Selection effect of needle exchange in Anchorage, Alaska

Trend Analyses of Users of a Syringe Exchange Program in Philadelphia, Pennsylvania: 1999-2014

This study examines trends of injection drug users' (IDUs) use of a Philadelphia, Pennsylvania, syringe exchange program (SEP) from 1999 to 2014, including changes in demographics, drug use, substance abuse treatment, geographic indicators, and SEP use. Prevention Point Philadelphia's SEP registration data were analyzed using linear regression, Pearson's Chi square, and t-tests. Over time new SEP registrants have become younger, more racially diverse, and geographically more concentrated in specific areas of the city, corresponding to urban demographic shifts. The number of new registrants per year has decreased, however syringes exchanged have increased. Gentrification, cultural norms, and changes in risk perception are believed to have contributed to the changes in SEP registration. Demographic changes indicate outreach strategies for IDUs may need adjusting to address unique barriers for younger, more racially diverse users. Implications for SEPs are discussed, including policy and continued ability to address current public health threats.

The Health Benefits of Secondary Syringe Exchange

From a process evaluation, participants in San Francisco's syringe exchange program (SEP) are described. Three groups, primary, secondary, and nonexchangers, were interviewed for a total of 244 study participants recruited from eight needle exchange sessions. Fifty percent of all primary exchangers exchanged for one or more injecting drug user(s) (IDUs). Three general routes of syringe distribution were identified between primary and secondary exchangers: between close friends and lovers; for people who lived in close proximity to them; and with customers who bought drugs from them. Focusing on why some go to SEPs and why some rely on others to go for them, findings are summarized primarily as the barriers for not attending SEPs, including exposure, legal status, illness, drug lifestyle, and conflicts with service provision. The secondary exchangers had similar risk reduction profiles to the SEP users that overall were better than the nonexchangers. For example, they shared syringes and cookers significantly fewer times than nonexchangers. The results demonstrate that these client-provided exchanges enable the SEP to overcome injection drug users' obstacles to program attendance, thereby reaching even hard to access members of IDU populations. We found the effects of these client-provided services to be positive for the larger IDU population.

Treatment readiness, attitudes toward, and experiences with methadone and buprenorphine maintenance therapy among people who inject drugs in Malaysia

BACKGROUND

Little is known about attitudes toward and experiences with opioid maintenance therapy (OMT) among people who inject drugs in Malaysia, a country where people who inject drugs comprise 1.3% of the adult population.

METHODS

In 2010, 460 people who inject drugs in Greater Kuala Lumpur, Malaysia were surveyed to evaluate attitudes toward and experiences with OMT and treatment readiness. Attitudes towards OMT with both methadone and buprenorphine were assessed using an opinions scale. Multivariable linear regression was used to assess correlates of treatment readiness, measured with the 19-item Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES).

RESULTS

All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Few had had previous experience with methadone (9.3%) or buprenorphine (12.6%) maintenance therapy, yet many had used methadone (55.2%) or buprenorphine (51.7%) outside of treatment settings. Fifteen percent had injected buprenorphine in the past month, and of the few that were currently receiving buprenorphine maintenance therapy, almost all were injecting it. The majority of subjects exhibited a moderate level of treatment readiness and a preference for methadone over buprenorphine. Those with low treatment readiness scores were more likely to have previous experience with compulsory drug detention centers (p<0.01), needle/syringe exchange programs (p<0.005), or be of Indian ethnicity (p<0.001). Past use of methadone (p<0.01), older age (p<0.001), higher stress symptom severity (p<0.001), and sharing of needles or syringes (p<0.05) were associated with higher treatment readiness scores.

CONCLUSION

There are suboptimal levels of OMT experience among people who inject drugs that may be improved by addressing factors that influence patient attitudes. Those individuals with moderate treatment readiness may be targeted by brief motivational and cognitive interventions in primary care, prisons or OMT clinics aimed at improving entry into and retention in treatment.

Greater drug injecting risk for HIV, HBV, and HCV infection in a city where syringe exchange and pharmacy syringe distribution are illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004-2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU's used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs.

An evaluation of needle exchange programmes in China

OBJECTIVES

To provide an overview of needle exchange programme (NEP) models used in China and factors associated with their use by injecting drug users (IDU).

