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Bartholomew TS, Patel H, McCollister K, Feaster DJ, Tookes HE. Implementation and first-year operating costs of an academic medical center-based syringe services program. Harm Reduct J 2021; 18:116. [PMID: 34798887 PMCID: PMC8602990 DOI: 10.1186/s12954-021-00563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/29/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Syringe services programs (SSPs) remain highly effective, cost-saving interventions for the prevention of blood-borne infections among people who inject drugs. However, there have been restrictions regarding financial resources allocated to these programs, particularly in the US South. This study aimed to provide cost data regarding the implementation and first-year operations of an academic-based SSP utilizing fixed and mobile strategies, including the integration of onsite wound care. METHODS We conducted a micro-costing study that retrospectively collected detailed resource utilization and unit cost data for both the fixed and mobile SSP strategies, including onsite wound care, from both healthcare and societal perspectives. A three-step approach was used to identify, measure, and value intervention costs, and cost components were categorized into implementation, variable program, and time-dependent costs. Sensitivity analysis was performed to examine the impact of SSP operational changes (i.e., needs-based distribution and opt-out HIV/HCV testing) on the cost-per-participant. Cost data we presented as overall cost and cost-per-participant adjusted to 2017 US dollars. RESULTS A total of 452 and 129 participants enrolled in fixed and mobile SSP services, respectively. The total cost associated with implementation and first year operations for the fixed site was $407,217.22 or $729.72 per participant and $311,625.52 or $2415.70 per participant for the mobile unit. The largest cost component for both modalities was time-dependent costs (personnel and overhead), while intervention materials (syringes, injection equipment, naloxone) were less than 15% of the total program cost. DISCUSSION/CONCLUSION Implementation and operation of new SSP models continue to be low cost compared to treatment for the multitude of harms PWID face without access to evidence-based prevention. Future cost-effectiveness and cost-benefit analyses integrating a comprehensive SSP model within an academic institution, including onsite wound care and other medical services, will provide a more comprehensive understanding of this model, and state-level policy action must be taken to lift the prohibition of state and local funds for the implementation, sustainability, and maintenance of these programs in Florida.
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Affiliation(s)
- Tyler S Bartholomew
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, 1120 NW 14th St, Miami, FL, 33136, USA.
| | - Hardik Patel
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Kathryn McCollister
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, 1120 NW 14th St, Miami, FL, 33136, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, 1120 NW 14th St, Miami, FL, 33136, USA
| | - Hansel E Tookes
- Department of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, FL, USA
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Parker MA, Zoh RS, Nelson EJ, Owora AH. Correlates of disparities in syringe return ratios: A cross-sectional study of a syringe services program in New York. J Subst Abuse Treat 2020; 121:108193. [PMID: 33357603 DOI: 10.1016/j.jsat.2020.108193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/07/2020] [Accepted: 11/01/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Predictors of syringe exchange behavior are critical to informing secondary prevention measures needed to attenuate risk of blood-borne infections among persons who inject drugs (PWID). METHODS Participants included PWIDs who attended a syringe services program in New York from 2015 to 2017 (n = 1777). We analyzed the syringe return ratio (receipts/returns) with two distinct but related methodological strategies-threshold logistic regression and quantile regression-to identify correlates of disparities in syringe return ratios. RESULTS The majority of participants were white males negative for HIV (90% white, 63% male, 76% HIV-). Logistic and quantile regression models showed that the correlates of disparate syringe return ratios (i.e., magnitude and directionality of differences) changed across different percentile groups and quantile levels, respectively. At the median threshold, being single, urbanicity, and older age were associated with higher return ratios. Syringe return ratio disparities were more pronounced among subgroups of nontypical PWIDs (with extremely low or high return ratios) especially by urbanicity, race, relationship status, and type of housing. CONCLUSIONS Irrespective of urbanicity classification, correlates of syringe return ratios such as older age, Black race, single relationship status, and unstable housing appear to be critical to informing targeted secondary prevention initiatives that promote harm reduction behavior.
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Affiliation(s)
- Maria A Parker
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Roger S Zoh
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Erik J Nelson
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, United States
| | - Arthur H Owora
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, United States.
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Carico RR, Hussain N, Sheppard J, Thomas CB, Fenerty J. Syringe services programs and real-world research: An overview for pharmacists. J Am Pharm Assoc (2003) 2020; 60:e29-e33. [PMID: 32278515 DOI: 10.1016/j.japh.2020.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To review key arguments supporting and criticizing syringe services programs (SSPs). DATA SOURCES Peer-reviewed literature and publicly available documents. SUMMARY Pharmacy organizations-including the American Pharmacists Association and the American Society of Health-System Pharmacists-have stated that pharmacists should support programs that supply sterile injection materials to persons who use injection drugs. SSPs may include needle exchanges or other programs that meet these aims. Pharmacists should know that observational public health research demonstrates that SSPs can lower the transmission of blood-borne illnesses, improve linkage to care for substance use disorders, reduce health care expenditures, and reduce drug overdoses. Concerns about SSPs and increases in syringe litter or crime have not been borne out by research. Despite these findings and the positions of professional organizations, contemporary research suggests that pharmacists may be reluctant to support SSPs and other programs that would increase supply of sterile injection supplies to their communities. CONCLUSION The review of evidence in this commentary should help pharmacists better understand the evidence in favor of SSPs, the potential criticisms of SSPs, and the reasons that their profession is moving to support these programs.
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Comulada WS, Wynn A, van Rooyen H, Barnabas RV, Eashwari R, van Heerden A. Using mHealth to Deliver a Home-Based Testing and Counseling Program to Improve Linkage to Care and ART Adherence in Rural South Africa. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2020; 20:126-136. [PMID: 30259235 DOI: 10.1007/s11121-018-0950-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Community-based HIV testing and counseling (HTC) programs have become an important part of the healthcare system in South Africa and other low- and middle-income countries with a high HIV prevalence and strained primary healthcare system. Current HTC programs excel at identifying people living with HIV (PLH) but leave gaps in linkage to care and antiretroviral therapy (ART) as most HTC programs do not have the capacity to ensure that linkage has occurred. This article presents the protocol for an mHealth study, that is, pilot testing a mobile platform in KwaZulu-Natal (KZN), South Africa, to improve linkage to care and ART adherence after home-based HTC. Testing data are shared with designated clinics. PLH are identified using fingerprint scans, mobile numbers, or South African IDs. If PLH do not present at a designated clinic after testing HIV positive, study field staff are sent SMS alerts to prompt follow-up visits. Similarly, if PLH do not refill ART prescriptions after their initial 1-month dose runs out, SMS alerts that are sent to field staff. This paper presents the mHealth study protocol and baseline sample characteristics (N = 101 PLH). Analyses will summarize rates of linkage to care and ART prescription refills. Cost-effectiveness analyses will examine the costs and benefits of linkage and ART adherence using our mHealth system. Linkage to care rates will be compared between our study and a historical control, that is, provided by a prior HTC program that was conducted in KZN without our mHealth system (n = 615).
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Affiliation(s)
- W Scott Comulada
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 10920 Wilshire Blvd. Suite 350, Los Angeles, CA, 90024, USA.
| | - Adriane Wynn
- Department of Health Policy Management, University of California, Los Angeles, CA, USA
| | - Heidi van Rooyen
- Human and Social Development Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Ruanne V Barnabas
- Global Health and Medicine, University of Washington, Seattle, WA, USA
| | - Rajeev Eashwari
- eHealth Directorate, KwaZulu-Natal Provincial Department of Health, Durban, South Africa
| | - Alastair van Heerden
- Human and Social Development Research Programme, Human Sciences Research Council, Pretoria, South Africa.,Developmental Pathways to Health Research Unit, School of Community Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Dasgupta S, Broz D, Tanner M, Patel M, Halleck B, Peters PJ, Weidle PJ, O'Donnell J, Amlung J, McAlister C, Chapman E, Bailey A, Burnett J, Duwve J. Changes in Reported Injection Behaviors Following the Public Health Response to an HIV Outbreak Among People Who Inject Drugs: Indiana, 2016. AIDS Behav 2019; 23:3257-3266. [PMID: 31313095 DOI: 10.1007/s10461-019-02600-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A syringe services program (SSP) was established following the Indiana HIV outbreak among persons who inject drugs (PWID) in Scott County. Among Indiana-based PWID, we examined injection behaviors associated with HIV status, SSP use after its establishment, and changes in injection behaviors after the outbreak response. During 2016, we interviewed 200 PWID and assessed injection behaviors before the response by HIV status. We reported injection behaviors prior to the response and used Fisher's exact Chi square tests (P < 0.05) to assess differences by HIV status. Next, among persons who injected both before (July-December 2014) and after (past 30 days) the response, we (1) reported the proportion of persons who used the SSP to obtain sterile syringes, and assessed differences in SSP use by HIV status using Fisher's exact Chi square tests; and (2) compared distributive and receptive sharing of injection equipment and disposal of syringes before and after the outbreak response, and assessed statistical differences using McNemar's test. We also compared injection behaviors before and after the response by HIV status. Injecting extended release oxymorphone (Opana® ER); receptive sharing of syringes and cookers; and distributive sharing of cookers, filters, or water before the response were associated with HIV infection. SSP use was high (86%), particularly among HIV-positive compared with HIV-negative persons (98% vs. 84%). Injection equipment sharing decreased and safe disposal of used syringes increased after the response, especially among HIV-positive persons. Injection equipment sharing contributed to the outbreak. High SSP use following the response, particularly among HIV-positive persons, contributed to decreased high-risk injection practices.
