Public injecting and its association with mental health and other drug-related outcomes among people who inject drugs in Iran.BACKGROUND
 Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID).  We examined the prevalence of public injecting and associations with non-fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.


 Using respondent-driven sampling, we recruited 2684 PWID from 11 major cities between July 2019 and March 2020.  We defined public injecting as injecting primarily in public places, such as streets, parks, or abandoned buildings.  Multivariable logistic regression models assessed public injecting and its associated factors, as well as the association of public injecting with certain health outcomes.


 RESULTS
 Of 2388 respondents, 69.6 % reported public injecting in the previous year.  Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting.  Compared to PWID who primarily inject in non-public places, PWID who mostly used public places had significantly greater odds of reporting non-fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.


 These results suggest the potential utility of a safer injecting environment to mitigate the multiple harms associated with public injecting in Iran.  Optimizing health and well-being of PWID necessitates integrating supervised injection facilities into the current harm reduction programs and services in Iran.  Future studies should also consider the experiences of additional mental health harms associated with public injecting when exploring adverse health outcomes among PWID.
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Public injecting and its association with mental health and other drug-related outcomes among people who inject drugs in Iran.BACKGROUND
 Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID).  We examined the prevalence of public injecting and associations with non-fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.


 Using respondent-driven sampling, we recruited 2684 PWID from 11 major cities between July 2019 and March 2020.  We defined public injecting as injecting primarily in public places, such as streets, parks, or abandoned buildings.  Multivariable logistic regression models assessed public injecting and its associated factors, as well as the association of public injecting with certain health outcomes.


 Of 2388 respondents, 69.6 % reported public injecting in the previous year.  Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting.  Compared to PWID who primarily inject in non-public places, PWID who mostly used public places had significantly greater odds of reporting non-fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.


 CONCLUSION
 These results suggest the potential utility of a safer injecting environment to mitigate the multiple harms associated with public injecting in Iran.  Optimizing health and well-being of PWID necessitates integrating supervised injection facilities into the current harm reduction programs and services in Iran.  Future studies should also consider the experiences of additional mental health harms associated with public injecting when exploring adverse health outcomes among PWID.
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