DESIGN

A cross-sectional survey.

METHOD

Fifteen NEP in Sichuan and Guangxi provinces were selected for study. The managers were asked to complete a short questionnaire and participate in an interview about the services offered, including needle turnover rates, number of clients, and use of peer educators. The local senior police officers were interviewed for their points of views about NEP. Finally, drug users using the NEP and those residents in compulsory detoxification centres were surveyed about using NEP services.

RESULT

The NEP offered services during normal working hours and used peer educators to do additional exchanging that involved secondary exchangers in the community. Needle turnover ranged from 70.1% to over 100%. Most attendees (82.3%) knew about the service through friends, but only 7.3% of local IDU were using the services. Peer educators could get almost all the needles they needed, but secondary exchangers could only get approximately two-thirds of their required needles. NEP attendees were more frequent injectors and had a higher education than non-attendees. Needle turnover was higher when peer educators had a higher wage and when local police were supportive of the programme.

CONCLUSION

NEP are improving in terms of needle turnover and attendance. Greater cooperation from police, higher wages for peer educators, and wider awareness of the programmes among IDU are needed to increase coverage.

Needle Exchange and Injection-Related Risk Behaviors in Chicago

OBJECTIVE

To examine whether needle exchange program (NEP) use by injecting drug users (IDUs) affects injection risk behaviors over time.

METHODS

Between 1997 and 2000, 901 IDUs in Chicago were recruited for a cohort study from a multisite NEP and an area with no NEP. Participants were interviewed and tested for HIV at baseline and 3 annual follow-ups. Non-NEP users received HIV prevention services consistent with the Indigenous Leader Outreach Model. Random-effect logistic models were used to compare 5 injection-related risk behaviors between NEP users and nonusers.

RESULTS

The 30-day prevalence of receptive needle sharing decreased from 27.6% at baseline to 10.0% at visit 4 in NEP users and from 47.1% to 20.0% in nonusers. Similar patterns were observed for lending used needles, and NEP users were less likely to reuse their own needles. In multivariate analyses, NEP use was significantly associated with reduced odds of greater than 60% for receptive needle sharing, 45% for lending used needles, and 30% for sharing other injection paraphernalia as well as approximately a 2-fold increase in the odds of always bleaching used needles.

CONCLUSIONS

NEP use facilitates long-term reductions in injection risk practices, and the reductions are in addition to the effects of a behavioral intervention alone.

Cessation of injection drug use and change in injection frequency: the Chicago Needle Exchange Evaluation Study

AIMS

To examine the effect of a needle exchange program (NEP) on incidence of injection cessation and change in injection frequency; to explore predictors for injection cessation and change in injection frequency; and to assess whether injection quitters transitioned to non-injected drug use.

DESIGN AND SETTING

Between 1997 and 2002, 901 injection drug users (IDUs) were recruited from an NEP program or an area with no NEP in Chicago, Illinois, interviewed for drug use behaviors, tested for HIV and followed for three annual visits. All participants were exposed to prevention services targeting HIV and drug abuse.

MEASUREMENTS

Injection cessation was defined as no injection drug use since the last interview, and changes in the number of injections in a typical month were examined.

FINDINGS

Sixteen per cent of study participants reported stopping injection for a median duration of 16 months, and most of them also ceased rather than initiated the use of non-injected drugs. Those who continued injecting reduced their injection frequency by 12% per year, on average. Independent predictors of injection cessation were infrequent injection at baseline, younger age and injecting with others. NEP use was not associated with injection cessation and change in injection frequency.

CONCLUSION

These results did not support the hypothesis that NEP use influences the frequency of injection over time. One-sixth of IDUs stopped injection for more than 1 year, providing a substantial window for relapse prevention interventions.

Health services usage by Alaskan injection drug users

OBJECTIVES

The purpose of this study was to explore health services usage among injection drug users in Anchorage, Alaska.

DESIGN

645 participants were recruited as part of a federally funded study of needle exchanges. They completed a health services usage questionnaire that elicited information on use of a health care provider (physician or nurse) and emergency room services. Chi-square and t-tests were used for the bivariate analyses, and multiple logistic regression was used to develop the final predictive models.