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Affiliation(s)
- Sharoda Dasgupta
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA.
| | - Dita Broz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | - Mary Tanner
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | - Monita Patel
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | | | - Philip J Peters
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | - Paul J Weidle
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | - Julie O'Donnell
- Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joseph Amlung
- Indiana State Department of Health, Indianapolis, IN, USA
| | - Cameron McAlister
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Erika Chapman
- Indiana State Department of Health, Indianapolis, IN, USA
| | - Ayriane Bailey
- Indiana State Department of Health, Indianapolis, IN, USA
| | - Janet Burnett
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | - Joan Duwve
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
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Allen ST, Grieb SM, O'Rourke A, Yoder R, Planchet E, White RH, Sherman SG. Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs. Harm Reduct J 2019; 16:33. [PMID: 31109339 PMCID: PMC6528286 DOI: 10.1186/s12954-019-0305-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/01/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Syringe services programs (SSPs) are evidence-based interventions that are associated with decreases in prevalence and incidence rates of HIV and viral hepatitis among people who inject drugs (PWID). SSPs are also effective conduits to deliver overdose prevention resources among PWID. In December 2015, the Kanawha-Charleston Health Department (KCHD) in West Virginia implemented a SSP; however, the program was indefinitely suspended in early 2018 following policy changes that would have forced the program to operate in ways that conflicted with established best practices. The purpose of this research is to explore the public health implications of the suspension of the KCHD SSP among rural PWID. METHODS We conducted semi-structured interviews with 27 PWID (59.3% male, 88.9% White) to explore access to sterile injection equipment and overdose prevention resources, high-risk injection practices, and HIV risk perceptions following the KCHD SSP suspension. Participants were recruited from street locations frequented by PWID. Interviews were audio-recorded and transcribed verbatim. We employed an iterative, modified constant comparison approach to systematically code and synthesize textual interview data. RESULTS Participants described the KCHD SSP as providing a variety of harm reduction services to PWID and being able to speak honestly with SSP staff about their drug use without fear of stigmatization. The suspension of the KCHD SSP fundamentally changed the public health landscape for PWID, ushering in a new era of increased risks for acquiring bloodborne infections and overdose. PWID described more frequently injecting with used syringes and engaging in a range of high-risk injection practices after the SSP was suspended. PWID also discussed having decreased access to naloxone and being less likely to get routinely tested for HIV following the KCHD SSP suspension. CONCLUSIONS This research demonstrates that the suspension of a SSP in rural West Virginia increased risks for HIV/HCV acquisition and overdose among PWID. The suspension of the SSP led to community-wide decreases in access to sterile injection equipment and naloxone among PWID. The suspension of the KCHD SSP should be viewed as a call to action for sustaining evidence-based interventions in the face of sociopolitical forces that attempt to subvert public health.
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Affiliation(s)
- Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | - Suzanne M Grieb
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA
| | - Allison O'Rourke
- DC Center for AIDS Research, Department of Psychology, George Washington University, 2125 G St. NW, Washington, DC, 20052, USA
| | - Ryan Yoder
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Elise Planchet
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
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Høj SB, Minoyan N, Artenie AA, Grebely J, Bruneau J. The role of prevention strategies in achieving HCV elimination in Canada: what are the remaining challenges? CANADIAN LIVER JOURNAL 2018; 1:4-13. [PMID: 35990720 PMCID: PMC9202798 DOI: 10.3138/canlivj.1.2.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 07/28/2023]
Abstract
BACKGROUND The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern. METHODS This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada. RESULTS A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility. CONCLUSIONS Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.
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Affiliation(s)
- Stine Bordier Høj
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Nanor Minoyan
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Andreea Adelina Artenie
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Jason Grebely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Julie Bruneau
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, Québec, Canada
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8
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Goodin A, Fallin-Bennett A, Green T, Freeman PR. Pharmacists' role in harm reduction: a survey assessment of Kentucky community pharmacists' willingness to participate in syringe/needle exchange. Harm Reduct J 2018; 15:4. [PMID: 29370808 PMCID: PMC5785823 DOI: 10.1186/s12954-018-0211-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/19/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pharmacists' role in harm reduction is expanding in many states, yet there are limited data on pharmacists' willingness to participate in harm reduction activities. This study assessed community pharmacists' willingness to participate in one harm reduction initiative: syringe/needle exchange. METHODS In 2015, all Kentucky pharmacists with active licenses were emailed a survey that examined attitudes towards participation in syringe/needle exchange. Response frequencies were calculated for community pharmacist respondents. Ordinal logistic regression estimated the impact of community pharmacist characteristics and attitudes on willingness to provide clean needles/syringes to people who inject drugs and to dispose of used syringes/needles, where both dependent variables were defined as Likert-type questions on a scale of 1 (not at all willing) to 6 (very willing). RESULTS Of 4699 practicing Kentucky pharmacists, 1282 pharmacists responded (response rate = 27.3%); the majority (n = 827) were community pharmacists. Community pharmacists were divided on willingness to provide clean needles/syringes, with 39.1% not willing (score 1 or 2 of 6) and 30% very willing (score 5 or 6 of 6). Few were willing to dispose of used needles/syringes, with only 18.7% willing. Community pharmacists who agreed that pharmacists could have significant public health impact by providing access to clean needles expressed 3.56 times more willingness to provide clean needles (95% CI 3.06-4.15), and 2.04 times more willingness to dispose of used needles (95% CI 1.77-2.35). Chain/supermarket pharmacists (n = 485, 58.6% of community pharmacies) were 39% less likely to express willingness to dispose of used needles (95% CI 0.43-0.87) when compared with independent community pharmacists (n = 342, 41.4% of community pharmacies). Independent pharmacists reported different barriers (workflow) than their chain/supermarket pharmacist colleagues (concerns of clientele). CONCLUSIONS Kentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.
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Affiliation(s)
- Amie Goodin
- College of Pharmacy, Pharmaceutical Outcomes and Policy, University of Florida, 1225 Center Drive, HPNP 2320, Gainesville, FL, 32610, USA.
| | | | - Traci Green
- Emergency Medicine, Injury Prevention Research Center, College of Medicine, Brown University, Providence, RI, USA
| | - Patricia R Freeman
- Pharmacy Practice and Science, Center for the Advancement of Pharmacy Practice, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLoS Med 2017; 14:e1002312. [PMID: 28542184 PMCID: PMC5443477 DOI: 10.1371/journal.pmed.1002312] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 04/28/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP). METHODS AND FINDINGS We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities. CONCLUSIONS We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.
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Sawangjit R, Khan TM, Chaiyakunapruk N. Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: a systematic review and meta-analysis. Addiction 2017; 112:236-247. [PMID: 27566970 DOI: 10.1111/add.13593] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/26/2016] [Accepted: 08/21/2016] [Indexed: 11/30/2022]
Abstract
AIMS To appraise the evidence critically for effectiveness of pharmacy-based needle/syringe exchange programmes (pharmacy-based NSPs) on risk behaviours (RBs), HIV/HCV prevalence and economic outcomes among people who inject drugs (PWID). DESIGN Systematic review and meta-analysis. SETTING Primary care setting. PARTICIPANTS Of 1568 studies screened, 14 studies with 7035 PWID were included. MEASURES PubMed, Embase, Web of Sciences, CENTRAL and Cochrane review databases were searched without language restriction from their inception to 27 January 2016. All published study designs with control groups that reported the effectiveness of pharmacy-based NSP on outcomes of interest were included. Outcomes of interest are risk behaviour (RB), HIV/hepatitis C virus (HCV) prevalence and economic outcomes. The estimates of pooled effects of these outcomes were calculated as pooled odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. Heterogeneity was assessed by I2 and χ2 tests. FINDINGS Most studies (nine of 14, 64.3%) were rated as having a serious risk of bias, while 28.6 and 7.1% were rated as having a moderate risk and low risk of bias, respectively. For sharing-syringe behaviour, pharmacy-based NSPs were significantly better than no NSPs for both main (OR = 0.50, 95% CI = 0.34-0.73; I2 = 59.6%) and sensitivity analyses, excluding studies with a serious risk of bias (OR = 0.52, 95% CI = 0.32-0.84; I2 = 41.4%). For safe syringe disposal and HIV/HCV prevalence, the evidence for pharmacy-based NSPs compared with other NSP or no NSP was unclear, as few of the studies reported this and most of them had a serious risk of bias. Compared with the total life-time cost of US$55 640 for treating a person with HIV infection, the HIV prevalence among PWID has to be at least 0.8% (for pharmacy-based NSPs) or 2.1% (for other NSPs) to result in cost-savings. CONCLUSIONS Pharmacy-based needle/syringe exchange programmes appear to be effective for reducing risk behaviours among people who inject drugs, although their effect on HIV/HCV prevalence and economic outcomes is unclear.
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Affiliation(s)
- Ratree Sawangjit
- Clinical Pharmacy Research Unit (CPRU), Department of Clinical Pharmacy, Faculty of Pharmacy, Mahasarakham University, Mahasarakham, Thailand.,School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.,Department of Pharmacy, Abasyn University Peshawar, Pakistan
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.,Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Population Health, University of Queensland, Brisbane, Australia.,School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
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11
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Abstract
Syringe exchange programs (SEPs) are effective structural interventions for HIV prevention among persons who inject drugs. In 2000, a buffer zone policy (the 1000 Foot Rule) was implemented in Washington, DC, that prohibited SEP operations within 1000 feet of schools. We examined changes in the amount of legal SEP operational space over time. We used data pertaining to school operations and their approximate physical property boundaries to quantify the impact of the 1000 Foot Rule on legal SEP operational space from its implementation in 2000-2013. Adherence to the 1000 Foot Rule reduced SEP operational space by more than 50 % annually since its implementation. These findings demonstrate the significant restrictions on the amount of legal SEP operational space in Washington, DC, that are imposed by the 1000 Foot Rule. Changing this policy could have a significant impact on SEP service delivery among injectors.
