Injections and infections: understanding syringe service program utilization in a rural state

Estimating the Cost-Saving Threshold of a Rural Syringe Services Program Before and During the COVID-19 Pandemic

This study aimed to examine shifts in the cost-savings threshold of a rural syringe services program (SSP) that resulted in the 12-months following the identification of the COVID-19 pandemic. We compared SSP operational costs during the 12-months immediately before and after identification of the COVID-19 pandemic using administrative data from the Cabell-Huntington Harm Reduction Program (CHHRP), which is operated by the Cabell-Huntington Health Department in West Virginia. Data included monthly counts of client encounters, sterile syringe distribution, and HIV testing. Cost-savings threshold analyses were conducted to estimate the number of HIV infections that would have to be averted for the CHHRP to be cost-saving in the 12-months before and after the identification of the COVID-19 pandemic. In the 12-months following identification of the COVID-19 pandemic, there was a 13.6% reduction in the number of client encounters and a 69.3% reduction in the number of HIV tests administered at the CHHRP. From the healthcare perspective, in the 12-months before and after the pandemic, the CHHRP cost $190,151 and $116,727, respectively. The number of averted HIV infections required for the CHHRP to be cost-saving was less than one across both time periods and for all estimates of lifetime HIV-related medical costs. There were shifts in the operational costs at the CHHRP after the identification of the COVID-19 pandemic; however, the costs of providing harm reduction services were significantly less than lifetime HIV treatment costs for a single person. Increasing investments in harm reduction is essential for eliminating HIV transmission.

Injection-Related Infections and Self-treatment Practices Among People Who Inject Drugs in Rural Appalachia

In this study of self-reported serious injection-related infections among people who inject drugs in rural Appalachia (n = 463), 50% reported reusing syringes/needles, 70.6% ever had an injection-site abscess, and 44.4% of those with a recent abscess took nonprescribed antibiotics. The study identifies opportunities to improve harm reduction services.

Racialized environments and syringe services program implementation: County-level factors

OBJECTIVE

Racialized health inequities in substance use-related harms might emerge from differential access to syringe service programs (SSPs). To explore this, we examined the association between county-level racialized environments, other factors, and (1) SSP presence, and (2) per capita syringe and (3) naloxone distribution.

METHODS

2021 US National Survey of SSP data (n=295/412;72 % response rate) was used to identify SSP presence and the sum of syringes and naloxone doses distributed in 2020 by county. Study measures included racial residential segregation (RRS; i.e., divergence and dissimilarity indexes for Black:Non-Hispanic White & Hispanic:Non-Hispanic White) and covariates (i.e., demographic proportions, urban/suburban/rural classifications, 2020 US presidential Republican vote share, and overdose mortality from 2019). We used logit Generalized Estimating Equations to determine factors associated with county-level SSP presence, and zero inflated negative binomial regression models to determine factors associated with per capita syringe and naloxone distribution.

RESULTS

SSPs were reported in 9 % (283/3106) of US counties. SSP presence was associated with higher divergence and dissimilarity indexes, urban and suburban counties, higher opioid overdose mortality, and lower 2020 Republican presidential vote share. Per capita syringes distributed was associated with lower RRS (divergence and Hispanic:White dissimilarity), lower racially minoritized population proportions and rural counties, while per capita naloxone distribution was associated with lower Hispanic and "other" population proportions, and rural counties.

CONCLUSIONS

Racialized environments are associated with SSP presence but not the scope of those programs. Preventing HIV and HCV outbreaks, and overdose deaths requires addressing community level factors that influence SSP implementation and accessibility.

Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach

BACKGROUND

Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID.

METHODS

We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks.

RESULTS

The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI.

CONCLUSIONS

Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.

Syringe reuse among people who inject drugs in rural Appalachian Kentucky

BACKGROUND

Personal syringe reuse (i.e., reuse of one's own syringes) can place people who inject drugs at increased risk for infectious disease but has received relatively little attention in published literature. The purpose of this study is to identify factors associated with syringe reuse among people who inject drugs in rural Kentucky.

METHODS

Participants (n = 238) completed interviewer-administered questionnaires on syringe reuse and demographic, behavioral, and service access characteristics. Unadjusted negative binomial regression with cluster-robust standard errors was used to model the associations with a logged offset for number of injections in the past 30 days.

RESULTS

The average age of the sample was 35 and 59.7 % were male. Most participants (77.7 %) reused syringes at least once in the past 30 days, using each syringe a median of three times. Reuse was higher among those who were older and reported a higher street price for syringes. Syringe reuse was lower among people who were within walking distance to a syringe service program (SSP) and who obtained most of their syringes from SSPs or pharmacies.

