open in order to explore the types of drugs most commonly used. We include both people who inject drugs (PWID, n = 17) and people who use drugs (PWUD) but do not inject (n = 14), because while injection with contaminated syringes is one of the most efficient ways to become infected with HIV, PWID and PWUD can be at risk for becoming infected through high-risk sexual behaviors. In addition, PWID and PWUD often are parts of the same drug using networks. We purposively oversampled to include more women than in the general drug using population.

Recruitment and consent

We used a combination of standard outreach techniques and participant referral to identify and recruit eligible participants for in-depth interviews. Members of the Uganda Harm Reduction Network who served as Research Assistants to the project recruited directly from selling “hotspots” in Uganda. Screening questions verified that the potential participant used cocaine, heroin, methamphetamine, or methaqualone in the past 30 days. We also asked participants about their alcohol use and sexual activity to disguise eligibility criteria to avoid false reporting of eligibility. Participants under 18 years old were excluded from in-depth interviews due to potential risks involved in obtaining parental informed consent for minors to participate in interviews focusing on illicit drug use. Eligible participants, or participants who were ineligible but indicated that they had previously used drugs, were asked to refer someone they know who uses drugs to the study. Again, we asked seed participants to bring or send potential participants to field staff for screening, and staff never directly approached an individual who was identified by a participant. Luganda informed consent forms were read aloud to participants by research interviewers. After reading the consent form, potential participants were asked if they had any questions and were asked questions by the interviewer to test their understanding of the project and their decision to participate or not. Participants who agreed to participate were asked to sign the form or to make their mark if illiterate to signify their consent. The research interviewer witnessed consent and signed the consent form.

In-depth interview procedures and content

Interviews took place in a private location in the community, for example a private room in a community center or the project car. We informed participants that all the information they gave us was confidential. Interviews took about 1½ hours to complete and were tape-recorded, except for interviews with three participants when a tape recorder was not available. Detailed notes were taken of these interviews. Interviews were conducted by an outreach worker with experience in qualitative and quantitative research at the UHRN, and a graduate student who is a native Ugandan. Interviews were conducted in Luganda. All interviews were transcribed and translated into English by a bilingual translator.

Interviews contained both a structured quantitative survey as well as open-ended qualitative questions. The quantitative portion included demographics: age, employment, income level, sources of income, and education level. We also assessed the quantity and frequency of use of various drugs. This brief demographic interview was followed by an open-ended ethnographic interview in which the following topics were explored among others: 1) drug use history; 2) subsistence strategies to support drug use; 3) where and how injection equipment is obtained, and a description of injection practices including how drugs are prepared or shared; 4) sexual experiences and HIV risk behaviors while using drugs; 5) experiences trying to quit or cut down on drugs including knowledge of places that offer drug treatment or people who have successfully quit; and 6) any experiences with harm reduction services such as SEPs and HIV testing.

Qualitative analysis

All taped interviews were transcribed, and text data was coded and analyzed for key themes and patterns of response using MAXQDA software. All authors participated in developing the code book. Authors 3, a US-based MA qualitative researcher, 5, a graduate student in Public Health from Uganda and 6, a US medical student coded data while author 3 checked coding for consistency and accuracy. Disagreements were discussed and resolved by consensus. Data analysis was primarily descriptive and included drug and sexual risks participants described, contextual reasons for these risks, and the availability and accessibility of harm reduction services to reduce risks. New themes that were iteratively discovered during analysis were added to the final coding tree. The coding tree is shown in Table 1 below.

Table 1

Coding tree.

Injection

Types of drugs

Marijuana

alcohol

heroin

cocaine

other

Police

Safety/ avoiding police and detection

Butabika hospital

Prison

Drug confiscation

Torture

Quit attempts

Withdrawal

Overdose

Frequency & quantity of use

Initiation of drug use

Slums

Ghettos

Drug use networks

Subsistence activities

drug selling/ flipping/ transporting (by users)

robbery/ crime

trash pickup/ recycling

Employment

Activities when using

Sex work/ exchange/ paying for sex

Availability of syringes

friends

dealers

pharmacy

syringe exchange/ satellite distribution

Injection risks

sharing

reusing

flushing

teaching

mixing/ measuring

cleaning

Prevention outreach

Credit/ reciprocity among users

School/ education

Hiding/ concealing drug use

HIV awareness

peer conversations

status

stigma

sex risk (including knowledge)

testing

Condoms

Brothels

Substance use treatment/ lack of

Substance use/ drug stigma

Cost of drugs

Homelessness/ Housing

Drug Selling

Delivery

Organization

Rules

Sites

Drug Using

Sites

Site rules

Results

Seventeen of the 30 participants reported injection drug use (57%). Of these, 65% reported injecting cocaine, 52% heroin, and 35% injected both heroin and cocaine. Participant characteristics are described in Table 2 below.

Table 2

Participant characteristics.

	Men, n (%)	Women, n (%)	Total, n (%)
Sample Characteristics	n = 20	n = 10	n = 30
Age (mean, SD)	27.1 (4.3)	30 (5.3)	28.1 (4.7)
Injection Drug Use	9 (45)	8 (80)	17 (57)
Drugs injected
Just Heroin	0	3 (30)	3 (10)
Just Cocaine	4 (20)	2 (20)	6 (20)
Both	5 (25)	3 (30)	8 (27)
HIV
Had a test	16 (80)	8 (80)	24 (80)
HIV+	2 (10)	3 (30)	5 (17)
Sex work	0	7 (70)	7 (23)
Exchanged sex (excluding sex workers)	5 (25)	3 (30)	8 (27)

Injection risk behavior

Participants reported buying syringes from pharmacies, sharing them from friends or obtaining them from drug dealers. Only three reported obtaining syringes from a syringe exchange (see below). Nearly all participants who injected drugs reported sharing injection equipment. While syringes are legally available for sale in Uganda, most participants who injected reported that they were too expensive to buy for a single use, or even for a single person. As a result, people who injected drugs often shared with each other, like the man below who reported injecting cocaine daily.

Interviewer: Under which circumstances do you share those syringes?

Participant 4: You see, the way those syringes are expensive, you have to share even needles as well as alcohol. We have to share, today it’s me and tomorrow it might be him without any money on him. (23-year-old man)

In this situation of scarcity, even people who knew the risks of sharing and took precautions to protect themselves reported that they would share their used syringes with other users. This was sometimes done voluntarily to help others avoid withdrawal while at other times, people reported searching for discarded syringes when they did not have one. The woman below injected 80 times a day but insisted she would only sniff if she did not have a syringe.

Participant 1: Syringes sometimes get lost and some use them in a group. Some syringes are shared in a group of two to three people. But that is harmful, dangerous because of transmission of HIV/AIDS. That’s why when I don’t have my own, I don’t use. Others use and give others to use. You know am educated at least but others share the syringe. When I don’t have the syringe, I don’t use the injection. When I use a syringe and throw it away, they search for it and sometimes we fight for it.

Interviewer: So, when you give them, they share the needle?

Participant 1: They ask me, and I give them, but I don’t use it again. So, we need more syringes to reduce on the rate of HIV infection. (20-year-old woman)

Syringes can also be bought from people on the street, not directly from pharmacies. However, many participants reported that people who sell on the streets often purchase all available syringes from the local pharmacy, creating a monopoly and selling syringes even more expensively.

Interviewer: Can you buy [syringes] somewhere else?

Participant 1: Yes, they are there, they sell but expensively. That’s why we use in groups and it’s dangerous. They are big people who come and buy all leaving us with an option but sharing the syringes. (20-year-old woman)

The expense of syringes also led many to reuse syringes many times. This sometimes led to syringe clogging and contributed to abscesses among injectors.

Interviewer: So, for you to know that this syringe is no longer necessary for usage and you throw it away, how many times do you use it?

Participant 12: Why throw it away?

Interviewer: You don’t throw away?

Participant 12: They read the budget, where were you? All prices were hiked including that of syringes, so we don’t easily throw them away. (30-year-old man, reported injecting cocaine every 30 minutes every day)

Syringes were generally replaced when they no longer functioned, in other words, clogged or stuck.