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Affiliation(s)
- Sean T Allen
- Department of Prevention & Community Health, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe St., Room E6534, Baltimore, MD, 21205, USA.
| | - Monica S Ruiz
- Department of Prevention & Community Health, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA
| | - Jeff Jones
- Department of Health Policy & Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, PO Box 8015, Statesboro, GA, 30460, USA
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12
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Linton SL, Cooper HLF, Kelley ME, Karnes CC, Ross Z, Wolfe ME, Chen YT, Friedman SR, Des Jarlais D, Semaan S, Tempalski B, Sionean C, DiNenno E, Wejnert C, Paz-Bailey G. Associations of place characteristics with HIV and HCV risk behaviors among racial/ethnic groups of people who inject drugs in the United States. Ann Epidemiol 2016; 26:619-630.e2. [PMID: 27576908 DOI: 10.1016/j.annepidem.2016.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/18/2016] [Accepted: 07/26/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Investigate whether characteristics of geographic areas are associated with condomless sex and injection-related risk behavior among racial/ethnic groups of people who inject drugs (PWID) in the United States. METHODS PWID were recruited from 19 metropolitan statistical areas for 2009 National HIV Behavioral Surveillance. Administrative data described ZIP codes, counties, and metropolitan statistical areas where PWID lived. Multilevel models, stratified by racial/ethnic groups, were used to assess relationships of place-based characteristics to condomless sex and injection-related risk behavior (sharing injection equipment). RESULTS Among black PWID, living in the South (vs. Northeast) was associated with injection-related risk behavior (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.21-4.17; P = .011), and living in counties with higher percentages of unaffordable rental housing was associated with condomless sex (AOR = 1.02, 95% CI = 1.00-1.04; P = .046). Among white PWID, living in ZIP codes with greater access to drug treatment was negatively associated with condomless sex (AOR = 0.93, 95% CI = 0.88-1.00; P = .038). CONCLUSIONS Policies that increase access to affordable housing and drug treatment may make environments more conducive to safe sexual behaviors among black and white PWID. Future research designed to longitudinally explore the association between residence in the south and injection-related risk behavior might identify specific place-based features that sustain patterns of injection-related risk behavior.
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Affiliation(s)
- Sabriya L Linton
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Hannah L F Cooper
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Mary E Kelley
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Conny C Karnes
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Zev Ross
- ZevRoss Spatial Analysis, Ithaca, NY
| | - Mary E Wolfe
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yen-Tyng Chen
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Samuel R Friedman
- Institute for Infectious Disease Research, National Development and Research Institutes, New York, NY
| | - Don Des Jarlais
- Baron Edmond de Rothschild Chemical Dependency Institute, Mount Sinai Beth Israel, New York, NY
| | - Salaam Semaan
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Barbara Tempalski
- Institute for Infectious Disease Research, National Development and Research Institutes, New York, NY
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13
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Bernard CL, Brandeau ML, Humphreys K, Bendavid E, Holodniy M, Weyant C, Owens DK, Goldhaber-Fiebert JD. Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States. Ann Intern Med 2016; 165:10-19. [PMID: 27110953 PMCID: PMC5118181 DOI: 10.7326/m15-2634] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear. OBJECTIVE To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID. DESIGN Empirically calibrated dynamic compartmental model. DATA SOURCES Published literature and expert opinion. TARGET POPULATION Adult U.S. PWID. TIME HORIZON 20 years and lifetime. INTERVENTION PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage. OUTCOME MEASURES Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years. RESULTS OF SENSITIVITY ANALYSIS Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence. LIMITATION Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited. CONCLUSION PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
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Affiliation(s)
- Cora L. Bernard
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Margaret L. Brandeau
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Keith Humphreys
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Eran Bendavid
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Mark Holodniy
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Christopher Weyant
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Douglas K. Owens
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Jeremy D. Goldhaber-Fiebert
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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14
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Holtgrave DR. HIV Prevention, Cost-Utility Analysis, and Race/Ethnicity: Methodological Considerations and Recommendations. Med Decis Making 2016; 24:181-91. [PMID: 15090104 DOI: 10.1177/0272989x04263342] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this methodological article, the author reviews 1) the disproportionate impact that HIV/AIDS is having on communities of color in the United States, 2) what is known about the cost-effectiveness of HIV prevention interventions for racial/ethnic minority communities (including the methods used in these studies), and 3) the relative lack of methodological guidance in the field for conducting economic evaluation studies specifically for communities of color. The author finds that race/ethnicity affects cost-utility analyses in several heretofore unrecognized ways. In this article, methodological techniques to address these concerns are proposed. In particular, the author recommends cost-utility analytic strategies that maximize comparability among studies and avoid the introduction of methodological discrimination.
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Affiliation(s)
- David R Holtgrave
- Department of Behavioral Science, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
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15
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Allen ST, Ruiz MS, Jones J, Turner MM. Legal space for syringe exchange programs in hot spots of injection drug use-related crime. Harm Reduct J 2016; 13:16. [PMID: 27112328 PMCID: PMC4845437 DOI: 10.1186/s12954-016-0104-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Copious evidence indicates that syringe exchange programs (SEPs) are effective structural interventions for HIV prevention among persons who inject drugs (PWID). The efficacy of SEPs in supporting the public health needs of PWID populations is partially dependent on their accessibility and consistent utilization among injectors. Research has shown that SEP access is an important predictor of PWID retention at SEPs, yet policies exist that may limit the geographic areas where SEP operations may legally occur. Since 2000 in the District of Columbia (DC), SEP operations have been subject to the 1000 Foot Rule (§48-1121), a policy that prohibits the distribution of "any needle or syringe for the hypodermic injection of any illegal drug in any area of the District of Columbia which is within 1000 feet of a public or private elementary or secondary school (including a public charter school)." The 1000 Foot Rule may impede SEP services in areas that are in urgent need for harm reduction services, such as locations where injections are happening in "real time" or where drugs are purchased or exchanged. We examined the effects of the 1000 Foot Rule on SEP operational space in injection drug use (IDU)-related crime (i.e., heroin possession or distribution) hot spots from 2000 to 2010. METHODS Data from the DC Metropolitan Police Department were used to identify IDU-related crime hot spots. School operation data were matched to a dataset that described the approximate physical property boundaries of land parcels. A 1000-ft buffer was applied to all school property boundaries. The overlap between the IDU-related crime hot spots and the school buffer zones was calculated by academic year. RESULTS When overlaying the land space associated with IDU-related crime hot spots on the maps of school boundaries per the 1000-ft buffer zone stipulation, we found that the majority of land space in these locations was ineligible for legal SEP operations. More specifically, the ineligible space in the identified hot spots in each academic year ranged from 51.93 to 88.29 % of the total hot spot area. CONCLUSIONS The removal of the 1000 Foot Rule could significantly improve the public health of PWID via increased access to harm reduction services. Buffer zone policies that restrict SEP operational space negatively affect the provision of harm reduction services to PWID.
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Affiliation(s)
- Sean T. Allen
- />Department of Epidemiology, Johns Hopkins University, 615 N. Wolfe St., Baltimore, MD 21205 USA
| | - Monica S. Ruiz
- />Department of Prevention & Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC 20052 USA
| | - Jeff Jones
- />Department of Health Policy & Management, Jiann-Ping Hsu College of Public Health at Georgia Southern University, PO Box 8015, Statesboro, GA 30460 USA
| | - Monique M. Turner
- />Department of Prevention & Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC 20052 USA
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16
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Abstract
Prior research has explored spatial access to syringe exchange programs (SEPs) among persons who inject drugs (PWID), but these studies have been based on limited data from short periods of time. No research has explored changes in spatial access to SEPs among PWID longitudinally. The purpose of this research is to examine spatial access to SEPs among PWID who accessed services at a SEP in Washington, District of Columbia (DC), from 1996 to 2010. The geometric point distance estimation technique was used to calculate the mean walking distance PWID traveled from the centroid point of their zip code of home residence to the mobile exchange site where they accessed SEP services. Analysis of variance (ANOVA) was used to examine differences in walking distance measures by year. The results of this research suggest that the distance DC PWID traveled to access SEP services remained relatively constant (approximately 2.75 mi) from 2003 to 2008, but increased to just over 4 mi in 2010. This research provides support for expanding SEP operations such that PWID have increased access to their services. Increasing SEP accessibility may help resolve unmet needs among injectors.
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17
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Abstract
Syringe exchange programs (SEPs) lower HIV risk. From 1998 to 2007, Congress prohibited Washington, DC, from using municipal revenue for SEPs. We examined the impact of policy change on IDU-associated HIV cases. We used surveillance data for new IDU-associated HIV cases between September 1996 and December 2011 to build an ARIMA model and forecasted the expected number of IDU-associated cases in the 24 months following policy change. Interrupted time series analyses (ITSA) were used to assess epidemic impact of policy change. There were 176 IDU-associated HIV cases in the 2 years post-policy change; our model predicted 296 IDU-associated HIV cases had the policy remained in place, yielding a difference of 120 averted HIV cases. ITSA identified significant immediate (B = −6.0355, p = .0005) and slope changes (B = −.1241, p = .0427) attributed to policy change. Policy change is an effective structural intervention for HIV prevention when it facilitates the implementation of services needed by vulnerable populations.
