An economic analysis of needle exchange and pharmacy-based programs to increase sterile syringe availability for injection drug users

Impact of medications for opioid use disorder among persons hospitalized for drug use-associated skin and soft tissue infections

BACKGROUND

Skin and soft tissue infections (SSTI) are common complications of injection drug use. We aimed to determine if rehospitalization and recurrent SSTI differ among persons with opioid use disorder (OUD) hospitalized for SSTI who are initiated on MOUD within 30 days of discharge and those who are not.

METHODS

We performed a retrospective analysis of commercially insured adults aged 18 years and older in the U.S. with OUD and hospitalization for injection-related SSTI from 2010-2017. The primary exposure was initiation of MOUD in the 30 days following hospitalization for SSTI. The primary outcomes included 30-day and 1-year 1) all-cause rehospitalization and 2) recurrent SSTI. We calculated the incidence rates for the two groups: MOUD group and no MOUD group for the primary outcomes. We developed Cox models to determine if rehospitalization and recurrent SSTI differ between the two groups.

RESULTS

Only 5.5 % (357/6538) of people received MOUD in the month following their index SSTI hospitalization. 30-day rehospitalization incidence was higher in the MOUD group compared to no MOUD (35.9 vs 27.5 per 100 person-30 days) and one-year SSTI recurrence was lower (10.3 vs 18.7 per 100 person-years). In multivariable modeling, the MOUD group remained at significantly higher risk of 30-day rehospitalization compared to the no MOUD group and at lower risk for one-year SSTI recurrence.

CONCLUSIONS

MOUD receipt following SSTI hospitalization decreases risk of recurrent SSTI among persons with OUD. Further expansion of these in-hospital services could provide an effective tool in the U.S. response to the opioid epidemic.

Estimated cost of comprehensive syringe service program in the United States

OBJECTIVE

To estimate the cost of establishing and operating a comprehensive syringe service program (SSP) free to clients in the United States.

METHODS

We identified the major cost components of a comprehensive SSP: (one-time start-up cost, and annual costs associated with personnel, operations, and prevention/medical services) and estimated the anticipated total costs (2016 US dollars) based on program size (number of clients served each year) and geographic location of the service (rural, suburban, and urban).

RESULTS

The estimated costs ranged from $0.4 million for a small rural SSP (serving 250 clients) to $1.9 million for a large urban SSP (serving 2,500 clients), of which 1.6% and 0.8% is the start-up cost of a small rural and large urban SSP, respectively. Cost per syringe distributed varied from $3 (small urban SSP) to $1 (large rural SSP), and cost per client per year varied from $2000 (small urban SSP) to $700 (large rural SSP).

CONCLUSIONS

Estimates of the cost of SSPs in the United States vary by number of clients served and geographic location of service. Accurate costing can be useful for planning programs, developing policy, allocating funds for establishing and supporting SSPs, and providing data for economic evaluation of SSPs.

Leveraging a Legacy of Activism: Black Lives Matter and the Future of HIV Prevention for Black MSM

This year marks the 30th anniversary of AIDS Education and Prevention. As we approach the United Nations goal of ending the AIDS epidemic by 2030, it is a useful time to reflect on and learn from history. In the United States, no such endeavor can be successful without addressing the specific context of Black men who have sex with men. In this commentary I highlight factors that led us to a state in which Black MSM represent approximately a quarter of all people living with HIV in the United States. I also look back at the power of activism during the beginning of the HIV epidemic. Using Black Lives Matter as a contemporary framework, I highlight natural linkages between activism 30 years ago, its incarnation and relationship to public health today, and its promise as the way forward in achieving the elimination of AIDS for Black MSM by 2030.