Interviewer: So, when do you replace the needle?

Participant 1: Sometimes you push, and it’s stuck and not working. That’s when you stop. Others use one needle for a week. But it is also not good. Every time you inject you need to buy needles-syringes. Even if you want to use the needle like three times a day then you need to buy three needles. (20-year-old woman, injects 80 times a month)

Syringes were also shared because people who inject drugs often pooled their money to buy drugs and, as a result, mixed the drugs in the same container and drew the drugs from it, or injected a portion from the same syringe. While PWIDs recognized that this was risky, it also bonded them together in their shared risk.

Interviewer: Have you ever shared needles with anyone else? In what circumstances have you done this?

Participant 22: Yes, especially when we did not have enough money to have enough drug. Sharing is a sign of brotherhood in this location. That is why we call each other “blood”. (29-year-old man, injects heroin and cocaine every day)

Syringes were also shared when PWID bought premeasured syringes from drug dealers. PWID did not know whether these were clean or used syringes and reported returning syringes to dealers after injecting.

Interviewer: Tell me where you obtain needles or syringes to inject your drugs?

Participant 28: I obtained needle and syringe from a drug seller. He gave me already mixed drug. I did not take part in mixing the drug. And after him injecting me, the used ones were taken by him. (27-year-old woman, used to but no longer injects)

Another risk associated with injection in Uganda that is perhaps not as prevalent in developed countries, is the availability and accessibility of clean water to dilute drugs for injection. Very few participants reported buying bottled water or receiving saline water for injection. Most often, participants reported using tap water to mix drugs.

Interviewer: Describe how you prepare drugs for injection. Where do you get your water? What do you use to mix your drugs (spoon or bottle cap)? Does anyone else use the same thing (cooker) to mix their drugs?

Participant 11: We always use water from the tap to mix, if it is hard drug, we have to pound it on the spoon then we mix it with water. We get this water from the tap. After making a solution we put in our syringes that has a needle and our leader injects us. Not everyone knows how to inject drugs, you might end up injecting someone in the part which cannot be injected. However even on the stomach sometimes can be injected. (29-year-old man)

Some PWID sterilized their water for injecting by boiling it themselves, getting it preboiled from their dealers, or purchasing sterile water from pharmacies. However, sterile water bought in pharmacies was reported to be expensive.

Interviewer: How do you prepare the drugs for injection? Where do you get the water?

Participant 1: Where we get water from where we buy the drugs. They boil the water and put it in a tin. If you are nice to them they give you and we buy drip water (saline water) that is used for drips and not mixed with any other drugs. So, when we buy, and they measure and mix for us—we inject. That’s why these drugs are expensive. If you can’t afford the saline water, you use the local one. (20-year-old woman)

In the absence of any water source, some users reported using blood to prepare their drugs.

Interviewer: First, tell me how do you make the drug for injecting?

Participant 7: You get the drug, put it on a spoon, then mix it. Then, first get some blood from the veins, so when you don’t have water, you mix using blood. (25-year-old man)

Sex-related risks

Male participants reported getting money to buy drugs in a variety of ways including through work, (mainly in informal transportation (boda boda or motorcycle taxis), construction or street vending), through selling drugs or stealing. A sizeable number of women reported sex work or sex exchanges, even those who did not inject like the woman below.

Interviewer: Have you ever exchanged money for sex?

Participant 9: That’s my job.

Interviewer: How about sex for drugs?

Participant 9: Sometimes, when I fail to get money on a bad day, I exchange sex for drugs…. At first, I did not like it but am now getting used. It’s what I have to do to survive.

Interviewer: Why do you say you didn’t like it the first time?

Participant 9: I thought it was bad; from the way people stigmatize us and the way they talk about us. But conditions pushed me to do it because I don’t have any other job I can do.

Interviewer: Any other bad experience?

Participant 9: The body is now used and it’s hard to stay without consuming the drug. Am sometimes forced to do bad things to get the drug. (31-year-old female)

Condom use in these encounters was rare. The women knew condoms would protect them from getting HIV but often reported forgetting to use one, especially if they were already high. Condom use also depended on whether the client was willing to pay more for condomless sex and the woman’s desperation for drugs.

Men also reported exchanging drugs for sex if women did not have money to buy drugs as the man below reports. However, even though men also engaged in sex exchanges, their participation in this was much more sporadic when an opportunity presented itself as described by the man below. In contrast, women who considered sex work their jobs, often had several sexual partners in a day.

Interviewer: Ok, have you ever sold for someone marijuana or other drugs?

Participant 4: Yes.

Interviewer: How much were you paid?

Participant keeps quiet.

Interviewer: How much?

Participant 4: There is a woman I bought it for and she refused to pay me and decided to play sex with her and closed the chapter.

Interviewer: Meaning sometimes you exchange sex for drugs? The last time you bought for someone and exchanged sex, what do you recall that happened?

Participant 4: Yes,

Interviewer: You are only laughing, tell me what happened?

Participant 4: You see what happened, we played sex and without a condom, and I enjoyed. I think if everyone was playing sex without a condom, things would be sweet. (23-year-old male).

Condoms were often not used in these encounters as male clients prefered and would often pay more for condomless sex.

Interviewer: Have you ever exchanged sex for money, drug, or something else valuable?

Participant 25: Yes, I always exchange sex for money and the drug. Sex work has been my source of earning for many years and I have always been paid depending on the time spend with the client and the nature of sex to play [i.e. protected or not protected using a condom]. Meanwhile, the addiction to drugs means you cannot do without a drug. There are sometimes when I do not have required money to possess a drug or when I am with my friends to give me a shot. In this condition, I have asked for a drug from known drug dealers and paid in kind. Most times in a bar, when a guy buys me alcohol they expect sex in return. (27-year-old female)

Harm reduction services

As mentioned, the UHRN piloted a syringe exchange program in the year we conducted this study. Approximately three participants reported receiving syringes from an active drug user who gave syringes to people he knew. This included one woman and two men.

Interviewer: You told me about the injectables, heroin and cocaine; could you tell me where you obtain the syringes you use to inject drugs?

Participant 1: Am going to say but don’t take him away. For syringes, we have [UHRN peer recruiter] and he is always supplying us syringes so we don’t get sick. These days he is not bringing the syringes and I don’t know why. That’s why these days I don’t inject and am missing. All I beg from the government is to help us because not all those who smoke, inject and sniff drugs are dangerous. We do it because of problems like having no money, standards of living, stress; joblessness leads us to that other than taking us to prisons. …… It’s bad to take drugs but we are addicted. The government should help the addicts such that the syringes are supplied. We need more syringes and we are dying seriously. (20-year-old woman)

Serving as a peer health worker can have beneficial effects for the people who use drugs who often reduce their own risks or drug use to serve as a positive model for their peers. A UHRN peer syringe distributer described these benefits when describing his work.

Participant 7: I just mobilize drug users and when I do it, am given some money. We also organize blood testing and counselling programs for drug users. That’s how I earn some money.

Interviewer: Which organizations are those?

Participant 7: Harm Reduction…. When I wake up in the morning, I take a shower and I know I have a program with so and so and I start making phone calls. That’s how my day starts. So, whoever gives me a program then I have to fulfil it. I don’t think about drugs all the time.

Interviewer: So, like in that schedule, when do you take the drugs?

Participant 7: …[W]hen I reach my place.

Interviewer: Why don’t you take it anywhere apart from your place?

Participant 7: I am in the process of quitting drug use and I don’t want other people to see me. If they see me on the street taking drugs, they will not respect me…. Like they think all the time you are high. Even when you are talking sense, they think you are high on drugs. (25-year-old man)

This participant obtained syringes from the UHRN to pass for free to his drug using peers. As mentioned, he took this role very seriously and avoided using drugs in front of his peers for fear they would not listen to his harm reduction advice, and because he was trying to cut down on his drug use. The fact that only three participants reported that they received syringes from an outreach worker suggests the need to expand the program. Unfortunately, the pilot lasted only a year and funding for it had just ended by the time the interviews for this project were conducted.