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Affiliation(s)
- Monica S Ruiz
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
| | - Allison O'Rourke
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA
| | - Sean T Allen
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA
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18
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Allen ST, Ruiz MS, Roess A, Jones J. Assessing seasonality of travel distance to harm reduction service providers among persons who inject drugs. Harm Reduct J 2015; 12:45. [PMID: 26458881 PMCID: PMC4603974 DOI: 10.1186/s12954-015-0081-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/05/2015] [Indexed: 12/02/2022] Open
Abstract
Background Prior research has examined access to syringe exchange program (SEP) services among persons who inject drugs (PWID), but no research has been conducted to evaluate variations in SEP access based on season. This is an important gap in the literature given that seasonal weather patterns and inclement weather may affect SEP service utilization. The purpose of this research is to examine differences in access to SEPs by season among PWID in the District of Columbia (DC). Findings A geometric point distance estimation technique was applied to records from a DC SEP that operated from 1996 to 2011. We calculated the walking distance (via sidewalks) from the centroid point of zip code of home residence to the exchange site where PWID presented for services. Analysis of variance (ANOVA) was used to examine differences in walking distance measures by season. Differences in mean walking distance measures were statistically significant between winter and spring with PWID traveling approximately 2.88 and 2.77 miles, respectively, to access the SEP during these seasons. Conclusions The results of this study suggest that seasonal differences in SEP accessibility may exist between winter and spring. PWID may benefit from harm reduction providers adapting their SEP operations to provide a greater diversity of exchange locations during seasons in which inclement weather may negatively influence engagement with SEPs. Increasing the number of exchange locations based on season may help resolve unmet needs among injectors.
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Affiliation(s)
- Sean T Allen
- Department of Prevention and Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
| | - Monica S Ruiz
- Department of Prevention and Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
| | - Amira Roess
- Department of Prevention and Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
| | - Jeff Jones
- Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health at Georgia Southern University, PO Box 8015, Statesboro, GA, 30460, USA.
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19
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Yang Y, Latkin CA, Luan R, Yang C. A cross-sectional study of the feasibility of pharmacy-delivered harm reduction services among people who inject drugs in Xichang, China. BMC Public Health 2015; 15:885. [PMID: 26370245 PMCID: PMC4570635 DOI: 10.1186/s12889-015-2236-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 09/07/2015] [Indexed: 12/02/2022] Open
Abstract
Background HIV prevalence is high in Liangshan, China (1.1 %). In 2012, people who inject drugs (PWID) in Xichang, the capital city, contributed to 60.0 % of the HIV infections. The goal of the current study was to examine the feasibility of implementing pharmacy-delivered harm reduction services (PDHRS) for PWID. Methods Face-to-face structured interviews with 403 PWID included questions on PWID’s experiences of syringe services and their specific experiences, acceptance, and potential usage of PDHRS. Results There were some reports of harassment/bad treatment from pharmacists (12.2 %) and police (17.6 %). Non-prescription syringe sales (NPSS) from pharmacies in single piece were the main source (82.1 %) of syringes. 72.5 % of PWID reported visiting 31.5 % of the identified pharmacies. Most (74.7 %) PWID disposed of their used syringes by throwing them away. Only one PWID brought used syringes back to a pharmacy in the past 30 days. Half of the PDHRS, such as printed materials about HIV, Hepatitis C and STIs; risk reduction services; (16.9 %) and sharps container to dispose of syringes (0.2 %) were offered by a few pharmacies (<20 % for each service). The acceptance rates among PWID toward currently offered services were high (≥91.1 %). All potential PDHRS were acceptable by most (68–95.3 %) PWID, and correspondingly 67–94.5 % of PWID reported they would use each service if offered. Conclusions NPSS from pharmacies provided many PWID in Liangshan with new syringes. However, disposal of used syringes was problematic. At the time of investigation, half of 16 assessed PDHRS were already available in pharmacies in Xichang. PWID were ready to use all the potential PDHRS and14 of 16 PDHRS were feasible to provide. HIV testing kits may be available in pharmacies in the future. Many pharmacy-delivered harm reduction services are feasible and acceptable among PWID in Xichang, China.
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Affiliation(s)
- Yi Yang
- Department of Social Medicine and Health Administration, School of Administration, Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Wenjiang District, Chengdu, 611137, China. .,Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St. 2nd FL, Baltimore, MD 21205, USA.
| | - Carl A Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St. 2nd FL, Baltimore, MD 21205, USA.
| | - Rongsheng Luan
- Department of Epidemiology and Biostatistics West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Cui Yang
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St. 2nd FL, Baltimore, MD 21205, USA.
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Jozaghi E. Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection. HEALTH & JUSTICE 2015; 3:16. [PMCID: PMC5151785 DOI: 10.1186/s40352-015-0028-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/17/2015] [Indexed: 07/28/2023]
Abstract
Background Supervised consumption rooms or supervised injection facilities (SIFs) are venues that have reduced the risk of needle sharing and deaths caused by drug overdose among people who inject drugs (PWID). As a result of such a decline in the mortality rate, numerous studies have been able to illustrate its cost-effectiveness. However, studies have neglected to examine the same phenomena for unsanctioned SIFs that are run by peer drug users and provide assisted injections. Methods The current study will determine whether the former unsanctioned SIF, that provided assisted injection and was operated by the grass root organization called Vancouver Area Network of Drug Users (VANDU), cost less than the health care consequences of not having such a program in Vancouver, Canada. By analyzing data gathered in 2013, this paper relies on two mathematical models to estimate the number of new HIV and HCV infections prevented by the former unsanctioned facility in Vancouver’s Downtown Eastside. Results A conservative estimate indicates that the SIF location that provided assisted injections has a benefit-cost ratio of 33.1:1 due to its low operational cost. At the baseline sharing rate, the facility, on an average, reduced 81 HCV and 30 HIV cases among PWID each year. Such reductions in blood borne infections among PWID resulted in annual savings worth CAN$4.3 million dollars in health care expenditure. In addition to this, the current paper relies on a sensitivity analysis based on different needle sharing rate scenarios. Conclusions The sensitivity analysis and the baseline rates indicate that funding SIF facilities operated by peer drug users that facilitate assisted injection appear to be an efficient and effective use of financial resources in the public health domain since they lead to a significant decline in the rate of mortality within a vulnerable population.
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Affiliation(s)
- Ehsan Jozaghi
- School of Criminology, Simon Fraser University, Burnaby, British Columbia Canada
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Tookes H, Diaz C, Li H, Khalid R, Doblecki-Lewis S. A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida. PLoS One 2015; 10:e0129360. [PMID: 26075888 PMCID: PMC4468183 DOI: 10.1371/journal.pone.0129360] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 05/07/2015] [Indexed: 11/30/2022] Open
Abstract
Background Infections related to injection drug use are common. Harm reduction strategies such as syringe exchange programs and skin care clinics aim to prevent these infections in injection drug users (IDUs). Syringe exchange programs are currently prohibited by law in Florida. The goal of this study was to estimate the mortality and cost of injection drug use-related bacterial infections over a 12-month period to the county safety-net hospital in Miami, Florida. Additionally, the prevalence of HIV and hepatitis C virus among this cohort of hospitalized IDUs was estimated. Methods and Findings IDUs discharged from Jackson Memorial Hospital were identified using the International Classification of Diseases, Ninth Revision, codes for illicit drug abuse and endocarditis, bacteremia or sepsis, osteomyelitis and skin and soft tissue infections (SSTIs). 349 IDUs were identified for chart abstraction and 92% were either uninsured or had publicly funded insurance. SSTIs, the most common infection, were reported in 64% of IDUs. HIV seroprevalence was 17%. Seventeen patients (4.9%) died during their hospitalization. The total cost for treatment for injection drug use-related infections to Jackson Memorial Hospital over the 12-month period was $11.4 million. Conclusions Injection drug use-related bacterial infections represent a significant morbidity for IDUs in Miami-Dade County and a substantial financial cost to the county hospital. Strategies aimed at reducing risk of infections associated with injection drug use could decrease morbidity and the cost associated with these common, yet preventable infections.
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Affiliation(s)
- Hansel Tookes
- Department of Internal Medicine, Jackson Memorial Hospital, Miami, Florida, United States of America
- * E-mail:
| | - Chanelle Diaz
- Department of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Hua Li
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Rafi Khalid
- Department of Jackson Health System Research, Jackson Memorial Hospital, Miami, Florida, United States of America
| | - Susanne Doblecki-Lewis
- Department of Internal Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, United States of America
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Yang Y, Latkin C, Luan R, Yang C. Reality and feasibility for pharmacy-delivered services for people who inject drugs in Xichang, China: Comparisons between pharmacy staff and people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 27:113-20. [PMID: 26123897 DOI: 10.1016/j.drugpo.2015.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 03/06/2015] [Accepted: 05/28/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2010, the reported overall HIV prevalence in Liangshan China (1.14%) was 19.7 times of the overall estimated prevalence in China (0.058%), and injection drug use contributed to 60.0% of overall HIV infections in Xichang, the Capital city of Liangshan. With one national methadone clinic and three outpatient service sites, and three NEP sites, the HIV prevalence among people who inject drugs (PWID) in Xichang was estimated as 18.0% (2.8 times of national HIV prevalence among PWID) in 2012. METHODS Face-to-face questionnaire interviews were used in a cross-sectional study to assess experience, attitudes, possibility and acceptability of implementing 8 pharmacy-delivered services among PWID (n=403). The concordance of attitudes, possibility and acceptability between PWID and pharmacy staff (n=50) was examined. RESULTS Rather than medical facility (23.1%), and NEP (8.9%), pharmacies were the main source of syringes for PWID in the last 12 months (82.1%), PWID (63.5%) reported syringes could be bought in single piece and at the price of $0.16 USD (59.3%). In the last 30 days, only 1 PWID brought used syringes back to a pharmacy. Pharmacy staff's attitudes were generally negative but nearly neutral (average score -0.18), discrimination/business concerns against pharmacy-delivered services existed, and 4 of 5 compared attitude questions between PWID and pharmacy staff were statistically different (p<0.01). 5 of 8 pharmacy-delivered services were available for PWID at low level (≤16.9%). Pharmacy staff's supportive perception for pharmacy-delivered services focused on pharmacies' initiate roles targeting on general population more than on PWID. PWID were more supportive and optimistic than pharmacy staff toward potential usage of pharmacy-delivered services (p<0.05). CONCLUSION Pharmacy-delivered services for PWID in Xichang were partly in reality, and could be feasible. It is urgently needed to address the legal requirements and remuneration for pharmacies. Pharmacy staff should receive additional training on services related knowledge and skills, cultural sensitivity toward PWID. Successful pharmacy-delivered services would benefit from identifying mutual interest and benefit between pharmacies and PWID.
