Drug injection rates and needle-exchange use in New York City, 1991-1996

Factors Associated with HIV Seroprevalence among Participants Enrolling at a Needle Exchange Program

The purpose of this study was to identify HIV risk factors associated with participants who were HIV seropositive at Needle Exchange Program (NEP) entry. A sample of injection drug users (IDUs) who enrolled in an NEP between 1994–1997 were recruited into a prospective study and tested for HIV antibodies. Demographic and recent drug use characteristics were collected. Logistic regression models were constructed to identify factors associated with HIV-seropositive status at NEP entry. Of 811 evaluation participants, 87% were African American, 67% were male, and 30% were HIV seropositive. The multivariate model indicated that daily cocaine injection (Adjusted OR (AOR)=1.98), daily speedball injection (AOR=2.36), daily heroin injection (AOR=0.55), cohabitation with someone (AOR=0.7), and employment (AOR=0.4) were all significantly associated with HIV seroprevalence at NEP entry (p<0.05). These findings indicate that HIV-seropositive individuals entering NEP practice particularly risky behaviors and are more likely to need help in order to minimize the harm of drugs and HIV infection than their HIV-seronegative counterparts.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

Psychiatric comorbidity is associated with drug use and HIV risk in syringe exchange participants

The present study evaluated the effects of psychiatric comorbidity on substance use disorder prevalence, HIV risk behavior, and other problem severity in male and female out-of-treatment injection drug users newly registered at a syringe exchange program. Participants (N = 338) were administered the Structured Clinical Interview for the DSM-IV, the Addiction Severity Index, and the Risk Assessment Battery, and classified into one of four diagnostic groups: (1) no antisocial personality disorder (APD) or Axis I psychiatric disorder (N = 162), (2) APD only (N = 74), (3) Axis I psychiatric disorder only (N = 55), or (4) APD plus Axis I psychiatric disorder (N = 47). Psychiatric comorbidity was associated with higher rates of substance use disorder and more HIV risk and other problem severity. In general, participants with both APD and an Axis I disorder exhibited the most problem severity. APD was uniquely associated with higher prevalence for each substance use disorder assessed in this study and with elevated HIV risk. These results support and extend studies conducted with opioid-dependent individuals recruited from treatment and community settings, and reinforce the need to develop interventions to encourage syringe exchange program participants to enroll in treatment.

Evaluation of Needle Exchange Programs

Needle exchange programs exist in every major population area in the United States and in many other countries. Some operate legally under emergency health decrees issued by local departments of health, with the stated intention of risk reduction through the removal of used injection equipment from use by injection drug users. It is theorized that this results in a reduced transmission of human immunodeficiency virus, hepatitis, and, possibly, other blood-borne diseases. Needle exchange programs also offer access to drug treatment programs for the participants. It is a difficult but necessary task to evaluate these programs. This article examines examples of evaluations attempted in the past and discusses the challenges of such evaluations. Experimental evaluations, economic program analysis, legal aspects, and risk-benefit assessment along with ethical aspects are considered. An outline of program evaluation is proposed. Needle exchange programs offer an opportunity to encourage risk reduction and to offer counseling and access to health care for individuals at high risk. It is essential that such programs demonstrate their effectiveness. Assumptions of efficacy are insufficient for health care in the twenty-first century.