HIV testing and condom distribution

While most participants reported having been tested for HIV, the frequency of testing was very low. Participants rarely sought out testing on their own; they were most commonly tested after being approached by outreach workers like UHRN trained users who took their peers to get HIV tests at UHRN centers.

Interviewer: Have you ever taken an HIV test? Where was it?

Participant 1: I went to Namwongo. It was group of us and we went with (UHRN trained peer educator who supplied syringes). Seriously am okay. This is where they pricked, and I was okay. With me I was okay, but others are sick… and others okay (negative). This all because of sharing the needles (20-year-old woman).

Other participants reported getting tested for HIV from organizations other than UHRN. These were not necessarily focused on PWID, but provided condoms, rapid testing and even information about anti-retroviral treatment (ART) and post-exposure prophylaxis for those who felt they may have been exposed to HIV.

Despite regular outreach to promote HIV testing and educate people who use drugs and the general population to test regularly for HIV, many refused to get tested. Some had heard that HIV is no longer a problem because everyone already has it and there is effective medication.

Interviewer: Have you heard your friends or other drug users discuss HIV? What have they said?

Participant 21: Yes, that HIV is nowadays a disease for everyone, it does not eliminate. They do not fear HIV since it does not kill customers. (33-year-old woman)

Conversely, others chose not to take the test because they are afraid of learning they are HIV positive.

Interviewers: Have you ever taken an HIV test?

Participant 9: It has been a long time…. I even fear because now I meet different men, so I don’t know whether they have infected me or not…. The truth is that now I can’t go for an HIV test. I will first wait and fall sick, then I go for a test. (31-year-old woman)

The woman reported that she “couldn’t” go because she is too afraid and will only go if she is confronted by symptoms. Some reported that they knew people who would commit suicide if they found out they had HIV or try to infect others, indicating a high level of stigma regarding diagnosis and a lack of knowledge that one can live a long and healthy life with treatment.

Participant 14: Some… have this cheap thinking and reasoning that if he wakes up and is tested HIV positive, he commits suicide and another one was saying that in case he is tested and found to be HIV positive then he would infect like ten people before dying. (28-year-old man)

To date, PWID have not received HCV testing as part of the services they receive. As a result, it is not known how many are infected with HCV.

Participants reported that they had been offered condoms and educated about their use by outreach workers. However, condom use was still low due to participants forgetting, being high, or not liking condoms, even among those who had tested positive.

Overdose prevention

Participants reported high rates of overdose from heroin use. As one participant said:

Participant 2: Actually, everyone who uses that drug of injection, he or she has overdosed because sometimes when you get money, you understand, you can go and shop as much as you want. After that you get too high and overdose. (26-year-old man)

Statistics regarding the number of fatal overdoses are not readily available.

While Naloxone is on Uganda’s list of essential drugs, it is not yet available or accessible in the country. Thus, no participants users reported knowing what to do in cases of opioid overdose, although they sometimes reported using urine for alcohol poisoning.

Participant 31: We have also been also had cases of clients who are affected by overdose. And managing someone who has got overdose with especially hard drugs like brown sugar [heroin] is hard for us. With alcohol we have always managed overdose using human urine. (33-year-old woman)

Urine is not an effective treatment for opioid or alcohol overdoses. As the participant says, participants are left without effective means of reversing opioid overdoses.

Quitting or reducing drug use

Very few participants reported trying to reduce or stop their drug use or of knowing anyone who had successfully quit using drugs. Many believed that quitting drugs was “impossible” because their bodies now needed the drug to function.

Interviewer: Ok, have you ever thought about stopping or reducing the use of drugs?

Participant 9: I can’t stop.

Interviewer: Why?

Participant 9: It’s because the body is now used. Even if it’s after an hour of not taking the drug, I feel badly off. I have to look for money and take the drug. (31-year-old woman)

Participants who used drugs interpreted symptoms of withdrawal or craving as the body not being able to function without the drug. In part this may because people who use drugs have not been given information about drug treatment with the assistance of MAT or through common cognitive behavioral therapy approaches such as learning to cope with cravings and withdrawal. In fact, most participants claimed not to know anywhere where substance abuse treatment was offered or anyone who was successful in quitting.

Interviewer: Is there any person you know that stopped using drugs?

Participant 5: The one I know died. (30-year-old man)

Some participants mentioned prison as being a place where some temporarily abstained from drugs but claimed that most started their substance use as soon as they were released. Others mentioned the Butabika psychiatric hospital as the only place they knew of that people who use drugs were taken to recover from substance use. Without exception, participants reported that people taken to Butabika were mistreated and left in worse condition than when they entered.

Participant 1: You know, I fear being taken to rehabilitation…. One day my dad took me to Butabika, but life was hard. They injected me, and I would sleep the whole day. It’s bad. When I came back, I said am not going back to my dad to take me to Butabika. In Butabika we eat posho [food made from sorghum or millet flour with the consistency of dough]. Some patients have saliva coming out of their mouths. You can get mad [crazy] from there. We need a better place (20-year-old woman)

Discussion

Results from our study demonstrate several risky injection practices in Uganda that could increase HIV incidence if actions are not taken. These are very similar to those found in other parts of the world, and include sharing syringes, sharing mixing containers, reusing syringes multiple times, using dirty water or blood to mix drugs and engaging in sex work [20-22]. While all participants reported knowing about the risks of contracting HIV by sharing syringes and other injection paraphernalia such as cookers and water, and syringes are available for sale without a prescription in pharmacies, the price of syringes and PWIDs’ poverty made using a new syringe for each injection economically infeasible. According to a study conducted by Alliance Uganda and the UHRN [26], almost 40% of 125 PWID surveyed reported using syringes from two to four times, while 17.7% reported using them 10 or more times. Similarly, many PWID often had to pool resources to buy drugs, increasing the risk of sharing mixing water. These risks are common to all PWID in places without significant harm reduction efforts, such as syringe exchange programs, in locations were PWID can access them [27-30].

However, results from this study also reveal risks that may be unique to low- and middle-income countries, or to Uganda. First, the use of tap water to dilute drugs may increase the risk of abscesses, endocarditis, Hepatitis A and B and other infections even more than in developing countries because of the high levels of pathogenic viruses and bacteria in drinking water [31]. According to Water.org, 61% of Ugandans do not have access to safe drinking water as a result of rapid urbanization and poor sanitation infrastructure [32]. Large quantities of pathogenic bacteria have been found in springs that are the main source of drinking water for Kampala residents. Further, most PWID in Uganda live in informal settlements, or slum areas, many of which may have poorly designed pit latrines or lack sanitation facilities at all. Second, many participants reported buying premeasured drugs in syringes from drug dealers and then returning the used syringes to these dealers. It is not known whether these syringes are new or have been sterilized, but the willingness of PWIDs to buy drugs and inject with dealers’ syringes is also a sign of the scarcity of clean needles in Kampala.

The UHRN pilot syringe exchange program was highly popular among users who received syringes in this way. A report of the SEP by UHRN reported that from July to September 2018, 2244 clean syringes were distributed to 120 PWID. Peers distributed syringes and kits containing cotton swabs, tourniquets, sterilized water, disposal bins and spoons. This program should be expanded to provide syringes and other safer injection materials to more PWID [18]. Peer-led interventions such as these have been shown to be successful in countries around the world where drug using outreach workers are able to access other people who use drugs that traditional outreach workers may not be able to [33]. These programs build on the altruism that people who use drugs have for other people who use drugs. Many peer-led interventions have shown that those who are trained to conduct outreach among their peers reduce their own risk behaviors, including drug use, to reduce cognitive dissonance between their own actions and the advice they give to others [33-36], much like the peer educator who tried to reduce his drug use in order to be credible and effective. Continued drug use among peer educators can also lead their drug using peers to assume that they are only doing outreach for the money which allows them to discount their messages [37]. The government of Uganda and UHRN have committed to expanding the program to drop-in centers (DICs) that will be in different parts of the country.