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Affiliation(s)
- Yi Yang
- Department of Social Medicine and Health Administration, School of Administration, Chengdu University of Traditional Chinese Medicine, 1166 Liutai Avenue, Wengjiang District, Chengdu 611137, China; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St. 2nd FL, Baltimore, MD 21205, United States
| | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St. 2nd FL, Baltimore, MD 21205, United States.
| | - Rongsheng Luan
- Department of Epidemiology and Biostatistics, West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, China
| | - Cui Yang
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St. 2nd FL, Baltimore, MD 21205, United States
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Jozaghi E, Jackson A. Examining the potential role of a supervised injection facility in Saskatoon, Saskatchewan, to avert HIV among people who inject drugs. Int J Health Policy Manag 2015; 4:373-9. [PMID: 26029896 DOI: 10.15171/ijhpm.2015.73] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/25/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Research predicting the public health and fiscal impact of Supervised Injection Facilities (SIFs), across different cities in Canada, has reported positive results on the reduction of HIV cases among People Who Inject Drugs (PWID). Most of the existing studies have focused on the outcomes of Insite, located in the Vancouver Downtown Eastside (DTES). Previous attention has not been afforded to other affected areas of Canada. The current study seeks to address this deficiency by assessing the cost-effectiveness of opening a SIF in Saskatoon, Saskatchewan. METHODS We used two different mathematical models commonly used in the literature, including sensitivity analyses, to estimate the number of HIV infections averted due to the establishment of a SIF in the city of Saskatoon, Saskatchewan. RESULTS Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon. CONCLUSION The opening of a SIF in Saskatoon, Saskatchewan is financially prudent in the reduction of tax payers' expenses and averting HIV infection rates among PWID.
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Affiliation(s)
- Ehsan Jozaghi
- School of Criminology, Simon Fraser University, Burnaby, BC, Canada
| | - Asheka Jackson
- School of Criminology, Simon Fraser University, Burnaby, BC, Canada
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Allen S, Ruiz M, O'Rourke A. How far will they go? Assessing the travel distance of current and former drug users to access harm reduction services. Harm Reduct J 2015; 12:3. [PMID: 25889589 PMCID: PMC4353450 DOI: 10.1186/s12954-015-0043-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/11/2015] [Indexed: 11/30/2022] Open
Abstract
Background Prior research has explored spatial access to syringe exchange programs (SEPs) among people who inject drugs (PWID), but little is known about service utilization by former PWID who continue to access services (e.g., HIV screenings and referrals for social services) at harm reduction providers. The purpose of this research is to examine differences in access to SEPs between current and former PWID seeking services at a mobile SEP in Washington, DC. Findings A geometric point distance estimation technique was applied to data collected as part of a PWID population estimation study that took place in Washington, DC, in March and April 2014. We calculated the walking distance from the centroid point of home residence zip code to the mobile exchange site where PWID presented for services. An independent samples t-test was used to examine differences in walking distance measures between current and former PWID. Differences in mean walking distance were statistically significant with current and former PWID having mean walking distances of 2.75 and 1.80 miles, respectively. Conclusions The results of this study suggest that former PWID who are engaging with SEPs primarily for non-needle exchange services (e.g., medical or social services) may have decreased access to SEPs than their counterparts who are active injectors. This research provides support for expanding SEP operations such that both active and former PWID have increased access to harm reduction providers and associated health and social services. Increasing service accessibility may help resolve unmet needs among current and former PWID.
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Affiliation(s)
- Sean Allen
- Department of Prevention & Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
| | - Monica Ruiz
- Department of Prevention & Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
| | - Allison O'Rourke
- Department of Prevention & Community Health, Milken Institute School of Public Health at The George Washington University, 950 New Hampshire Ave, Suite 300, Washington, DC, 20052, USA.
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South J, Bagnall AM, Hulme C, Woodall J, Longo R, Dixey R, Kinsella K, Raine G, Vinall-Collier K, Wright J. A systematic review of the effectiveness and cost-effectiveness of peer-based interventions to maintain and improve offender health in prison settings. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02350] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BackgroundOffender health is deemed a priority issue by the Department of Health. Peer support is an established feature of prison life in England and Wales; however, more needs to be known about the effectiveness of peer-based interventions to maintain and improve health in prison settings.ObjectivesThe study aimed to synthesise the evidence on peer-based interventions in prison settings by carrying out a systematic review and holding an expert symposium. Review questions were (1) what are the effects of peer-based interventions on prisoner health and the determinants of prisoner health?, (2) what are the positive and negative impacts on health services within prison settings of delivering peer-based interventions?, (3) how do the effects of peer-based approaches compare with those of professionally led approaches? and (4) what are the costs and cost-effectiveness of peer-based interventions in prison settings?Data sourcesFor the systematic review, 20 electronic databases including MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature and EMBASE were searched from 1985. Grey literature and relevant websites were also searched. To supplement the review findings 58 delegates, representing a variety of organisations, attended an expert symposium, which provided contextual information.Review methodsTwo reviewers independently selected studies using the following inclusion criteria: population – prisoners resident in prisons and young offender institutions; intervention – peer-based interventions; comparators: review questions 3 and 4 compared peer-led and professionally led approaches; outcomes – prisoner health or determinants of health, organisational/process outcomes or views of prison populations; study design: quantitative, qualitative and mixed-methods evaluations. Two reviewers extracted data and assessed validity using piloted electronic forms and validity assessment criteria based on published checklists. Results from quantitative studies were combined using narrative summary and meta-analysis when appropriate; results from qualitative studies were combined using thematic synthesis.ResultsA total of 15,320 potentially relevant papers were identified of which 57 studies were included in the effectiveness review and one study was included in the cost-effectiveness review; most were of poor methodological quality. A typology of peer-based interventions was developed. Evidence suggested that peer education interventions are effective at reducing risky behaviours and that peer support services provide an acceptable source of help within the prison environment and have a positive effect on recipients; the strongest evidence came from the Listener scheme. Consistent evidence from many predominantly qualitative studies suggested that being a peer deliverer was associated with positive effects across all intervention types. There was limited evidence about recruitment of peer deliverers. Recurring themes were the importance of prison managerial and staff support for schemes to operate successfully, and risk management. There was little evidence on the cost-effectiveness of peer-based interventions. An economic model, developed from the results of the effectiveness review, although based on data of variable quality and a number of assumptions, showed the cost-effectiveness of peer-led over professionally led education in prison for the prevention of human immunodeficiency virus (HIV) infection.LimitationsThe 58 included studies were, on the whole, of poor methodological quality.ConclusionsThere is consistent evidence from a large number of studies that being a peer worker is associated with positive health. Peer support services can also provide an acceptable source of help within the prison environment and can have a positive effect on recipients. This was confirmed by expert evidence. Research into cost-effectiveness is sparse but a limited HIV-specific economic model, although based on a number of assumptions and evidence of variable quality, showed that peer interventions were cost-effective compared with professionally led interventions. Well-designed intervention studies are needed to provide robust evidence including assessing outcomes for the target population, economic analysis of cost-effectiveness and impacts on prison health services. More research is needed to examine issues of reach, utilisation and acceptability from the perspective of recipients and those who choose not to receive peer support.Study registrationThis study was registered as PROSPERO CRD42012002349.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jane South
- Institute for Health and Wellbeing, Leeds Metropolitan University, Leeds, UK
| | - Anne-Marie Bagnall
- Institute for Health and Wellbeing, Leeds Metropolitan University, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - James Woodall
- Institute for Health and Wellbeing, Leeds Metropolitan University, Leeds, UK
| | - Roberta Longo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Rachael Dixey
- Institute for Health and Wellbeing, Leeds Metropolitan University, Leeds, UK
| | - Karina Kinsella
- Institute for Health and Wellbeing, Leeds Metropolitan University, Leeds, UK
| | - Gary Raine
- Institute for Health and Wellbeing, Leeds Metropolitan University, Leeds, UK
| | - Karen Vinall-Collier
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Judy Wright
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Jozaghi E, Reid AA, Andresen MA. A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2013; 8:25. [PMID: 23837814 PMCID: PMC3710233 DOI: 10.1186/1747-597x-8-25] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 07/03/2013] [Indexed: 11/16/2022]
Abstract
Background This paper will determine whether expanding Insite (North America’s first and only supervised injection facility) to more locations in Canada such as Montreal, cost less than the health care consequences of not having such expanded programs for injection drug users. Methods By analyzing secondary data gathered in 2012, this paper relies on mathematical models to estimate the number of new HIV and Hepatitis C (HCV) infections prevented as a result of additional SIF locations in Montreal. Results With very conservative estimates, it is predicted that the addition of each supervised injection facility (up-to a maximum of three) in Montreal will on average prevent 11 cases of HIV and 65 cases of HCV each year. As a result, there is a net cost saving of CDN$0.686 million (HIV) and CDN$0.8 million (HCV) for each additional supervised injection site each year. This translates into a net average benefit-cost ratio of 1.21: 1 for both HIV and HCV. Conclusions Funding supervised injection facilities in Montreal appears to be an efficient and effective use of financial resources in the public health domain.
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Affiliation(s)
- Ehsan Jozaghi
- School of Criminology, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, Canada V5A 1S6.
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Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral factors in assessing impact of HIV treatment as prevention. AIDS Behav 2012; 16:1085-91. [PMID: 22491813 DOI: 10.1007/s10461-012-0186-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant ("testing and linkage to care," "treatment as prevention," and/or "treatment as clinical care"). We observe that the impact of "treatment as prevention" on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.