Trends in Injection Risk Behaviors among People Who Inject Drugs and the Impact of Harm Reduction Programs in Ukraine, 2007-2013

The study examined trends in injection risk behaviors among people who inject drugs (PWIDs) and assessed the impact of harm reduction programs in Ukraine during 2007-2013. We performed a secondary analysis of the data collected in serial cross-sectional bio-behavioral surveillance surveys administered with PWIDs in Ukraine in 2007, 2008, 2011, and 2013. Using data from 14 Ukrainian cities, we assessed short-term trends in injection risk behaviors with the Cochran-Armitage test for trend and multivariable logistic regression models, adjusted for age, sex, region, marital status, education level, occupation, age at injection drug use initiation, experience of overdose, and self-reported HIV status. The overall test for trend indicated a statistically significant decrease over time for sharing needle/syringe during the last injection (p < 0.0001), sharing needle/syringe at least once in the last 30 days (p < 0.0001), and using a common container for drug preparation (p < 0.0001). The prevalence of injecting drugs from pre-loaded syringes was high (61.0%) and did not change over the study period. After adjusting for all significant confounders and comparing to 2007, the prevalence of sharing needle/syringe during the last injection was unchanged in 2008 (OR = 1.06, 95% CI = 0.92, 1.21), and declined in 2011 (OR = 0.18, 95% CI = 0.15, 0.22) and 2013 (OR = 0.17, 95% CI = 0.14, 0.21). Sharing needles/syringes in the last 30 days significantly decreased when compared to that in 2007 (2008: OR = 0.81, 95% CI = 0.74, 0.89; 2011: OR = 0.43, 95% CI = 0.38, 0.47; and 2013: OR = 0.31, 95% CI = 0.27, 0.35). The prevalence of using common instruments for drug preparation also decreased compared to that in 2007 (2008: OR = 0.88, 95% CI = 0.85, 0.91; 2011: OR = 0.85, 95% CI = 0.85, 0.90; and 2013: OR = 0.74, 95% CI = 0.71, 0.76). The observed reduction in the prevalence of injection risk behavior over time is encouraging. Our findings suggest that prevention programs in Ukraine have positive impact and provide support for governmental expansion of these programs.

Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: a systematic review and meta-analysis

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.

A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida

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.

The cost-effectiveness of harm reduction

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment

To examine whether increasing investment in needle/syringe exchange programs (NSPs) in the US would be cost-effective for HIV prevention, we modeled HIV incidence in hypothetical cases with higher NSP syringe supply than current levels, and estimated number of infections averted, cost per infection averted, treatment costs saved, and financial return on investment. We modified Pinkerton's model, which was an adaptation of Kaplan's simplified needle circulation theory model, to compare different syringe supply levels, account for syringes from non-NSP sources, and reflect reduction in syringe sharing and contamination. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion.

Structural interventions for HIV prevention in the United States

BACKGROUND

Structural interventions change the environment in which people act to influence their health behaviors. Most structural interventions research for HIV infection has focused on developing countries, with the United States receiving substantially less attention. This article identifies some social determinants of HIV vulnerability in the United States and structural interventions to address them.

METHODS

Review of the medical, public health, and social science literature.

RESULTS

Evidence supports widespread implementation of a number of structural interventions in the United States clearly proximate to HIV, including comprehensive sex education, universal condom availability, expanded syringe access for drug users, health care coverage, and stable housing. Sociological plausibility supports evaluation and implementation of other interventions that target social determinants more distal but of relevance to HIV, such as initiatives to eliminate racial and ethnic disparities in criminal sentencing, to promote early childhood education and to decrease poverty.

CONCLUSIONS

Structural interventions that address social determinants of HIV infection may be among the most cost effective methods of preventing HIV infection in the United States over the long term.

HIV testing practices and attitudes on prevention efforts in six diverse Chicago communities

Data describing local level HIV testing practices and attitudes regarding HIV prevention are rarely available, yet would be useful for HIV policy and evaluation. A comprehensive health survey was conducted in six community areas of Chicago (n = 1,699) in 2002-2003. The HIV prevention module of this survey was used for this analysis. The proportion that ever tested for HIV ranged from 40 to 75% and 11 to 38% were tested in the past 12 months. Residents favored: needle exchange programs (59-77%), HIV information in high schools (95-100%) and elementary schools (85-94%), and condom distribution in high schools (74-93%). Attitudes were less favorable regarding pharmacies selling clean needles (37-58%) and condom distribution in elementary schools (22-66%). Adults in these areas are over three times more likely to have been tested recently than adults nationally. Residents strongly favor community based HIV prevention initiatives such as needle exchange programs, condom distribution in high schools, and HIV prevention taught in schools. These evidence-based observations may be valuable in planning HIV prevention programs and in shaping policy.