Naloxone should be provided as part of the kit of materials offered to PWID by their peers. Police, ambulance drivers and emergency department physicians should be trained in its use. Policy changes that will reduce the fear that people who use drugs may be arrested for trying to seek medical help for a peer who has overdosed are needed. Second, medication assisted therapy (MAT) should be made available to PWID and other opioid users who wish to stop. Buprenorphine or methadone could be offered in UHRN DICs since many people who use drugs around the world have expressed their preference for MAT in harm reduction facilities rather than medical clinics, due in part to the more tolerant and welcoming environments found in these locations [38]. In addition, the UHRN has reported that many people who use drugs avoid medical clinics because they fear being reported to police or otherwise face discrimination from staff [39]. While MAT is stigmatized among many users in the United States and other countries as people argue that it is replacing one drug with another [40], it may be more acceptable to people who use drugs in Uganda who reported needing medicine to help them abstain from the drugs that their bodies still need. However, psychosocial treatment is also needed as recognized by the participants in this study.

Results from this study suggest a near absence of any type of drug treatment, including abstinence only or 12-step programs. Most participants reported not knowing anyone who had successfully quit using drugs and did not know of any drug treatment facilities. A few had heard of people going to Butabika mental hospital for drug treatment and were afraid to go there as well. A study conducted by the Mental Disability Advocacy Centre observed a failure to provide for basic needs, such as sufficient food, and degrading treatment, involuntary confinement, seclusion and chemical restraints and a failure to provide biomedical or psychosocial treatment [41]. The participants’ description of her time fits well with the reports observations and helps explain participants’ fear of being sent to Butabika.

Additional services are needed to develop a combination prevention intervention that can effectively halt the spread of HIV and reduce other risks among PWID. First, efforts to increase rates of HIV testing among PWID are needed to link those with HIV into care. Few PWID in this study reported getting an HIV test more than once every few years, and some avoided testing altogether. Given the high rates of risk, and the prevalence of HIV rates among PWID estimated, HIV testing is a necessary first step to get PWID into HIV treatment and virally suppressed to prevent transmission to others. Social network HIV testing, in which PWID or other key populations are given monetary incentives to receive an HIV test and incentives for referring other members of their networks for an HIV test, has been very effective in increasing HIV testing among people who use crack cocaine in El Salvador and could increase testing rates in Uganda (Authors pub). Testing for Hepatitis C is needed to assess its prevalence among PWID and advocate for medications to treat it.

Limitations

The present study has several limitations including the small sample size. Given that not all participants injected drugs, we may not have reached saturation of themes regarding drug injection risks. This study should be considered exploratory and its value lies in revealing the HIV risks of people who use injection and non-injection drugs in a setting that has only recently seen illicit drug use. However, the similarity of risks reported by participants within the study and in comparison to research conducted with people who inject drugs in other settings adds confidence to our results. In addition, experiences of people who used a variety of non-injection drugs may not have been adequately captured. The study was conducted in a number or drug hotspots in Kampala Uganda and may not represent the experiences of drug users in other parts of the country. However, because more harm reduction services are available in Kampala than elsewhere in the country, we felt that it was important to document gaps in these efforts in Kampala as they are likely to be greater in other parts of the country.

Conclusions

Injection drug use is a growing problem in Uganda and PWID are at high risk for HIV and HCV infection through injection and sexual risk behaviors. Aside from a small pilot that used peers to distribute syringes, PWID reported having to buy syringes from pharmacies which caused many to share due to the expense of syringes. A multi-component harm reduction intervention including syringes, naloxone, condoms, and MAT is needed to prevent HIV/HCV infection in Uganda.

(DOCX)

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4 Dec 2019

PONE-D-19-30396

Injection and Sexual Risk among People who Inject Drugs in Kampala, Uganda: A Qualitative Analysis

PLOS ONE

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Reviewer #1: Dickson-Gomez et al. explore injection and sexual risk behaviors among people who inject drugs in Kampala, Uganda. While certainly a worthy area of study, given the paucity of data from low-and-middle income countries with emerging injection drug use epidemics, this manuscript will need to be re-worked in several ways to ensure validity and robustness of findings and conclusions.

Major comments:

1. While I recognize that this is a particularly difficult population to work with, I am not certain why recruitment could not have been more purposive in that only injection drug users were recruited. Instead, it is misleading to state that 30 participants were recruited, and then go on to describe only the experiences of the 17 among them who were actually injecting for some parts of the manuscript and more general experiences of the other users in other parts of the manuscript. Infact this demarcation is not at all clear. It is also unclear if saturation of themes were achieved with these 17 interviews (among injecting PWID), which the authors themselves admit is a limitation. This is a major methodological flaw in the study. Instead the authors should aspire to conduct a more robust qualitative study, recruiting enough injecting (male and female) PWID to explore these areas in detail until saturation of themes is achieved. Respondent driven sampling (which the authors used partially) can be a powerful way to recruit participants. The experiences of male and female PWID also need to be more clearly delineated since there is enough data to suggest that HIV disproportionately affects female PWID. Barriers to receive harm reduction services also differ significantly between male and female PWID. Instead what appears in this manuscript is the experiences of male and female PWID inter-mingled such that the sexual risk behaviors among female PWID (who are also sex workers) is explored in detail, and yet little is known about the sexual risk behaviors of male PWID. The other alternative is to focus exclusively on female PWID (as has been done in other studies in other settings) as a separate manuscript.

2. The organization of the manuscript can also be significantly improved. Some suggestions are as follows:

a) The qualitative methodology needs to be explained in greater detail. Representative questions are presented (and can perhaps be organized under broad headings in a table); however not all questions are sufficiently dealt with in the results. For example, the authors state that they explored transitions to drug use and why injecting did or did not occur but do not describe this in the results.

b) Parent and child nodes for coding can be presented in a table.

c) At the very beginning, in the introduction, a pre-amble can be provided on the following: i) size estimates of PWID in Uganda (at least what is known), ii) existence of syringe exchange programs and opioid agonist therapy services, iii) targeted intervention programs for PWID, iv) voluntary testing and counseling centers, iii) government ART centers. While this data is offered in the manuscript, it is interspersed in the results and discussion. Whereas describing this information at the beginning provides clarity and helps the reader recognize what is available. Subsequent themes on barriers to receive services (including paucity of services) or other factors can then be appreciated in this context. The authors note that a "package of interventions" is recommended for PWID -- indeed, this is also the WHO's recommendation for key populations (given the challenges in reaching and linking such hard to reach populations). Presenting what is available in Uganda, and noting that as is the case in many countries, service delivery to key populations often tends to be fragmented (even if services are available) will offer context as well.

d) The quotes in the results section are interspersed with paragraphs such as data on clean water in Uganda. Firstly, for each theme that is explored, representative quotes can either be provided in text, or additional quotes can be provided in table format (or in an appendix). Secondly, the addition of explanatory data is distracting, and should only be reserved for the discussion section if relevant. The results section should be solely limited to the exploration of themes and presentation of quotes.

Minor comments:

1. There are numerous grammatical and spelling errors throughout the manuscript, and shifting from past tense to present tense within the same paragraph.

2. The authors note that they recruited 30 participants but state that they conducted 31 interviews. This is perhaps a typographical error?

3. Examples of well written qualitative papers exploring similar issues among PWID in low and middle income countries can serve as a guide for how to write this manuscript (see below for some references). Overall it is an important area of study. With more robust recruitment and methodology, this submission can emerge as a much stronger and valuable manuscript in the literature:

Kermode M et al. Harm Reduct J. 2007 Dec 5;4:19. My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India.

Kermode M et al. BMC Int Health Hum Rights. 2013 Jan 29;13:9. Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India.

Reviewer #2: Overall, this work helps fill an important gap in the prevention literature, which is severely lacking for this country. The work is presented cohesively. I do not have any major comments. Minor suggestions regarding syntax and grammar follow below.