CONCLUSION

Syringe reuse among people who inject drugs in rural Kentucky is common. However, these data suggest that increased access to syringes from SSPs and pharmacies, as well as policy-level interventions that reduce street syringe price, might reduce syringe reuse and related harms.

Substance use patterns, sociodemographics, and health profiles of harm reduction service recipients in Burlington, Vermont

BACKGROUND

Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision.

METHODS

Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test.

RESULTS

Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits).

CONCLUSIONS

Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.

Impact of harm minimization interventions on reducing blood-borne infection transmission and some injecting behaviors among people who inject drugs: an overview and evidence gap mapping

BACKGROUND

This study aimed to synthetize the evidence on the effectiveness of harm minimization interventions on reducing blood-borne infection transmission and injecting behaviors among people who inject drugs (PWID) through a comprehensive overview of systematic reviews and evidence gap mapping.

METHODS

A systematic review was conducted with searches in PubMed and Scopus to identify systematic reviews assessing the impact of interventions aimed at reducing the harms associated with injectable drug use. The overall characteristics of the studies were extracted and their methodological quality was assessed using AMSTAR-2. An evidence gap map was constructed, highlighting the most frequently reported outcomes by intervention (CRD42023387713).

RESULTS

Thirty-three systematic reviews were included. Of these, 14 (42.2%) assessed the impact of needle/syringe exchange programs (NSEP) and 11 (33.3%) examined opioid agonist therapy (OAT). These interventions are likely to be associated with reductions of HIV/HCV incidence (10-40% risk reduction for NSEP; 50-60% for OAT) and sharing injecting paraphernalia (50% for NSEP, 25-85% for OAT), particularly when combined (moderate evidence). Behavioral/educational interventions were assessed in 12 reviews (36.4%) with most authors in favor/partially in favor of the use of these approaches (moderate evidence). Take-home naloxone programs and supervised-injection facilities were each assessed in two studies (6.1%), which reported inconclusive results (limited/inconsistent evidence). Most authors reported high levels of heterogeneity and risk of bias. Other interventions and outcomes were inadequately reported. Most systematic reviews presented low or critically low quality.

CONCLUSION

The evidence is sufficient to support the effectiveness of OAT, NSEP and their combination in reducing blood-borne infection transmission and certain injecting behaviors among PWID. However, evidence of other harm minimizations interventions in different settings and for some outcomes remain insufficient.

Use of Syringe Service Programs in Rural vs Urban Maine: A Harm-Reduction Study

Introduction

Syringe service programs (SSPs) reduce HIV and viral hepatitis transmission, as well as the prevalence of improperly disposed needles and needle stick injuries among first responders. Infections associated with injection drug use are rising in rural areas, including Maine, leading to concerns that SSP services are difficult to access for rural residents.

Methods

A cross-sectional survey of 101 participants hospitalized with infections associated with injection drug use at 4 hospitals in Maine was collected over a 15-month period. Descriptive analyses were performed. Statistical analyses were completed using Fisher's exact tests, Pearson's chi-squared tests, and Student's t tests.

Results

Of 101 participants, 66 (65%) lived in urban areas, and 35 (35%) lived rurally. Participants living in rural areas reported less SSP use in the past 3 months (76% urban vs 43% rural). Rural participants also had a higher prevalence of injecting buprenorphine than urban participants (6% urban vs 12% rural). Rural participants were also more likely to obtain needles from pharmacies than urban participants (40% urban vs 71% rural).

Discussion

SSP programs are underrepresented and accessed less in rural areas of Maine. Rural populations of people who inject drugs have unique health characteristics and syringe-use practices.

Conclusions

These findings highlight the need to develop rural SSP programs that address the unique needs of rural populations.

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis

BACKGROUND

Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states.

METHODS

PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use.

RESULTS

Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]).

CONCLUSION

This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

'I feel like they're actually listening to me': a pilot study of a hospital discharge decision-making conversation guide for patients with injection drug use-associated infections

Background

The prevalence of injection drug use (IDU)-associated infections and associated hospitalizations has been increasing for nearly two decades. Due to issues ranging from ongoing substance use to peripherally inserted central catheter safety, many clinicians find discharge decision-making challenging. Typically, clinicians advise patients to remain hospitalized for several weeks for intravenous antimicrobial treatment; however, some patients may desire other antimicrobial treatment options. A structured conversation guide, delivered by infectious disease physicians, intended to inform hospital discharge decisions has the potential to enhance patient participation in decisions. We developed a conversation guide in order to: (1) investigate its feasibility and acceptability and (2) examine experiences, outcomes, and lessons learned from use of the guide.