Utilization patterns and correlates of retention among clients of the needle exchange program in Baltimore, Maryland

NEP effectiveness at a population level depends on several factors, including the number of injection drug users (IDUs) retained, or consistently accessing services. Patterns of retention in the Baltimore Needle Exchange Program (BNEP) from 1994 to 2006 were calculated using enrollment surveys and client records. We used Andersen's Behavioral Model of Health Services Use to frame our examination of factors associated with retention. Client retention was measured in two ways: whether a client returned to the exchange within 12 months of enrollment and how many times a client returned within these 12 months. BNEP clients (N=12,388) were predominantly male (69%), African-American (73%), and >or=age 30 (86%). Nearly two-thirds (64%) of clients returned within 12 months of their first BNEP visit. The median number of return visits per client within 12 months was one (IQR: 0-5). Young age (<30), being married, having an injection drug use history of less than 20 years, and living farther from the BNEP site were characteristics independently associated with both measures of low retention in multivariate analysis. Among younger injectors, geographical proximity was a particularly important predictor of retention. Further insight into the influence of these factors may help in developing programmatic changes that will be effective in increasing retention.

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

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

Intérêt d’un programme d’échange de seringues en pharmacie d’officine pour les usagers de drogues par voie intraveineuse

OBJECTIVES

To demonstrate that a syringe exchange program can reduce syringe re-use, to encourage HCV screening by injection drug users (IDUs), and to provide a new harm reduction tool through the pharmacy network.

METHODS

Staff at the volunteer pharmacies were trained before participating in this decentralized syringe exchange program based on making the Steribox (with its single-use Sterifilt filter) injection kit available free to IDUs. They were asked but not required to return used material to a waste container in the pharmacy. Pharmacists also informed them of the risk of HCV contamination and encouraged screening.

RESULTS

The number of Steribox kits dispensed by the involved pharmacies quadrupled 6 months after the study began, although the number of IDUs using the pharmacy did not increase and kit sales in other local pharmacies did not decease. The disposal rate was almost 80%. The relationship between pharmacists and users clearly improved, and the dispensing of kits has become an opportunity for dialogue. Four participants who injected Subutex accepted referrals to a methadone maintenance treatment program and began treatment. The pharmacists demonstrated their ability to manage this new harm reduction tool.

DISCUSSION

The 400% increase in the number of kits dispensed is an indicator of the effect of price on use of sterile injection material. Cost is undoubtedly a factor in syringe re-use. Paid syringes were reused nearly ten times each, compared with 4 times for the free ones. Appropriate disposal was a responsible act that most IDUs performed. The improvement of the relationship between IDUs and pharmacists increased the access of the former to the healthcare system and enhanced the local healthcare network. Referral to the methadone maintenance treatment program was an unexpected and happy result. The dialogue established around injection tools allowed the pharmacists to provide advice as they dispensed Sterifilt and to promote its use by IDUs.

Structural interventions to prevent HIV/sexually transmitted disease: are they cost-effective for women in the southern United States?

BACKGROUND

Structural interventions are theoretically promising for populations with a low prevalence of HIV, because they can reach large numbers of people to influence their social norms and collective risky behaviors for a relatively low cost per person. Because HIV transmission is continuing to increase among women in the southern United States, interventions to stem this epidemic are particularly warranted. This study explores whether structural interventions may be a cost-effective way to prevent HIV in this population.

METHODS

We used the cost-effectiveness estimator, "Maximizing the Benefit" to determine the relative cost-effectiveness of 6 structural HIV prevention interventions. "Maximizing the Benefit" is a spreadsheet tool using mathematical models to estimate the cost per HIV infection prevented taking into account the epidemiologic contexts, behavioral change as a result of an intervention, and the costs of intervention. We applied estimates of HIV prevalence related to blacks in the southern United States.