Methods:

• Correct “people who used illicit drug use” in the first sentence

• Change “assess” to past tense

• Compound adjectives should be hyphenated. For example, “injection and drug related sexual risk” should be “injection- and drug-related sexual risk”.

• “HIV risky” should be “HIV risk”

Results

• The sentence “As a result, nearly all participants who injected drugs reported sharing injection equipment” is placed a bit prematurely in the paragraph—it only becomes clear why participants were reusing syringes in the following sentences. I would simply remove “As a result” to circumvent this issue. This also prevents repetition of this phrase within the paragraph.

• You may want to consider labelling quotes with “Interviewer” and “Participant ##” at the very least, to help the reader distinguish between speakers. Labelling by participant number also shows the reader that the quotes are not all derived from a small number of participants. There is some labelling throughout the section, but it is inconsistent.

• The paragraph that begins with “In this situation of scarcity” is a run-on sentence. Consider breaking this up into separate sentences to make it more digestible.

• The information about an external study conducted by the UHRN should not be presented in the results section. It can be linked to the results in the discussion section, as appropriate. Similarly, any discussion about the implications of the results, or framing context, should not be introduced in the results section.

• In the sentence which contains “reported returning syringes to users after injecting”, did the authors mean to say that syringes were returned to sellers after injecting?

Discussion/Conclusion

• There are some acronyms used in the conclusion which are not defined anywhere.

• Much of the conclusion seems to be discussion about implications of this research, rather than a conclusion proper. I would suggest restructuring this content so that the conclusion is more succinct, and the discussion includes the implications of this research and suggestions for future work.

**********

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Reviewer #1: No

Reviewer #2: Yes: Alberto Edeza

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Submitted filename: PLosOne December 2 2019.docx

Click here for additional data file.

2 Jan 2020

Thank you for your careful review of our manuscript “Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: A qualitative analysis.” The reviewers thought there was merit in the paper, but suggested a number of revisions which we outline below. Unfortunately, I did not read that we should submit a copy with track changes and one without, so I have highlighted the parts that were changed in the revised manuscript “with tracked changes.” We also address editor comments regarding format, data accessibility and making supplementary material such as interview guides available.

“While I recognize that this is a particularly difficult population to work with, I am not certain why recruitment could not have been more purposive in that only injection drug users were recruited. Instead, it is misleading to state that 30 participants were recruited, and then go on to describe only the experiences of the 17 among them who were actually injecting for some parts of the manuscript and more general experiences of the other users in other parts of the manuscript. Infact this demarcation is not at all clear. It is also unclear if saturation of themes were achieved with these 17 interviews (among injecting PWID), which the authors themselves admit is a limitation. This is a major methodological flaw in the study. Instead the authors should aspire to conduct a more robust qualitative study, recruiting enough injecting (male and female) PWID to explore these areas in detail until saturation of themes is achieved. Respondent driven sampling (which the authors used partially) can be a powerful way to recruit participants. The experiences of male and female PWID also need to be more clearly delineated since there is enough data to suggest that HIV disproportionately affects female PWID. Barriers to receive harm reduction services also differ significantly between male and female PWID. Instead what appears in this manuscript is the experiences of male and female PWID inter-mingled such that the sexual risk behaviors among female PWID (who are also sex workers) is explored in detail, and yet little is known about the sexual risk behaviors of male PWID. The other alternative is to focus exclusively on female PWID (as has been done in other studies in other settings) as a separate manuscript.” We believe that it was important, given the scarcity of knowledge about illicit drug use in Uganda, to include both PWID and PWUD but did not inject. Both groups engaged in sex exchange and other sexual-risk behaviors as we now clarify. The additional risk faced by women PWID and PWUD are in the frequency in which they exchanged sex, as many considered sex work as their main means of support. We believe that we received saturation of themes for injectors and non-injectors, women and men.

Reviewer 1 suggested several improvements in organization, including the following.

“The qualitative methodology needs to be explained in greater detail. Representative questions are presented (and can perhaps be organized under broad headings in a table); however not all questions are sufficiently dealt with in the results. For example, the authors state that they explored transitions to drug use and why injecting did or did not occur but do not describe this in the results.” We have taken out descriptions of questions which were not analyzed or presented in this paper. The entire interview guide is included in supplementary materials.

“Parent and child nodes for coding can be presented in a table.” We have included the coding tree in a Table in the manuscript.

“At the very beginning, in the introduction, a pre-amble can be provided on the following: i) size estimates of PWID in Uganda (at least what is known), ii) existence of syringe exchange programs and opioid agonist therapy services, iii) targeted intervention programs for PWID, iv) voluntary testing and counseling centers, iii) government ART centers. While this data is offered in the manuscript, it is interspersed in the results and discussion. Whereas describing this information at the beginning provides clarity and helps the reader recognize what is available. Subsequent themes on barriers to receive services (including paucity of services) or other factors can then be appreciated in this context. The authors note that a "package of interventions" is recommended for PWID -- indeed, this is also the WHO's recommendation for key populations (given the challenges in reaching and linking such hard to reach populations). Presenting what is available in Uganda, and noting that as is the case in many countries, service delivery to key populations often tends to be fragmented (even if services are available) will offer context as well.” The first paragraph of the paper included the size of the PWID population in Uganda, existence of syringe exchange programs and MAT, and targeted intervention programs for PWID. We have included information on government ART centers and HIV testing through UHRN. We have also described the developmental phase of these programs, and the lack of coordinated services in most LMICs.

“The quotes in the results section are interspersed with paragraphs such as data on clean water in Uganda. Firstly, for each theme that is explored, representative quotes can either be provided in text, or additional quotes can be provided in table format (or in an appendix). Secondly, the addition of explanatory data is distracting, and should only be reserved for the discussion section if relevant. The results section should be solely limited to the exploration of themes and presentation of quotes.” This was also a comment made by Reviewer 2. We have taken out all references to previously published research and implications of results to the Discussion section.

“There are numerous grammatical and spelling errors throughout the manuscript, and shifting from past tense to present tense within the same paragraph.” We have corrected these errors.

“The authors note that they recruited 30 participants but state that they conducted 31 interviews. This is perhaps a typographical error?” Indeed, this was a typographical error. We conducted 30 interviews and this is now consistent throughout.

“Examples of well written qualitative papers exploring similar issues among PWID in low and middle income countries can serve as a guide for how to write this manuscript (see below for some references). Overall it is an important area of study. With more robust recruitment and methodology, this submission can emerge as a much stronger and valuable manuscript in the literature:

Kermode M et al. Harm Reduct J. 2007 Dec 5;4:19. My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India.

Kermode M et al. BMC Int Health Hum Rights. 2013 Jan 29;13:9. Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India.”

We thank the reviewer for this suggestion and carefully read the manuscripts.

From Reviewer 2:

“Methods:

• Correct “people who used illicit drug use” in the first sentence

• Change “assess” to past tense

• Compound adjectives should be hyphenated. For example, “injection and drug related sexual risk” should be “injection- and drug-related sexual risk”.

• “HIV risky” should be “HIV risk”

We have made all these changes.

Results

• The sentence “As a result, nearly all participants who injected drugs reported sharing injection equipment” is placed a bit prematurely in the paragraph—it only becomes clear why participants were reusing syringes in the following sentences. I would simply remove “As a result” to circumvent this issue. This also prevents repetition of this phrase within the paragraph.

We have followed this suggestion.

• You may want to consider labelling quotes with “Interviewer” and “Participant ##” at the very least, to help the reader distinguish between speakers. Labelling by participant number also shows the reader that the quotes are not all derived from a small number of participants. There is some labelling throughout the section, but it is inconsistent.

We have followed this suggestion and include Participant ID numbers to distinguish participants.

• The paragraph that begins with “In this situation of scarcity” is a run-on sentence. Consider breaking this up into separate sentences to make it more digestible.

We have broken up this sentence.