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Affiliation(s)
- David R Holtgrave
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA.
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Public health errors: costing lives, millions at a time. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2012; 16:211-5. [PMID: 20357606 DOI: 10.1097/phh.0b013e3181bee698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reynolds GL, Fisher DG, Napper LE. Assessment of risky injection practices associated with hepatitis B, hepatitis C, and human immunodeficiency virus and using the blood-borne virus transmission risk assessment questionnaire. J Addict Dis 2012; 31:80-8. [PMID: 22356671 DOI: 10.1080/10550887.2011.642755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Risky injection practices among injection drug users (IDUs) contribute to the spread of blood-borne infections such as human immunodeficiency virus, hepatitis B, and hepatitis C. The Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ). was developed in Australia to determine risk behaviors for specific infections. Blood testing for human immunodeficiency virus, hepatitis B, and hepatitis C was performed on all participants, and data on blood tests were linked to questionnaires. The BBV-TRAQ was administered to 242 current and former injection drug users in Long Beach, California, and the Long Beach data were compared with the original Australian data. In the comparison of the mean scores on the three subscales and total scores on the BBV-TRAQ between the samples, means for all three subscales and the total BBV-TRAQ score were significantly different, with Long Beach scores consistently lower than the Australian sample. The injecting and sexual risk subscales were significantly different across levels of AIDS risk perception for all three types of injectors; however, the other skin penetration practices subscale had no significant association with AIDS risk perception for any of the injection drug user groups. Despite recent efforts to educate injectors about the risks associated with practices captured by the other skin penetration practices subscale, such as tattooing and sharing razors, this subscale does not have an association with AIDS risk perception. injection drug users in Australia may have better access to health care, giving their self-report of infection greater validity than the California sample.
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Affiliation(s)
- Grace L Reynolds
- Center for Behavioral Research and Services, California State University, Long Beach, Long Beach, California 90813, USA.
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Mårdh PA, Shoubnikova M, Genç M, Chaplinkas S, Unzeitig V. Health care of female commercial sex workers. EUR J CONTRACEP REPR 2011. [DOI: 10.1080/13625189909040811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Zaller ND, Yokell MA, Jeronimo A, Bratberg JP, Case P, Rich JD. Adverse event associated with a change in nonprescription syringe sale policy. J Am Pharm Assoc (2003) 2011; 50:619-22. [PMID: 20833621 DOI: 10.1331/japha.2010.09162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report and describe the possible correlation of a change in syringe sale policy at a community pharmacy with an adverse clinical outcome. SETTING Providence, RI, in summer 2009. PATIENT DESCRIPTION 27-year-old white woman with a long-standing history of chronic relapsing opiate addiction and human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfection. CASE SUMMARY The patient presented to the hospital emergency department with 5 days of severe diffuse pain, swelling in her hands and feet, and several days of rigors with fevers, sweats, and chills. She was diagnosed with sepsis resulting from a disseminated methicillin-resistant Staphylococcus aureus (MRSA) infection. The patient was treated with intravenous antibiotics, neurosurgical drainage of an epidural abscess, intensive care unit care for 1 week, and acute hospitalization for 8 weeks. MAIN OUTCOME MEASURES Not applicable. RESULTS A few weeks before the patient was hospitalized, pharmacists at her local neighborhood pharmacy decided to stop selling syringes in packages of 10. Instead, syringes were sold at a minimum quantity of 100. The patient did not know where to obtain sterile syringes and began reusing syringes. CONCLUSION The patient introduced pathogenic bacteria from her skin into her bloodstream through unsafe injection practices. The change in syringe sale policy at her local pharmacy likely inadvertently contributed to this severe and life-threatening situation. Consideration of the implications of syringe sale policy must include an understanding of the barriers that influence individual pharmacist's decisions regarding particular store policies that affect over-the-counter syringe sales. Legalized sale of nonprescription syringes in community pharmacies alone is not enough to curb the epidemic of unsafe injection practices in the United States. All medical risks that are inherent in the use of unsafe syringes, including blood-borne viral pathogens (e.g., HIV, HCV) and bacterial infections (e.g., MRSA), should be considered.
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Affiliation(s)
- Nickolas D Zaller
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
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Rose VJ, Backes G, Martinez A, McFarland W. Non-prescription syringe sales in California: a qualitative examination of practices among 12 local health jurisdictions. J Urban Health 2010; 87:561-75. [PMID: 20405227 PMCID: PMC2900573 DOI: 10.1007/s11524-010-9445-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Legislation permitting non-prescription syringe sales (NPSS) was passed in 2004 in California as a structural intervention designed to expand access to syringes for injection drug users. As of December 2009, 19 of California's 61 local health jurisdictions (LHJs) have approved policies to authorize pharmacies to sell non-prescription syringes. The legislation faces termination in 2010 if current evaluation efforts fail to demonstrate outcomes defined in the legislation. Using qualitative methods, we examined the systems and procedures associated with implementation; identified facilitators and barriers to implementation among 12 LHJs, and documented the role of public health in initiating and sustaining local programs. We identified consistent activities that led to policy implementation among LHJs and discovered several barriers that were associated with failure to implement local programs. Factors leading to NPSS were public health leadership; an inclusive planning process, marketing the program as a public health initiative; learning from others' efforts, successes, and failures; and identifying acceptable syringe disposal options in advance of program implementation. Health departments that were confronted with political and moral arguments lost momentum and ultimately assigned a lower priority to the initiative citing the loss of powerful public health advocates or a lack of human resources. Additional barriers were law enforcement, elected officials, and pharmacy opposition, and failure to resolve syringe disposal options to the satisfaction of important stakeholders. The lessons learned in this study should provide useful guidance for the remaining LHJs in California without NPSS programs.
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Affiliation(s)
- Valerie J Rose
- Policy and Evaluation Research, Public Health Foundation Enterprises, Inc., c/o 3311 Florida Street, Oakland, CA 94602, USA.
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Vlahov D, Robertson AM, Strathdee SA. Prevention of HIV infection among injection drug users in resource-limited settings. Clin Infect Dis 2010; 50 Suppl 3:S114-21. [PMID: 20397939 PMCID: PMC3114556 DOI: 10.1086/651482] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of approximately 16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub-Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (ie, methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.
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Affiliation(s)
- David Vlahov
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, New York 10029, USA.
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Strike C, Watson TM, Lavigne P, Hopkins S, Shore R, Young D, Leonard L, Millson P. Guidelines for better harm reduction: evaluating implementation of best practice recommendations for needle and syringe programs (NSPs). THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 22:34-40. [PMID: 20413288 DOI: 10.1016/j.drugpo.2010.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/16/2010] [Accepted: 03/16/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations. METHODS An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document. RESULTS The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%, n=28) and satellite NSPs (84%, n=52) distributed cookers following the dissemination of the document. All core NSPs (100%, n=32) and nearly all satellite NSPs (97%, n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%, n=27) distributed glass stems than the core NSPs (16%, n=5). Commonly cited implementation barriers included funding, senior management and decision-making. CONCLUSION Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.
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Affiliation(s)
- Carol Strike
- Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario, Canada.
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Andresen MA, Boyd N. A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 21:70-6. [DOI: 10.1016/j.drugpo.2009.03.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 01/27/2009] [Accepted: 03/27/2009] [Indexed: 11/30/2022]
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Rotheram-Borus MJ, Swendeman D, Chovnick G. The past, present, and future of HIV prevention: integrating behavioral, biomedical, and structural intervention strategies for the next generation of HIV prevention. Annu Rev Clin Psychol 2009; 5:143-67. [PMID: 19327028 DOI: 10.1146/annurev.clinpsy.032408.153530] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the past 25 years, the field of HIV prevention research has been transformed repeatedly. Today, effective HIV prevention requires a combination of behavioral, biomedical, and structural intervention strategies. Risk of transmitting or acquiring HIV is reduced by consistent male- and female-condom use, reductions in concurrent and/or sequential sexual and needle-sharing partners, male circumcision, and treatment with antiretroviral medications. At least 144 behavioral prevention programs have been found effective in reducing HIV transmission acts; however, scale up of these programs has not occurred outside of the United States. A series of recent failures of HIV-prevention efficacy trials for biomedical innovations such as HIV vaccines, treating herpes simplex 2 and other sexually transmitted infections, and diaphragm and microbicide barriers highlights the need for behavioral strategies to accompany biomedical strategies. This challenges prevention researchers to reconceptualize how cost-effective, useful, realistic, and sustainable prevention programs will be designed, delivered, tested, and diffused. The next generation of HIV prevention science must draw from the successes of existing evidence-based interventions and the expertise of the market sector to integrate preventive innovations and behaviors into everyday routines.
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Affiliation(s)
- Mary Jane Rotheram-Borus
- Semel Institute for Neuroscience and Human Behavior, University of California-Los Angeles, CA 90024-6521, USA.
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Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2009; 25:611-24. [PMID: 17132577 DOI: 10.1080/09595230600944529] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Alison Ritter
- Australian National University, Canberra, Australian Capital Territory, Australia.
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Islam M, Wodak A, Conigrave KM. The effectiveness and safety of syringe vending machines as a component of needle syringe programmes in community settings. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2008; 19:436-41. [PMID: 17766100 DOI: 10.1016/j.drugpo.2007.07.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 04/07/2007] [Accepted: 07/16/2007] [Indexed: 11/21/2022]
Abstract
Syringe vending machines (SVMs) have been introduced in Europe and Australasia as part of the effort to increase the availability of sterile needles and syringes to injecting drug users (IDUs). This qualitative review of 14 published and grey literature studies examines whether community-based SVMs as a component of a comprehensive needle syringe programme (NSP) assist to reduce the spread of HIV and other blood-borne viruses amongst IDUs. The available evidence suggests that SVMs increase access to sterile injecting equipment, reduce needle and syringe sharing, and are likely to be cost efficient. SVMs also complement other modes of NSP delivery as they are used by IDUs who are less likely to attend staffed NSPs or pharmacies. If installed and properly maintained in a well-chosen location and with the local community well prepared, SVMs can enhance the temporal and geographical availability of sterile injecting equipment.