RESULTS

All the structural interventions were cost-effective compared with average lifetime treatment costs of HIV, but mass media, condom availability, and alcohol taxes theoretically prevented the largest numbers of HIV infections.

CONCLUSIONS

Although the assumptions used in cost-effectiveness estimates have many limitations, they do allow for a relative comparison of different interventions and help to inform policy decisions related to the allocation of HIV prevention resources. Structural interventions hold the greatest promise in reducing HIV transmission among low-prevalence populations.

Behavioral interventions for HIV-positive and HCV-positive drug users

The nature, context and frequency of use of various licit and illicit non-injection drugs associated with an elevated risk of HIV infection. Beyond HIV, a high proportion of HIV-infected IDUs are co-infected with HCV (hepatitis C virus). In this review, we provide a brief review of the epidemiology of these problems, discuss behavioral interventions that can reduce ongoing high risk behaviors among HIV-seropositive IDUs and MSM-DUs, and review the literature which has evaluated their effectiveness. The majority of these interventions have focused on HIV-seronegative heterosexuals and therefore need to be considered in this larger context; however, where possible we discuss the potential impact of these interventions among HIV-seropositive persons. In addition, we briefly discuss interventions which have the potential to simultaneously reduce ongoing transmission of both HIV and HCV. Finally, given the dearth of information on the effectiveness of behavioral interventions in reducing the burden of the HIV and HCV epidemics among persons already infected with either or both viruses, we describe some newer, promising interventions and offer suggestions for future studies.

Efficient allocation of resources to prevent HIV infection among injection drug users: the Prevention Point Philadelphia (PPP) needle exchange program

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.

Update and overview of practical epidemiologic aspects of HIV/AIDS among injection drug users in the United States

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.

Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence

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.

Needle exchange programs and drug infection behavior

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.

The cost-effectiveness of HIV preventive measures among injecting drug users in Svetlogorsk, Belarus

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.

More pharmacists in high-risk neighborhoods of New York City support selling syringes to injection drug users

OBJECTIVE

To document changes in pharmacists' opinions and practices from the time of passage to implementation of a law permitting selling syringes without a prescription (the Expanded Syringe Access Demonstration Program [ESAP]).

DESIGN

Two cross-sectional randomized telephone surveys.

SETTING

High-risk neighborhoods of New York City.

SUBJECTS

Pharmacists.

MAIN OUTCOME MEASURES

Support for selling syringes without a prescription to injection drug users (IDUs).

RESULTS

We completed 130 surveys at baseline (BL) in August 2000, from neighborhoods with high numbers of injection-related acquired immunodeficiency syndrome (AIDS) cases and 231 surveys at law change (LC) in January 2001. To correct for differences in sampling, we limited the analysis to pharmacies in ZIP Codes represented in both samples and weighted results to adjust for the median income level of those postal codes. From BL (n = 83) to LC (n = 84), law awareness increased (43% to 90%, P < .001), as did personal support for selling syringes without a prescription to IDUs (36% to 63%, P < .001). From BL to LC, a larger proportion of supporters believed that selling syringes was an important part of human immunodeficiency virus (HIV) prevention and would help decrease HIV transmission, and a smaller proportion was concerned about customer discomfort and increased drug use. A total of 40% of respondents were ESAP registered at LC but registration was not associated with support for selling syringes to IDUs.

CONCLUSIONS

Support for ESAP among pharmacists increased in high-risk neighborhoods as the program was implemented. The finding that some pharmacists were ESAP registered but did not support selling syringes to IDUs and others were supportive, but not ESAP registered, may have program implications.

Impact of increased syringe access: preliminary findings on injection drug user syringe source, disposal, and pharmacy sales in Harlem, New York

OBJECTIVE

To evaluate the New York State Expanded Syringe Access Demonstration Program (ESAP) through injection drug user (IDU) surveys, discarded needles and syringes studies, and pharmacy sales and experiences surveys.

DESIGN

Pre-post comparison.