• The information about an external study conducted by the UHRN should not be presented in the results section. It can be linked to the results in the discussion section, as appropriate. Similarly, any discussion about the implications of the results, or framing context, should not be introduced in the results section

We have removed all instances of external studies referenced in the results section and moved them to the Discussion. This includes the information about water quality, the effectiveness of peer led interventions as well as the UHRN study mentioned.

• In the sentence which contains “reported returning syringes to users after injecting”, did the authors mean to say that syringes were returned to sellers after injecting?

Yes, we have corrected this mistake.

Discussion/Conclusion

• There are some acronyms used in the conclusion which are not defined anywhere.

• Much of the conclusion seems to be discussion about implications of this research, rather than a conclusion proper. I would suggest restructuring this content so that the conclusion is more succinct, and the discussion includes the implications of this research and suggestions for future work.

We have moved much of what was formerly in conclusions to the discussion section as the information in conclusions discussed implications of findings. We have also defined all acronyms. The conclusion now only contains a brief summary of findings.

We hope that these changes adequately address reviewers’ concerns.

Sincerley,

Julia Dickson-Gomez

Professor of Epidemiology

Institute for Health and Equity

Medical College of Wisconsin

Submitted filename: PLOS revision letter.docx

Click here for additional data file.

23 Jan 2020

PONE-D-19-30396R1

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda:  A qualitative analysis

PLOS ONE

Dear Dr. Dickson-Gomez,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Mar 08 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dr Dickinson-Gomez and colleagues have submitted a revised manuscript that explores injection and sexual risk behaviors, and access of harm reduction services among people who use drugs in Uganda. Overall, this revised version is an improvement from the initial submission.

However, I do think that the manuscript warrants at least another round of major revisions in order to make it both suitable for publication and valuable to readers.

MAJOR Comments:

1. In this revision, the authors have been more transparent about their rationale to recruit both people who inject drugs and people who use drugs; the study also clearly includes both genders which is certainly valuable. In their response to my concern that the small number of participants may not have facilitated achievement of saturation of themes, the author state the following: “We believe that we received saturation of themes for injectors and non-injectors, women and men”. I want to point out that this directly contradicts what they write in the limitations section of this manuscript: “The present study has several limitations including the small sample size characteristic of qualitative studies. Given that not all participants injected drugs, we may not have reached saturation of themes regarding drug injection risks”. Also, I should note that nowhere in their methodology have they stated that they actually continued recruitment till saturation of themes was achieved.

I would suggest the following changes:

a. Small sample sizes are not a characteristic of qualitative studies. There are qualitative studies that include several hundred participants. It is best not to suggest this. What is true however is that, in general most investigators would halt recruitment when they start hearing the same themes (i.e., achieve saturation).

b. So instead of saying “we may not have achieved saturation of themes for certain topics”, and then stating (at least in their response ) that they did in fact achieve saturation, it’s best to perhaps characterize this as an exploratory qualitative study that despite its small numbers offers insights into risk behaviors among people in a neglected key population in need of services. The title of the manuscript can also be reworded as such: “Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: an exploratory qualitative study”.

2. While the results section has been reorganized, I think this section can further be improved. Again, explanations for certain observations is not needed in this section. Please see below for suggestions on how to improve this section.

3. Throughout the manuscript, the term “availability” of harm reduction services is used. I think what the authors are actually assessing is whether PWID accessed harm reduction services. As they state in the introduction, there are few if any harm reduction services that are available. What is also true is that few PWID are actually accessing even the available services.

4. Acronyms are used throughout the manuscript. However, they should be described in full the very first time they are used. Please ensure this is the case. Also, after an acronym is already used, there are places where full forms are still presented – for example: Syringe exchange programs.

MINOR Comments:

1. Abstract:

Background: Suggest modifying last statement as: “The objective of the research was to document injection and other drug related-risk behaviors among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention intervention.

Methods: This section needs more details on qualitative methodology. Again, the term “availability” is used to describe both injecting equipment and harm reduction services. I believe the authors meant to say PWUD/PWID access of harm reduction and drug treatment services.

Results: Should include the demographic characteristics at least briefly – how many were recruited etc. UHRN – acronym is used. Please provide full form following which acronym can be used in the rest of the manuscript.

Conclusions: Comprehensive (?drug use) prevention and treatment services. “Linkage and retention to HIV care” should be reworded for grammar: “ Linkage to and retention in HIV care”.

2. Introduction:

transshipment points: Trans-shipment (with a hyphen)

PEPFAR COP2018 – While many are familiar with PEPFAR, what does COP stand for?

“Most researchers argue that a combination of approaches are needed including: provision of clean syringes through syringe exchange programs (SEPs); frequent HIV testing and linkage to HIV care; antiretroviral therapy initiation after infection to reduce risk of onward transmission through viral suppression; medication assisted therapy; psychosocial support and pre- and post-exposure prophylaxis” : A colon is not needed after including and every point can be separated by commas.

“harm reduction centers to the rest of the country and include MAT, syringe exchange and PrEP”: sentence should be rephrased as “ harm reduction centers to the rest of the country that include services such as MAT, syringe exchange and PrEP.

“The current study presents results from qualitative interviews with 30 people in Kampala, Uganda who use injection and non-injection drugs to determine their behavioral risks for HIV and the availability of resources to reduce the harms associated with injection such as clean syringes, non-pharmaceutical drug treatment, condoms and HIV testing”. I am not sure what non-pharmaceutical drug treatment actually means? Buprenorphine for example is a pharmaceutical drug and is used in MAT programs.

“We include both people who inject drugs (PWID, n=17) and people who use drugs (PWUD) but do not inject (n=14), because while injection with contaminated syringes is one of the most efficient ways to become infected with HIV, PWID and PWUD can be at risk for becoming infected through highrisk sexual behaviors. In addition, PWID and PWUD often are parts of the same drug using networks”. This should be moved to methods.

3. Eligibility criteria and interview sampling characteristics

“We purposively oversampled to include more women than in the general drug using population, and injection and non-injection users and from each community”. This sentence is not clear and am not sure what this is supposed to mean. With overall small sample, I am not sure this is accurate either.

4. In-depth interview procedures and content:

“any experiences with harm reduction services such as clean needles and HIV testing”: I think the authors meant to say, “harm reduction services such as SEP and HIV testing”.

5. Qualitative analysis: The coding tree while helpful has some categories that clearly are based on the interview guide, and other terms that appear more random.

6. Results:

This section should just start with the descriptive details of patient characteristics. Other sections go on to elaborate on the various risk behaviors – so a summary does not need to be provided here.

Headings need to be broader and consistent with what you sought out to explore. For example, Syringe sharing, use of unclean water/ mixing practices will fall under a broader category of Injection related risk behaviors.

This entire section is written in present tense and is not consistent with the tense used in the rest of the manuscript

There are some typographical errors: “Some PWID sterilized their water for injecting by boiling it themselves, getting in pre-boiled from their dealers, or purchasing sterile water from pharmacies”. I think the authors meant to say “getting it pre-boiled”.

Again, please avoid providing explanations or consequences in the results section. For example: “If drugs, syringes, or spoons are shared after mixing drugs with blood, the risk for contracting HIV/HCV is high”.

Harm reduction services: There is suddenly a mention of an individual by name of “Ronald”—I am presuming that this was actually participant 7 who is identified as a peer syringe distributer and then is mentioned as being Ronald. It may suffice to just state that those who were peer educators experienced benefits without having to name Ronald.

Overdose prevention: “Workers at the UHRN and participants confirmed high rates of overdose from heroin use”. Theoretically, workers at UHRN were not part of this study, unless they also participated in interviews. It may be better to present overdose data collected by UHRN in the discussion if available and stick to just participant descriptions in this section

Quitting or reducing drug use: “In part this may because people who use drugs have not been given information about drug treatment, either through MAT, or by coping with withdrawal and cravings in the case of cocaine addiction”. This sentence is grammatically incorrect.

7. Discussion:

“While harm reduction efforts have mainly focused on PWID in the developing world, injecting with contaminated water may increase the risk of abscesses, sepsis, endocarditis or other infections associated with injection” – This is a repetition (already mentioned earlier in the paragraph).