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Affiliation(s)
- Mofizul Islam
- STIRC, Faculty of Medicine, The University of Sydney, Australia.
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Tempalski B, Cooper HL, Friedman SR, Des Jarlais DC, Brady J, Gostnell K. Correlates of syringe coverage for heroin injection in 35 large metropolitan areas in the US in which heroin is the dominant injected drug. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2008; 19 Suppl 1:S47-58. [PMID: 18295468 PMCID: PMC2706511 DOI: 10.1016/j.drugpo.2007.11.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 11/01/2007] [Accepted: 11/19/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Scientific consensus holds that if, at the outset of the HIV/AIDS epidemic, injection drug users (IDUs) had had better access to sterile syringes, much of the epidemic among IDUs in the U.S. could have been prevented. In the context of preventing infectious diseases, 100% syringe coverage - that is, one sterile syringe per injector for each injection - is a public health goal. Notably, we know little about variations in syringe coverage within the U.S. and elsewhere, or about the social and political factors that might determine this coverage. METHODS Using data from Holmberg (1996), the 1990 United States Census, the 2000 Beth Israel National Syringe Exchange Survey (n=72), and estimates of IDUs in metropolitan areas (MSAs); (Friedman et al., 2004), we explore the impact of (1) political factors (ACT UP, outreach, early syringe exchange programme (SEP) presence, men who have sex with men (MSM) per capita, drug arrests, and police per capita); (2) local resources for SEPs; and (3) indicators of socioeconomic inequality on SEP coverage. We define "syringe coverage" as the ratio of syringes distributed at SEPs to the number of syringes heroin injectors need in a year. We calculated the number of syringes heroin injectors need in a year by multiplying an estimate of the number of IDUs in each MSA by an estimate of the average number of times heroin injectors inject heroin per year (2.8 times per day times 365 days). In this analysis, the sample was limited to 35 MSAs in which the primary drug of choice among injectors was heroin. RESULTS SEP coverage varies greatly across MSAs, with an average of 3 syringes distributed per 100 injection events (S.D.=0.045; range: 2 syringes per 10 injection events, to 3 syringes per 10,000 injection events). In bivariate regression analyses, a 1 unit difference in the proportion of the population that was MSM per 1000 was associated with a difference of 0.002 in SEP coverage (p=0.052); early SEP presence was associated with a difference of 0.038 in coverage (p=0.012); and having government funding was associated with a 0.040 difference in SEP coverage (p=0.021). CONCLUSIONS This analysis suggests that longer duration of SEP presence may increase syringe distribution and enhance successful programme utilization. Furthermore, MSAs with greater proportions of MSM tend to have better SEP coverage, perhaps providing further evidence that grassroots activism plays an important role in programme implementation and successful SEP coverage. This research provides evidence that government funding for SEPs contributes to better syringe coverage.
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Affiliation(s)
- Barbara Tempalski
- National Development and Research Institutes, Inc., New York, NY, USA.
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Hornberger J, Holodniy M, Robertus K, Winnike M, Gibson E, Verhulst E. A Systematic Review of Cost-Utility Analyses in HIV/AIDS: Implications for Public Policy. Med Decis Making 2007; 27:789-821. [DOI: 10.1177/0272989x07306112] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objectives . To determine whether gaps exist in published cost-utility analyses as measured by their coverage of topics addressed in current HIV guidelines from the Department of Health and Human Services (DHHS). Design . A systematic review of US-based cost-effectiveness analyses of HIV/AIDS prevention and management strategies, based on original, published research. Methods . Predefined criteria were used to identify all analyses pertaining to prevention and management of HIV/AIDS; information was collected on type of strategy, patient demographics, study perspective, quality of the study, effectiveness measures, costs, and cost-effectiveness ratios. Results . One hundred and six studies were identified; 62 described strategies for averting new HIV infections, and 44 dealt with managing persons who are HIV positive. The quality of studies was generally high, but gaps were found in all studies. Especially common were omissions in reporting data abstraction methodology and discussions of direction and magnitude of potential biases. Among the 22 most highly rated papers (score of 90 or higher), only 1 was cited in the guidelines, and 3 papers reported on interventions that were superseded by newer approaches. Using a $100,000 threshold, the guidelines usually endorsed interventions found to be cost-effective. Exceptions included recommending postexposure prophylaxis (PEP) for populations in which PEP is unlikely to be cost-effective and not recommending primary resistance testing in treatment-naive persons, although the intervention was reported to have a cost-effectiveness ratio of less than $50,000. Conclusions . Despite an abundant literature on the cost-utility of HIV/AIDS-targeted strategies, guidelines cite relatively few of these papers, and gaps exist regarding assessments of some strategies and special populations.
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Affiliation(s)
- John Hornberger
- The SPHERE Institute/Acumen, LLC, Burlingame, California, Department of Veterans Affairs, Palo Alto, California, Department of Medicine, Stanford University School of Medicine, Stanford, California,
| | - Mark Holodniy
- AIDS Research Center, VA Palo Alto Health Care System, Palo Alto, California, Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, Veterans Health Administration, Public Health Strategic Health Care Group, Washington, DC
| | | | | | - Erin Gibson
- The SPHERE Institute/Acumen, LLC, Burlingame, California
| | - Eric Verhulst
- The SPHERE Institute/Acumen, LLC, Burlingame, California
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Heimer R, Grau LE, Curtin E, Khoshnood K, Singer M. Assessment of HIV testing of urban injection drug users: implications for expansion of HIV testing and prevention efforts. Am J Public Health 2007; 97:110-6. [PMID: 17138916 PMCID: PMC1716244 DOI: 10.2105/ajph.2005.078105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2006] [Indexed: 01/18/2023]
Abstract
OBJECTIVES We sought to determine the extent of HIV testing among urban injection drug users (IDUs) to assess whether an expansion of targeted testing programs would be consistent with national goals to identify previously undetected infections. METHODS IDUs in 5 US cities (Oakland, Calif; Chicago, Ill; Hartford and New Haven, Conn; and Springfield, Mass) were recruited either by chain referral or time-location sampling. The IDUs were questioned about HIV testing, and factors associated with HIV testing were analyzed. RESULTS Ninety-three percent of 1543 IDUs had been tested. Among those tested but who did not report having been told that they were HIV seropositive, 90% had been tested within the past 3 years. Women and syringe-exchange customers were more likely to have been tested ever and in the recent past. We estimated the number of undetected infections among urban IDUs in the United States to be less than 40000. CONCLUSIONS Testing for HIV has reached the vast majority of IDUs through the current options. Expending scarce prevention money to expand testing of IDUs is unlikely to be productive. Instead, resources should be used for proven HIV-prevention strategies including syringe exchange, drug treatment, and secondary prevention for those who are HIV positive.
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Affiliation(s)
- Robert Heimer
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn 06520-8034, USA.
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Parviz S, Fatmi Z, Altaf A, McCormick JB, Fischer-Hoch S, Rahbar M, Luby S. Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan. Int J Infect Dis 2006; 10:364-71. [PMID: 16793307 DOI: 10.1016/j.ijid.2005.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Revised: 06/28/2005] [Accepted: 07/08/2005] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To find the prevalence of HIV infection and risk behaviors among injecting drug users (IDUs) in Karachi, Pakistan. DESIGN A cross-sectional study of IDUs conducted in Karachi, Pakistan from February through June 1996. RESULTS Of the 242 IDUs, 11 (4%) refused HIV testing. One (0.4%; 95% confidence interval (CI) = 0.37-0.48%) was HIV positive. All subjects were male. Over the past 6 months 47% had engaged in receptive needle sharing, 38% had perceived a change in their social network, 22% had had sexual intercourse, of whom only 7% always used condoms, and none had washed their needles with bleach. Younger age (28 vs. 31 years; p = 0.01), younger age at first injection (25 vs. 28 years; p = 0.001), fewer years of schooling (3 vs. 5 years; p = 0.001), lower monthly income (70 dollars vs. 80 dollars; p = 0.03), inhaling fumes of heroin from a foil in the year before injecting (OR = 4.8; CI = 2.2-10.3), injecting first time with heroin (OR = 3.6; CI = 1.2-12.6), having a temporary job (OR = 2.5; CI = 1.2-5.2), and a perceived change in one's social network (OR = 4.4; CI = 2.4-7.9) were all associated with receptive needle sharing. IDUs who knew about HIV spread through contaminated needles were less likely to share (OR = 0.4; CI 0.2-0.8). In the final logistic regression model receptive needle sharing was associated with inhaling of fumes of heroin on a foil in the year prior to injecting (adjusted OR = 5.6; CI = 2.6-12.0), a perceived change in one's social network (adjusted OR = 4.0; CI = 2.2-7.4), and inversely associated with age at first time of injection (beta = -0.07; p = 0.002). CONCLUSION Background HIV prevalence was low among IDUs in Karachi despite high-risk behavior in 1996. In order to control HIV transmission among IDUs in Pakistan, continual HIV surveillance with well-coordinated and effective HIV risk reduction, and drug demand reduction programs need to be implemented among drug users.
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Affiliation(s)
- Shehzad Parviz
- Community Health Sciences Department, The Aga Khan University, Karachi, Pakistan.