Methods

We interviewed physicians after they each piloted the conversation guide with two patients. We interviewed patients immediately after the conversation and again 4-6 weeks later. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data.

Results

Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N = 8) completed antimicrobial treatment. Nearly all participants believed the conversation guide was important for incorporating patient values and preferences. Patients reported an increased sense of autonomy, but felt post-discharge needs could be better addressed. Physician participants identified the guide's long length and inclusion of pain management as areas for improvement.

Conclusions

A novel conversation guide to inform hospital discharge decision-making for patients with IDU-associated infections was feasible, acceptable, and fostered the incorporation of patient preferences and values into decisions. While we identified areas for improvement, overall participants believed that this novel conversation guide helped to improve patient care and autonomy.

The impact of the COVID-19 pandemic on people who inject drugs accessing harm reduction services in an rural American state

Background

The impact of public health policies during the COVID-19 pandemic on people who inject drugs (PWID) has varied across regions. In other countries, recent research has shown that PWID access to harm reduction services, despite rapid adaptations, has been negatively impacted. Our study describes these impacts in a rural state.

Methods

We conducted semi-structured interviews with PWID, community partners, and healthcare providers in the rural state of Maine (USA). We explored how changes made during the pandemic impacted access to harm reduction services, including basic services (i.e., shelter), syringe service programs, safe drug supply, low barrier treatment, and peer support. Interviews were analyzed using the framework method to apply Penchansky’s model of access, with Saurman’s modification, which includes six dimensions of access—accessibility, availability, acceptability, affordability, accommodation, awareness.

Results

We interviewed thirty-six stakeholders (N = 9 community partners, N = 9 healthcare providers, N = 18 PWID). Policies such as mobile outreach expansion, mail delivery of equipment, and relaxed telemedicine regulations facilitated accessibility to syringe service programs and low barrier buprenorphine treatment. Public health policies, such as social distancing and screening policies, reduced contact, which subsequently reduced acceptability and awareness of many services. Elimination of the one-for-one needle exchange in some areas increased, acceptability (i.e., perception of service), and affordability for PWID. However, some areas actually began enforcing a one-for-one needle exchange policy, which reduced affordability, acceptability, and awareness of services.

Conclusions

Changes resulting from the COVID-19 pandemic have impacted all dimensions of access to harm reduction services among PWID. While some barriers to harm reduction services were unavoidable during the pandemic, we found that specific policy decisions mitigated service barriers, while other policies exacerbated them. Relaxing needle exchange policies were particularly helpful in facilitating access to harm reduction services by giving community organizations flexibility to adapt to the evolving needs of PWID. These results can inform policies and service delivery to optimally mitigate the negative impacts on PWID during, and beyond, the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00660-2.

Hepatitis C virus: Its prevalence, risk factors and genotype distribution in Pakistan

Hepatitis C is a dangerous liver disease transmitted by Hepatitis C virus (HCV). HCV constitutes an important health issue in Pakistan. In Pakistani setting HCV is found frequently and is recognized as an alarming health problem. In this cross sectional study we reviewed published data regarding the seroprevalence of hepatitis C in general community, blood donors and pregnant females and risk factors linked with its occurrence in Pakistan. Data retrieved from163 studies published from 2001 to 2022 was utilized and weighted mean was calculated. Data of 1,875,232 individuals was collected and arranged into three groups, depending upon the population type such as (1) general population, (2) pregnant women, (3) blood donors. General population (765,426) and blood donors (973,260) formed the most of population. Mean Hepatitis C virus prevalence in general public and blood donors was 16.47% and 8.2% respectively. In pregnant females (136,546) the mean frequency was 9.3%. This study exhibits that the frequency of Hepatitis C in general population, pregnant females and blood donors groups was 11.32%. The data suggested that risks factors for transmitting HCV infection in Pakistan include unsterilized needle use, blood transfusions, shaving by barbers, lack of trained staff, needle stick injuries, injection drug users, household contacts/spousal transmission, unsterilized dental and surgical Instruments, improper disposal of hospital waste, poor infra-structure and others. The frequency of HCV infection is distressing in Pakistan. Health education and awareness programs are needed for decreasing Hepatitis C infection in Pakistan. The data necessitate the implementation of preventive and remedial approaches to decrease the disease load and mortality in Pakistan.