Reviewer #2: Dear Author,

This manuscript presents a significant contribution to the literature around injection-related risk behaviors for HIV and other blood borne pathogens among PWID and PWUD in Uganda. As a formative study, this qualitative work paints a broad picture of the context of drug use among some PWID and PWUD in Uganda, and clearly delineates avenues that should be pursued in further work. The authors addressed all of my comments. I recommend that the manuscript be accepted.

A small note--during proofing, in the first sentence of the conclusion, change 'in' to 'is'.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Alberto Edeza

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

18 Feb 2020

Dear Dr. Msafirir Francis and Reviewers,

Thank you for your careful review of the paper which was found to be improved but still in need of some clarification, particularly with regards to whether we achieved data saturation. We agree with Reviewer 1’s comments and do not claim to have reached data saturation and changed the title and limitations accordingly. We have also included access as well as availability of harm reduction materials where appropriate and corrected typos and grammatical errors.

In this revision, the authors have been more transparent about their rationale to recruit both people who inject drugs and people who use drugs; the study also clearly includes both genders which is certainly valuable. In their response to my concern that the small number of participants may not have facilitated achievement of saturation of themes, the author state the following: “We believe that we received saturation of themes for injectors and non-injectors, women and men”. I want to point out that this directly contradicts what they write in the limitations section of this manuscript: “The present study has several limitations including the small sample size characteristic of qualitative studies. Given that not all participants injected drugs, we may not have reached saturation of themes regarding drug injection risks”. Also, I should note that nowhere in their methodology have they stated that they actually continued recruitment till saturation of themes was achieved.

I would suggest the following changes:

a. Small sample sizes are not a characteristic of qualitative studies. There are qualitative studies that include several hundred participants. It is best not to suggest this. What is true however is that, in general most investigators would halt recruitment when they start hearing the same themes (i.e., achieve saturation).

b. So instead of saying “we may not have achieved saturation of themes for certain topics”, and then stating (at least in their response ) that they did in fact achieve saturation, it’s best to perhaps characterize this as an exploratory qualitative study that despite its small numbers offers insights into risk behaviors among people in a neglected key population in need of services. The title of the manuscript can also be reworded as such: “Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: an exploratory qualitative study”.

We have made the suggested change in wording in the limitations section and the title of the paper.

While the results section has been reorganized, I think this section can further be improved. Again, explanations for certain observations is not needed in this section. Please see below for suggestions on how to improve this section.. Throughout the manuscript, the term “availability” of harm reduction services is used. I think what the authors are actually assessing is whether PWID accessed harm reduction services. As they state in the introduction, there are few if any harm reduction services that are available. What is also true is that few PWID are actually accessing even the available services.

We have included accessibility along with availability when appropriate. For example, HCV testing and Naloxone is currently not available. Clean syringes, HIV testing and condoms are available but not always accessible or accessed. We have tried to clarify these differences throughout.

Acronyms are used throughout the manuscript. However, they should be described in full the very first time they are used. Please ensure this is the case. Also, after an acronym is already used, there are places where full forms are still presented – for example: Syringe exchange programs.

We have spelled out all acronyms the first time they appear.

MINOR Comments:

Abstract:

Background: Suggest modifying last statement as: “The objective of the research was to document injection and other drug related-risk behaviors among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention intervention.

We have edited the sentence as suggested.

Methods: This section needs more details on qualitative methodology. Again, the term “availability” is used to describe both injecting equipment and harm reduction services. I believe the authors meant to say PWUD/PWID access of harm reduction and drug treatment services.

We mean both availability and accessibility and have included both terms. As stated before, some services are currently not available like MAT, Naloxone, or HCV testing, others are available but so difficult to access as to make them virtually unavailable (e.g. the availability of clean syringes in pharmacies but their unaffordability, and the unavailability of SEPs except for the pilot study.

Results: Should include the demographic characteristics at least briefly – how many were recruited etc. UHRN – acronym is used. Please provide full form following which acronym can be used in the rest of the manuscript.

Demographics of the sample are included in a table. Acronyms are spelled out when first used.

Conclusions: Comprehensive (?drug use) prevention and treatment services. “Linkage and retention to HIV care” should be reworded for grammar: “ Linkage to and retention in HIV care”.

We have corrected this error

Introduction:

transshipment points: Trans-shipment (with a hyphen)

We have corrected this error

PEPFAR COP2018 – While many are familiar with PEPFAR, what does COP stand for?

COP stands for Country Operational Plan. We omitted this since it did not seem necessary for comprehension.

“Most researchers argue that a combination of approaches are needed including: provision of clean syringes through syringe exchange programs (SEPs); frequent HIV testing and linkage to HIV care; antiretroviral therapy initiation after infection to reduce risk of onward transmission through viral suppression; medication assisted therapy; psychosocial support and pre- and post-exposure prophylaxis” : A colon is not needed after including and every point can be separated by commas.

We have made this change.

“harm reduction centers to the rest of the country and include MAT, syringe exchange and PrEP”: sentence should be rephrased as “ harm reduction centers to the rest of the country that include services such as MAT, syringe exchange and PrEP.

We have made this change.

“The current study presents results from qualitative interviews with 30 people in Kampala, Uganda who use injection and non-injection drugs to determine their behavioral risks for HIV and the availability of resources to reduce the harms associated with injection such as clean syringes, non-pharmaceutical drug treatment, condoms and HIV testing”. I am not sure what non-pharmaceutical drug treatment actually means? Buprenorphine for example is a pharmaceutical drug and is used in MAT programs.

Non-pharmaceutical treatment includes Cognitive behavioral therapy, or even self-help groups and 12-step programs. We included these because MAT was not yet available in Uganda.

“We include both people who inject drugs (PWID, n=17) and people who use drugs (PWUD) but do not inject (n=14), because while injection with contaminated syringes is one of the most efficient ways to become infected with HIV, PWID and PWUD can be at risk for becoming infected through highrisk sexual behaviors. In addition, PWID and PWUD often are parts of the same drug using networks”. This should be moved to methods.

We moved this to the Methods Section.

Eligibility criteria and interview sampling characteristics

“We purposively oversampled to include more women than in the general drug using population, and injection and non-injection users and from each community”. This sentence is not clear and am not sure what this is supposed to mean. With overall small sample, I am not sure this is accurate either.

We meant that we recruited both injection and non-injection drug users and attempted to oversample women to get their perspectives. We did not attempt to sample from each community and we have corrected this misunderstanding.

In-depth interview procedures and content:

“any experiences with harm reduction services such as clean needles and HIV testing”: I think the authors meant to say, “harm reduction services such as SEP and HIV testing”.

You are correct and we have made this change.

5. Qualitative analysis: The coding tree while helpful has some categories that clearly are based on the interview guide, and other terms that appear more random.

We now highlight that the coding tree came directly from research questions as well as unexpected themes in the data such as Butabika, the mental hospital where some had received drug treatment, and which was widely feared by drug users. Similarly, we added drug confiscation as this was reported as drug users reported that police frequently confiscated drugs.

6. Results:

This section should just start with the descriptive details of patient characteristics. Other sections go on to elaborate on the various risk behaviors – so a summary does not need to be provided here.

We eliminated a description of the risk behaviors and only include the participant characteristics.

Headings need to be broader and consistent with what you sought out to explore. For example, Syringe sharing, use of unclean water/ mixing practices will fall under a broader category of Injection related risk behaviors.

We have put Syringe Sharing and Use of Unclean Water/Mixing Practices under Injection Risk. We relabeled Sex Exchange and Sex-Related Risk behaviors.

This entire section is written in present tense and is not consistent with the tense used in the rest of the manuscript

Most of the section was written in the past tense with some general statements such as “Naloxone is not currently available” in the present tense. We have corrected the few instances in which this was not the case.

There are some typographical errors: “Some PWID sterilized their water for injecting by boiling it themselves, getting in pre-boiled from their dealers, or purchasing sterile water from pharmacies”. I think the authors meant to say “getting it pre-boiled”.