SETTING

In Harlem, New York City, risk surveys among street-recruited IDUs, needle/syringe street counts on 27 systematically sampled city blocks, and Harlem pharmacist reports of sales and experiences.

MAIN OUTCOME MEASURES

Number and types of IDU syringe sources, block mean counts of discarded needles and syringes, level of pharmacy nonprescription syringe sales (NPSS), and pharmacists' experiences.

RESULTS

Comparing 209 pre-ESAP with 396 post-ESAP IDUs, pharmacies as a primary syringe source increased: 3.4% to 5.3% (P < .001, and ever pharmacy use increased: 4.9% to 12.5% (P < .001), respectively. Compared with pre-ESAP IDUs, post-ESAP IDUs tended to be younger and more often black. Harlem pharmacy participation in ESAP increased considerably from March 1, 2001, to March 1, 2002, 49% to 79%, respectively. Among three Harlem pharmacies, there was a modest increase in NPSS; pharmacists reported no problems, and no discarded needles and syringes were observed in pharmacy areas. In the three pharmacies, the proportion of syringe sales that were NPSS was 46% (110 to 240 NPSS/month), 3% (25 to 90 NPSS/month), and 0%. The mean ratios of needles/syringes to background trash have not increased in Harlem since ESAP began.

CONCLUSION

To date, no evidence of harmful effects discarded needles/syringes, pharmacy altercations) resulting from ESAP were observed. While NPSS have increased in Harlem, pharmacy use among IDUs remains low. In Harlem, efforts are underway to increase ESAP awareness and reduce socioenvironmental barriers to ESAP.

Pharmacist support for selling syringes without a prescription to injection drug users in Rhode Island

OBJECTIVE

To examine pharmacists' attitudes and obstacles to syringe sales to IDUs without prescriptions in Rhode Island, around the time that such sales became legal in the state.

DESIGN

Self-administered written survey.

SETTING

Rhode Island.

PARTICIPANTS

400 randomly selected pharmacist members of the Rhode Island Pharmacists Association.

MAIN OUTCOME MEASURES

Responses to survey items.

RESULTS

Of the 400 pharmacists contacted, 131 (33%) completed and returned the survey; of these, 101 (77%) were pharmacists who worked in stores that provided direct nonprescription syringe sales to the public. The majority of these 101 pharmacists were willing to sell syringes to a suspected IDU without a prescription (65%), favored providing free sharps containers for disposal (68%), and supported providing pamphlets on safer injection practices (88%). Willingness to sell syringes to IDUs without a prescription was significantly correlated with various beliefs about possible consequences of sales.

CONCLUSION

The high level of support for nonprescription syringe sales to IDUs is promising. The correlation between the willingness to sell syringes to IDUs without a prescription and various beliefs suggests that future educational interventions might encourage pharmacists to sell syringes to this population without a prescription to decrease HIV and hepatitis transmission.

Risk-taking behaviors among injecting drug users who obtain syringes from pharmacies, fixed sites, and mobile van needle exchanges

Needle-exchange programs (NEPs) have been shown to be effective in reducing harm related to injection drug use and to act as an important link between the injection drug using community and preventive/treatment services. Different needle-exchange distribution methods may reach different subpopulations of injecting drug users (IDUs). We undertook this study to characterize risk behaviors by primary source of clean needles accessed by IDUs in a city with pharmacy access and fixed and mobile exchange programs. We hypothesized there would be a gradient of risk across the three types of distribution. Data were collected from within the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort study. Participants who primarily obtained clean needles from pharmacies, fixed sites, or mobile exchange vans were compared using the Cochran-Armitage trend test to test for trends in increasing risk behaviors across the three types of distribution. Ordinal multivariate regression was used to adjust the associations for potential confounders. Results illustrate clear trends for increasing risk profiles from pharmacy to fixed site to mobile exchange vans. Van users were generally at higher risk than fixed-site and pharmacy users. Independent predictors of van use were fewer years injecting, difficulty finding needles, Aboriginal ethnicity, incarceration in the previous 6 months, and injecting cocaine daily. An important component of needle-exchange programs is outreach to access those who are at highest risk. Use of distribution beyond fixed sites will improve such outreach, thereby increasing program effectiveness and further preventing the transmission of blood-borne infections.

