Table 2.

Policy, practice and research implications indicated in included studies and organised by health programme or service

Health programme/service	Policy and practice implications	Gaps and research implications
Services providing testing, prevention or treatment with antivirals for HIV or HCV	Address social and structural factors that impede HIV and HCV testing, treatment initiation and adherence. Scale up ART, TasP, testing and care linkages. Increase targeted approaches to reach marginalised PWID (eg, females and sex workers). Create policies to support MOUD services to promote inclusive HIV treatment and to improve HCV adherence. Suggested strategies to improve treatment adherence include: Improved housing stability for PWID, supportive housing models with harm reduction services. Integrated, multidisciplinary care to manage comorbid conditions and reduce barriers.	Research reasons for treatment discontinuation, factors associated with adherence and the effect of incarceration on HIV treatment adherence and access. Understand how stigma and marginalisation create barriers in accessing treatment. Evaluate interventions like integrated, multidisciplinary HIV and HCV care, supportive housing models and addiction treatments. Determine the optimal timing of treatment for PWID receiving MOUD and how these programmes affect antiviral treatment and access. Develop community-based testing initiatives that use peers to reach PWID who may not seek testing and treatment in conventional healthcare settings.
Supervised injection facilities	Use of SIFs to deliver a wider range of services (eg, HIV testing and treatment). Consider risk perceptions and priorities of PWID when designing harm reduction interventions. Amend legislation to create a more enabling environment for SIFs. Community support is fundamental for sustaining a SIF operation.	Collect geographically specific and up-to-date data to inform policy. Understand harm reduction needs of PWID in private residences and social determinants of IDU. Research individual or context-specific barriers and reasons for not accessing SIF services. Research social and behavioural effects of SIFs (eg, sharing practices). Gap in understanding needs and use of SIFs by street-involved youth. Further evaluation of SIFs: Develop and implement monitoring and evaluation programmes for SIFs. Consider more potential benefits in cost–benefit analysis (eg, diagnostics, immunisation, referral to detoxification facilities, decreased use of other medical services, expansion of services and increased operating hours). Consider intermediate outcomes (eg, changes in injecting practices) with epidemiological data due to challenge in evaluating an intervention without a traditional control group.
Medication treatment for opioid use disorder (MOUD)	Expansion of MOUD and harm reduction services by addressing system-level factors: Decriminalisation policies. Accessibility and funding. Decrease barriers that limit physicians’ ability to prescribe these medications. Enhance physician education in providing these services. Improve referral systems. Develop new pharmacotherapies for opioid use disorder. Integrate MOUD services with infectious disease care and addiction treatment. Include PWID in policy-making surrounding the availability and delivery of MOUD services, including the expansion of these services as harm reduction in hospitals.	Assess the impact of MOUD in combination with other harm reduction services and counselling and effects on infectious disease care. Need experimental designs. Studies need to assess impact of MOUD for certain population groups (eg, women). Explore perspectives of hospital staff regarding care of PWID and integration of harm reduction services into hospitals.
Integrated infectious disease and addictions services	Collaborative, multidisciplinary models, which include counselling and/or peer-based support groups extend beyond virological outcomes to improve social determinants of health.	Examine the impact of policy change on uptake of HCV and/or HIV treatment and care among PWID. Research the impact of diverse, innovative, integrated delivery strategies to improve uptake of HCV and/or HIV care in PWID. Investigate which aspects of care are likely to support changes in drug use patterns. Include individual’s ideas, beliefs and feelings after HCV treatment and reasons for not returning for care, or PWID experiences of effects of integrated care models on health and social inequities.
Needle exchange programmes	Expansion of NEPs and kit distribution programmes, particularly in prisons and hospitals. Decentralise NEPs, promoting peer-run initiatives and diversify distribution methods to reach more marginalised PWID. Include PWID and community members in programmatic decision making and consider local context when initiating NEPs.	Gaps in evaluation of NEPs. Implement ongoing evaluation and monitoring of programmes. Examine different models of distribution across settings and cultural contexts.
Broad harm reduction strategies	Expansion of harm reduction services, increased financial support for these services and their combination with HIV and HCV testing and treatment strategies, equity of access. Advance peer-based models of care. Reassess punitive drug policies. Improve evaluation and monitoring for harm reduction programmes. Support initiatives that address social harms affecting PWID and the social determinants of health. Involve marginalised groups of PWID (eg, youth and Indigenous) in programme planning.	Indigenous people in Canada may lack access to primary care and HCV testing. Since many provinces do not collect ethnicity data, national data on HCV prevalence does not extend to Indigenous communities. Understand HCV prevalence and determinants related to HCV transmission among Indigenous PWID. Understand youth engagement and access to harm reduction services. Examine injection equipment distribution policies and coverage and understand the risks from sharing injection equipment using robust study designs.
Mobile care initiatives and telehealth	Peer-led mobile initiatives play an important role in extending the reach of conventional public health programmes. Important to empower clients to make changes, by providing resources within an atmosphere of mutual respect, education, support, participation, commitment, power sharing. Multidisciplinary telehealth approaches can engage and retain patients in remote areas in the treatment of HCV. Culturally safe interventions that address the barriers to HIV prevention while supporting the strength of populations (eg, young Indigenous people) are urgently needed.	How specific characteristics of mobile outreach programmes may facilitate entry into inpatient addiction treatment or connect women to other services. Methods of including and evaluating community partnering, collaborating in healthcare delivery models for PWID.
Peer-delivered services	Improve delivery of care for PWID and address lack of trust and unfamiliarity with the healthcare system and healthcare professionals. Enable delivery of care and infectious disease prevention efforts to harder-to-reach, more marginalised PWID. Legal and regulatory frameworks need to accommodate assisted injections and consideration for peer-based delivery models.	Need for harm reduction initiatives to assess their accessibility to less autonomous PWID.
Treatment of infective endocarditis	Integrate addiction treatment with infectious disease care.	Gaps in understanding factors associated with PWID mortality.
Other health programmes and services	Increased access to harm reduction and addictions services, urgent primary care, immunisations, ambulatory and integrated care, and stable housing are needed to optimise health outcomes, reduce substance use-related deaths and decrease hospital utilisation. Incorporate mental health interventions with harm reduction services to support behaviour changes.	Further studies on reasons for hospital admissions and ER use in PWID/PLHIV. Determine effectiveness of mental health interventions in the community. Determine effectiveness of interventions in ER settings to prevent further ER visits and admissions.

ART, antiretroviral treatment; ER, emergency room; HCV, hepatitis C virus; IDU, injection drug use; MOUD, medication treatment for opioid use disorder; NEPs, needle exchange programmes; PLHIV, people living with HIV; PWID, people who inject drugs; SIF, supervised injection facility; TasP, treatment as prevention.