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Harris ZK. Efficient allocation of resources to prevent HIV infection among injection drug users: the Prevention Point Philadelphia (PPP) needle exchange program. HEALTH ECONOMICS 2006; 15:147-58. [PMID: 16145716 DOI: 10.1002/hec.1021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The objective of this study is to determine the allocation of resources within a multi-site needle exchange program (NEP) that achieves the largest possible reduction in new HIV infections at minimum cost. We present a model that relates the number of injection drug user (IDU) clients and the number of syringes exchanged per client to both the costs of the NEP and the expected reduction in HIV infections per unit time. We show that cost-effective allocation within a multi-site NEP requires that sites be located where the density of IDUs is highest, and that the number of syringes exchanged per client be equal across sites. We apply these optimal allocation rules to a specific multi-site needle exchange program, Prevention Point Philadelphia (PPP). This NEP, we find, needs to add 2 or 3 new sites in neighborhoods with the highest density of IDU AIDS cases, and to increase its total IDU client base by about 28%, from approximately 6400 to 8200 IDU clients. The case-study NEP also needs to increase its hours of operation at two existing sites, where the number of needles distributed per client is currently sub-optimal, by 50%. At the optimal allocation, the estimated cost per case of HIV averted would be dollar 2800 (range dollar 2300-dollar 4200). Such a favorable cost-effectiveness ratio derives primarily from PPP's low marginal costs per distributed needle.
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Affiliation(s)
- Zoë K Harris
- School of Epidemiology and Public Health, Yale University, USA.
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Santibanez SS, Garfein RS, Swartzendruber A, Purcell DW, Paxton LA, Greenberg AE. Update and overview of practical epidemiologic aspects of HIV/AIDS among injection drug users in the United States. J Urban Health 2006; 83:86-100. [PMID: 16736357 PMCID: PMC2258331 DOI: 10.1007/s11524-005-9009-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In a changing public health landscape in which local, state, and federal agencies must confront threats of bioterrorism, emerging infections, and numerous chronic diseases, transmission of HIV among injection drug users (IDUs) continues to be an important public health issue and one of the driving forces behind the HIV epidemic. Using a computerized MEDLINE search of published articles from January 1981 through October 2005, we conducted a literature review of practical epidemiologic aspects of HIV/AIDS among IDUs in the United States. Although recent trends indicate a decline in the proportion of newly diagnosed HIV infections associated with injection drug use, drug-use behaviors overall still account for 32% of new HIV diagnoses. Factors in addition to syringe sharing contribute to HIV transmission among IDUs: risky sexual behaviors, sharing of drug preparation equipment and drug solutions, and contextual and social factors. Promising approaches for HIV prevention include rapid HIV testing, office-based substance abuse treatment, behavioral interventions, improved communication about syringe exchange programs, and case management. HIV among IDUs continues to be an important public health problem in the 21st century. It is imperative that public health agencies continue to monitor and combat the HIV epidemic among IDUs to ensure that hard-won gains will not be eroded.
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Affiliation(s)
- Scott S Santibanez
- Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop K-39, Atlanta, GA 30333, USA.
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Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence. Subst Use Misuse 2006; 41:777-813. [PMID: 16809167 DOI: 10.1080/10826080600669579] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This first international review of the evidence that needle syringe programs reduce HIV infection among injecting drug users found that conservative interpretation of the published data fulfills six of the nine Bradford Hill criteria (strength of association, replication of findings, temporal sequence, biological plausibility, coherence of evidence, and reasoning by analogy) and all six additional criteria (cost-effectiveness, absence of negative consequences, feasibility of implementation, expansion and coverage, unanticipated benefits, and application to special populations). The Bradford Hill criteria are often used to evaluate public health interventions. The principal finding of this review was that there is compelling evidence of effectiveness, safety, and cost-effectiveness, consistent with seven previous reviews conducted by or on behalf of U.S. government agencies. Authorities in countries affected or threatened by HIV infection among injecting drug users should carefully consider this convincing evidence now available for needle syringe programs with a view to establishing or expanding needle syringe programs to scale.
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Affiliation(s)
- Alex Wodak
- Alcohol and Drug Service, St. Vincent's Hospital, Sydney, Australia.
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Lorvick J, Bluthenthal RN, Scott A, Gilbert ML, Riehman KS, Anderson RL, Flynn NM, Kral AH. Secondary syringe exchange among users of 23 California syringe exchange programs. Subst Use Misuse 2006; 41:865-82. [PMID: 16809176 DOI: 10.1080/10826080600669041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article describes the secondary syringe exchange (SSE) practices of injection drug users (IDUs) attending 23 syringe exchange programs (SEPs) in the state of California during 2002 (n=539). The sample was primarily heroin injecting, about two thirds male, half White and half other racial/ethnic groups. Participants were interviewed with a structured questionnaire that included items on sociodemographic factors, drug use practices, sexual practices, use of SEP and other social services, and satisfaction with SEP services. Interviews lasted about 30 minutes. SSE was highly prevalent: 75% of IDUs reported participating in SSE in the 6 months before interview. Program characteristics, such as legal status, SSE policy, and exchange policy, did not affect the prevalence of SSE among SEP clients. Infectious disease risk behaviors were significantly more common among SSE participants than nonparticipants. SSE participants were more likely to share syringes (p<.001) and cookers (p<.001) in the previous 6 months. SSE was significantly associated with being stuck with another person's syringe (needle-stick), a little-discussed "occupational hazard" of this practice. In multivariate analysis, the adjusted odds ratio of needle-stick among SSE participants was 2.8 (95% confidence interval, 1.3, 6.0). The high prevalence of SSE and the infectious disease risk associated with it warrant additional research to determine the causality of these associations. In the interim, SEPs should consider reinforcing HIV prevention education messages and training IDUs who engage in SSE in safe handling of biohazardous materials.
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Affiliation(s)
- Jennifer Lorvick
- Urban Health Program, RTI International, San Francisco, CA, USA.
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Wodak A, Cooney A. Effectiveness of sterile needle and syringe programmes. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2005. [DOI: 10.1016/j.drugpo.2005.02.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Karus D, Raveis VH, Marconi K, Selwyn P, Alexander C, Hanna B, Higginson IJ. Mental health status of clients from three HIV/AIDS palliative care projects. Palliat Support Care 2005; 2:125-38. [PMID: 16594242 DOI: 10.1017/s1478951504040180] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective:To describe mental health status and its correlates among clients of three palliative care programs targeting underserved populations.Methods:Mental Health Inventory (MHI-5) scores of clients from programs in Alabama (n= 39), Baltimore (n= 57), and New York City (n= 84) were compared.Results:Mean MHI-5 scores did not differ among sites and were indicative of poor mental health. Significant differences were noted among sites with regard to client sociodemographics, physical functioning, and perceptions of interpersonal relations. Results of multivariate regression models estimated for each site suggest variation in the relative importance of potential predictors among sites. Whereas poorer mental health was primarily associated with history of drug dependence at Baltimore and more physical symptomatology at New York, better mental health was most strongly correlated with more positive perceptions of interpersonal relationships at Baltimore and increasing age and more positive perceptions of meaning and purpose in life at New York.Significance of results:The data presented suggest the importance of assessing clients' history of and current need for mental health services. Evidence of a relationship between positive perceptions of meaning and purpose and better psychological function underscores the importance of existential issues for the overall well-being of those who are seriously ill.
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Affiliation(s)
- Daniel Karus
- Mailman School of Public Health, Columbia University, New York, New York 10032, USA.
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DeSimone J. Needle exchange programs and drug infection behavior. JOURNAL OF POLICY ANALYSIS AND MANAGEMENT : [THE JOURNAL OF THE ASSOCIATION FOR PUBLIC POLICY ANALYSIS AND MANAGEMENT] 2005; 24:559-77. [PMID: 15973795 DOI: 10.1002/pam.20115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This study examines how drug injection and needle sharing propensities respond when a needle exchange program (NEP) is introduced into a city. I analyze 1989-1995 Drug Use Forecasting data on adult male arrestees from 24 large U.S. cities, in nine of which NEPs opened during the sample period. After controlling for cocaine and heroin prices, AIDS prevalence, fixed effects for cities and years and city-specific time trends, the model indicates that the presence of a NEP is associated with declines of 13 percent in drug injection and 20 percent in needle sharing among drug injectors.
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Affiliation(s)
- Jeff DeSimone
- University of South Florida and National Bureau of Econimic Research, USA
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Abstract
AIM To undertake a cost-effectiveness analysis of a harm reduction and HIV prevention project for injecting drug users (IDUs) in Eastern Europe. Economic evaluation methods were adapted to consider the effect of an 8-month financing gap that negatively impacted on project implementation. DESIGN Financial and economic costs of implementing the intervention were analysed retrospectively. The data were also modelled to estimate the costs of a fully functioning project. Estimates of the intervention impact on sexual and drug injecting behaviour were obtained from existing pre- and post-intervention behavioural surveys of IDUs. A dynamic mathematical model was used to translate these changes into estimates of HIV infections averted among IDUs and their sexual partners. Projections of the potential effect of the shortfall in funding on the impact and cost-effectiveness of the intervention were made. SETTING Svetlogorsk, Belarus, where in 1997 the IDU HIV prevalence was 74%. FINDINGS The intervention averted 176 HIV infections (95% CI 60-270) with a cost-effectiveness of 359 dollars per HIV infection averted (95% CI 234-1054 dollars). Without the 2311 dollars reduction (7%) in financing, the estimated cost-effectiveness ratio of the project would have been 11% lower. The costing methods used to measure donated mass media can substantially influence cost and cost-effectiveness estimates. CONCLUSIONS Harm reduction activities among IDUs can be cost-effective, even when IDU HIV prevalence and incidence is high. Relatively small shortfalls in funding reduce impact and cost-effectiveness. Increased and consistent allocation of resources to harm reduction projects could significantly reduce the pace of the HIV epidemic in Eastern Europe.
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