New York City pharmacists' attitudes toward sale of needles/syringes to injection drug users before implementation of law expanding syringe access

In May 2000, New York State passed legislation permitting the sale, purchase, and possession of up to 10 needles and syringes (hereafter "syringes") without a prescription, intended to reduce blood-borne pathogen transmission among injection drug users (IDUs). To obtain baseline data on pharmacists' attitudes and practices related to human immunodeficiency virus (HIV) prevention and IDUs, a telephone survey was administered to 130 pharmacists systematically selected in New York City. Less than half of pharmacists were aware of the new law; 49.6% were willing to or supported providing nonprescription sales of syringes to IDUs. Pharmacists in support tended to be less likely to consider customer appearance "very important." Managing and supervising pharmacists were more likely than staff pharmacists to support syringe sales to IDUs. Managing and supervising pharmacists who stocked packs of 10 syringes and personal sharps disposal containers, pharmacists who supported syringe exchange in the pharmacy, and pharmacists who were willing to sell syringes to diabetics without a prescription were more likely to support syringe sales to IDUs. Syringe disposal was a prominent concern among all pharmacists. Those not in support of syringe sales to IDUs tended to be more likely to believe the practice would increase drug use. These data suggest the need for initiatives to address concerns about syringe disposal and tailored continuing education classes for pharmacists on HIV and viral hepatitis prevention among IDUs.

Syringe availability as HIV prevention: a review of modalities

This review examines recent research into modalities for improving access to sterile syringes for injection drug users (IDUs) as a means to reduce human immunodeficiency virus (HIV) transmission. English language studies with empirical data were collected through Uncover reports and MedLine searches from 1998 to 2000. Although syringe-exchange programs are the most established and well-evaluated means of improving access to sterile syringes, research on alternative modalities-such as pharmacy sale, injector-specific packs, mass distribution, and vending machines-and on coverage of special populations suggests the need to pursue multiple avenues of increasing syringe availability simultaneously and, in particular, to explore modalities other than syringe-exchange programs when HIV incidence is under control. The impacts on HIV transmission of cocaine injection and sex with IDUs need to be explored further. Finally, any evidence of declining hepatitis C incidence among young IDUs might serve as a surrogate for a sharp drop in injection-related HIV risk behaviors in that population.

Cost-threshold analyses of the National AIDS Demonstration Research HIV prevention interventions

OBJECTIVE

The goal of the multisite National AIDS Demonstration Research (NADR) program was to reduce the sexual and drug injection-related HIV risks of out-of-treatment injection drug users and their sex partners. Previous analyses have established that the NADR interventions were effective at changing participants' risky behaviors. This study was to determine whether the NADR program also was cost-effective.

METHODS

Data from eight NADR study sites were included in the analysis. A mathematical model was used to translate reported sexual and injection-related behavior changes into an estimate of the number of infections prevented by the NADR interventions and then to calculate the corresponding savings in averted HIV/AIDS medical care costs and quality-adjusted years of life, assuming United States values for these parameters. Because cost data were not collected in the original NADR evaluation, the savings in averted medical care costs were compared with the cost of implementing a similar intervention program for injection drug users.

RESULTS

The eight NADR interventions prevented approximately 129 infections among 6629 participants and their partners. Overall, the NADR program would be cost saving (i.e. provide net economic savings) if it cost less than US$2107 per person and would be cost-effective if it cost less than US$10,264 per person. Both of these estimates are considerably larger than the US$273 per person cost of the comparison intervention. There was substantial cross-site variability.

CONCLUSIONS

The results of this analysis strongly suggest that the NADR interventions were cost-saving overall and were, at the very least, cost-effective at all eight sites. In the United States and other developed counties, investments in HIV-prevention interventions such as these have the potential to save substantial economic resources by averting HIV-related medical care expenses among injection drug users.