RESULTS

The majority of respondents (n = 646) were male (77 percent). Race/ethnicity included 58 percent White, 22 percent Alaska Native, and 20 percent African American. The multivariate model predicting accessing a health care provider (HCP) included ever having had chlamydia (OR 2.7, CI 1.6, 4.5), current income from welfare or public assistance (OR 2.6, CI 1.7, 3.9), current income from disability (OR 5.0, CI 2.2, 11.4), current income from SSI (OR .30, CI .12, .77) and the number of days in the last 30 used opiates other than heroin (OR 1.04, CI 1.002, 1.078). The multivariate model predicting use of an emergency room (ER) was similar to that predicting use of an HCP, with the additional finding of a negative association between being African American and ER use.

CONCLUSION

The role of public assistance benefits enabling access to health care for IDUs has policy implications. Large public programs, such as the Indian Health Service, paid for much of the health care received by the IDUs recruited as part of this study.

Drug use and HIV risk practices of secondary and primary needle exchange users

This study examines HIV risk practices associated with secondary needle exchange, obtaining needles from a needle exchange program (NEP) through others who attend in person. We analyzed data from NEP logs, a survey and HIV testing from 901 drug injectors who (a) always visited NEPs themselves to get needles (primary-only NEP users), (b) obtained at least some NEP needles by having others exchange for them (mixed/secondary NEP users), and (c) obtained no needles from an NEP. About 22% of 40,000 NEP visits involved secondary exchanges, and these accounted for over half of all needles exchanged. In multiple logistic regression analyses, primary-only needle exchange was significantly associated with lower levels of receptive needle sharing, backloading, sharing other injection equipment and lending used needles, and positively associated with obtaining drug treatment. Mixed/secondary needle exchange was associated with less receptive needle sharing and a greater likelihood of drug treatment. Secondary exchange facilitated HIV risk reduction but the salutary effects of NEPs were attenuated in mixed/secondary exchangers.

HIV Risk Practices Among Needle Exchange Users and Nonusers in Chicago

OBJECTIVES

To assess associations between needle exchange program (NEP) use and drug injection risk practices.

METHODS

Between 1997-2000, injecting drug users (IDUs) in Chicago were recruited from NEPs and an area with no NEP, interviewed about risk practices, and counseled and tested for HIV. The risk practices of "regular NEP users"--those who obtained at least half of their needles from an NEP (n = 558)--were compared with those of IDUs who did not use an NEP (n = 175).

RESULTS

In multivariate analysis, regular NEP users, compared with NEP nonusers, were less likely to receptively share needles (adjusted odds ratio [AOR], 0.30; 95% CI, 0.19-0.46); lend used needles (AOR, 0.47; 95% CI, 0.31-0.71); share cookers (AOR, 0.39; 95% CI, 0.25-0.61), cottons (AOR, 0.48; 95% CI, 0.32-0.72), or water (AOR, 0.41; 95% CI, 0.27-0.63); or use a needle for >1 injection (0.15; 95% CI, 0.08-0.27). Among those who shared needles, regular NEP users were significantly more likely to do so for a smaller proportion of injections, with fewer partners and persons socially closer, and to have always bleached used needles before injecting.

CONCLUSIONS

Regular NEP use is associated with less frequent and lower risk HIV injection risk practices.

Needle exchange and injection drug use frequency: a randomized clinical trial

Despite a lack of evidence that needle exchange programs (NEPs) cause an increase in injection drug use, there are still concerns over fostering increased injection behavior with NEPs. The design was a randomized controlled trial conducted from May 1997 to June 2000 comparing injection drug users (IDUs) who are randomly assigned to have access to an NEP versus training in how to purchase needles and syringes (NS) at pharmacies. Of 653 IDUs recruited into the study, 600 were randomized: 426 were followed-up at 6 months, and 369 were followed-up at 12 months. Four hundred ninety were followed up at least once. There was no difference in the number of injections over time between the NEP and the Pharmacy Sales arms of the study or in the percentage of positive urine test results over time between the NEP and the Pharmacy Sales arms of the study for morphine and amphetamine. The decrease in the presence of cocaine was marginally greater between the arms of the study. The results do not support the hypothesis of NEPs causing an increase in injection drug use. This clinical trial provides the strongest evidence to date that needle exchanges do not produce this negative effect.