We believe we have caught and corrected the typographical errors.

Again, please avoid providing explanations or consequences in the results section. For example: “If drugs, syringes, or spoons are shared after mixing drugs with blood, the risk for contracting HIV/HCV is high”.

We have eliminated this.

Harm reduction services: There is suddenly a mention of an individual by name of “Ronald”—I am presuming that this was actually participant 7 who is identified as a peer syringe distributer and then is mentioned as being Ronald. It may suffice to just state that those who were peer educators experienced benefits without having to name Ronald.

Ronald, as mentioned in the original manuscript, was a pseudonym. However, we have changed the quotes to say [UHRN peer educator]. I do not know if Participant 7 and “Ronald” are the same person as we did not collect personal information like names.

Overdose prevention: “Workers at the UHRN and participants confirmed high rates of overdose from heroin use”. Theoretically, workers at UHRN were not part of this study, unless they also participated in interviews. It may be better to present overdose data collected by UHRN in the discussion if available and stick to just participant descriptions in this section

We have made this change.

Quitting or reducing drug use: “In part this may because people who use drugs have not been given information about drug treatment, either through MAT, or by coping with withdrawal and cravings in the case of cocaine addiction”. This sentence is grammatically incorrect.

We have corrected this sentence.

7. Discussion:

“While harm reduction efforts have mainly focused on PWID in the developing world, injecting with contaminated water may increase the risk of abscesses, sepsis, endocarditis or other infections associated with injection” – This is a repetition (already mentioned earlier in the paragraph).

We have eliminated this redundancy.

Reviewer #2: Dear Author,

This manuscript presents a significant contribution to the literature around injection-related risk behaviors for HIV and other blood borne pathogens among PWID and PWUD in Uganda. As a formative study, this qualitative work paints a broad picture of the context of drug use among some PWID and PWUD in Uganda, and clearly delineates avenues that should be pursued in further work. The authors addressed all of my comments. I recommend that the manuscript be accepted.

A small note--during proofing, in the first sentence of the conclusion, change 'in' to 'is'.

We have corrected this typo.

We hope that the revised manuscript has addressed all remaining concerns.

Sincerely,

Julia Dickson-Gomez

Submitted filename: PLOS ONE response to reviewers II.docx

Click here for additional data file.

31 Mar 2020

PONE-D-19-30396R2

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda:   An exploratory qualitative study

PLOS ONE

Dear Dr. Dickson-Gomez,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Thank you very much for working on the suggested revisions. Please kindly address reviewer -1 additional suggestions.

We would appreciate receiving your revised manuscript by May 15 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you very much for working on the suggested revisions. Please kindly address reviewer -1 additional suggestions.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Please see attached document.

I only have minor comments for the authors.

Abstract:

“ Availability and accessibility of syringes” – amended to “ Availability and accessibility of clean needles and syringes”

Introduction:

“While Uganda has been the site of abundant prevention and research efforts” – include the term “ HIV prevention and research efforts”.

“it is one of only two countries in Sub-Saharan Africa (SSA) in which incidence is increasing” – include the term “ HIV incidence”.

“In Kenya, of 101 current injectors, 52.5% were found to be HIV positive, attributed mainly to sharing injection equipment compared to 13.5% of heroin users who had not injected” – include reference

“In 2018, the Kampala Place Study estimated over 18,000 people who inject drugs (PWID) in Uganda” – include reference

“12-step prgrams as MAT was not available at the time of study” – typographical error in programs. “As MAT was not available at the time of study “ should be in parentheses

Methods:

“Some codes, such as Butabika and drug confiscation by police authorities emerged from the interviews and were added after careful reading of transcripts”. This can be re-written to just say that new themes that emerged were included in the final coding scheme.

Results:

Injection risk behaviors:

“In this situation of scarcity, even people who know the risks of sharing and take precautions to protect themselves reported that they would share their used syringes with other users” – modify tense: In this situation of scarcity, even people who knew the risks of sharing and took precautions to protect themselves reported that they would share their used syringes with other users.

“Syringes were also be shared when PWID bought premeasured syringes from drug dealers” – grammatical error. Should be modified as “Syringes were also shared when PWID bought premeasured syringes from drug dealers”.

“Unfortunately, the pilot lasted only a year and funding for it had just ended by the time the interviews for this project were conducted, and many participants reported that they had not seen Ronald or received syringes from him for some time”. Ronald is suddenly introduced here. I think this can just be limited to saying, “Unfortunately, the pilot lasted only a year and funding for it had just ended by the time the interviews for this project were conducted”.

“Some have heard that HIV is no longer a problem because everyone already has it and there is effective medication”. Change to past tense for consistency with rest of paragraph: Some had heard that HIV was no longer a problem because everyone already had it and there was effective medication.

“The woman reported that she “can’t” go because she is too afraid and will only go if she is confronted by symptoms”. Again, change to past tense

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Alberto Edeza

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Plos_one review.docx

Click here for additional data file.

1 Apr 2020

Thank you for the careful reading of the manuscript. We have made all the edits suggested by the reviewer outlined below.

I only have minor comments for the authors. Would recommend that the journal proof-read for grammar and typographical errors.

Abstract:

“ Availability and accessibility of syringes” – amended to “ Availability and accessibility of clean needles and syringes” We have made this change.

Introduction:

“While Uganda has been the site of abundant prevention and research efforts” – include the term “ HIV prevention and research efforts”. We have made this change.

“it is one of only two countries in Sub-Saharan Africa (SSA) in which incidence is increasing” – include the term “ HIV incidence”. We have made this change.

“In Kenya, of 101 current injectors, 52.5% were found to be HIV positive, attributed mainly to sharing injection equipment compared to 13.5% of heroin users who had not injected” – include reference The reference to this is now included.

“In 2018, the Kampala Place Study estimated over 18,000 people who inject drugs (PWID) in Uganda” – include reference We have included the reference.

“12-step prgrams as MAT was not available at the time of study” – typographical error in programs. “As MAT was not available at the time of study “ should be in parentheses. We have fixed the typo and placed the phrase in parentheses.

Methods:

“Some codes, such as Butabika and drug confiscation by police authorities emerged from the interviews and were added after careful reading of transcripts”. This can be re-written to just say that new themes that emerged were included in the final coding scheme. We have rewritten this sentence as suggested.

Results:

Injection risk behaviors:

“In this situation of scarcity, even people who know the risks of sharing and take precautions to protect themselves reported that they would share their used syringes with other users” – modify tense: In this situation of scarcity, even people who knew the risks of sharing and took precautions to protect themselves reported that they would share their used syringes with other users. We have changed the tense.

“Syringes were also be shared when PWID bought premeasured syringes from drug dealers” – grammatical error. Should be modified as “Syringes were also shared when PWID bought premeasured syringes from drug dealers”. We deleted the “be” from the sentence.

“Unfortunately, the pilot lasted only a year and funding for it had just ended by the time the interviews for this project were conducted, and many participants reported that they had not seen Ronald or received syringes from him for some time”. Ronald is suddenly introduced here. I think this can just be limited to saying, “Unfortunately, the pilot lasted only a year and funding for it had just ended by the time the interviews for this project were conducted”. We have ended the sentence where suggested and eliminated the reference to Ronald.

“Some have heard that HIV is no longer a problem because everyone already has it and there is effective medication”. Change to past tense for consistency with rest of paragraph: Some had heard that HIV was no longer a problem because everyone already had it and there was effective medication. We have changed this to past tense.

“The woman reported that she “can’t” go because she is too afraid and will only go if she is confronted by symptoms”. Again, change to past tense. We changed this to past tense as well.

Sincerely,

Julia Dickson-Gomez

Submitted filename: Uganda response to reviewer comments.docx

Click here for additional data file.

6 Apr 2020

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda:   An exploratory qualitative study

PONE-D-19-30396R3

Dear Dr. Dickson-Gomez,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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10 Apr 2020

PONE-D-19-30396R3

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda:   An exploratory qualitative study

Dear Dr. Dickson-Gomez:

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