HIV Risk Behaviors Associated with the Injection Process: Multiperson Use of Drug Injection Equipment and Paraphernalia in Injection Drug User Networks

This study examines drug acquisition and multiperson use of paraphernalia, drugs, and needles/syringes. Ethnographers observed 54 injection episodes in which IDUs were linked by HIV risk behaviors, and developed a typology of higher-risk, lower-risk, and nonsharing-risk networks. Multiperson use of injection paraphernalia or drug solution occurred in most injection events (94%). Serial use of syringes/needles occurred infrequently (14%) relative to “backloading” (37%) and reuse of paraphernalia (cookers 84%, cotton 77%, water 77%). Higher-risk injection networks were characterized by larger size and pooling of resources for drugs. Prevention messages must include avoiding reuse of injection paraphernalia and transfer of drug solution.     

Socio-demographic factors,health risks and harms associated with early initiation of injection among people who inject drugs in Tallinn,Estonia: Evidence from cross-sectional surveys

AimTo explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia.MethodsIDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation.ResultsA total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (n = 156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity.ConclusionsOur results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs.     

Improving access to sterile syringes and safe syringe disposal for injection drug users in methadone maintenance treatment

We evaluated a novel intervention designed to improve access to sterile syringes and safe syringe disposal for injection drug users (IDUs) newly enrolled in methadone maintenance, through interviews with two sequential cohorts of 100 recent entrants into a methadone program in the Bronx, NY. A substantial number of participants had injected in the previous 6 months, and most continued injecting during the early weeks of treatment. The intervention was associated with significant behavior changes among IDUs, including increased use of pharmacies as a primary source of syringes (11% vs. 37%, p < .05) and decreases in both purchasing of syringes on the street (51% vs. 27%, p < .05) and needle sharing (40% vs. 7%, p < .01). The intervention had no impact on the prevalence of injection or on syringe disposal practices. Our findings suggest that drug treatment programs can serve an important role in reducing injection-related risk behavior by facilitating access to sterile syringes.     

Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales

BackgroundInjecting drug users (IDUs) are at increased risk of acquiring and transmitting HIV and other bloodborne pathogens through the multi-person use of syringes. Although research has shown that increased access to syringes through syringe exchange programs (SEPs) is an effective strategy to reduce risky injection practices many areas of the United States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies over-the-counter sales of syringes has also been shown to reduce syringe sharing. The success of pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia laws, which in turn may contribute to fear among IDUs about being caught purchasing and carrying syringes.MethodsBetween 2003 and 2006, 851 out-of-treatment IDUs were recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were collected using audio-computer assisted interview (ACASI) technology. Multiple logistic regression analyses were performed to assess factors associated with purchasing syringes from pharmacies.ResultsIn our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes.ConclusionsGiven the absence of syringe exchange programs and the relatively high prevalence of HCV and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source of syringes among African-American IDUs in this study sample is problematic. The study findings support the need for effective multilevel interventions to increase access to clean needles in this population, as well as for policy interventions, such as legalization of SEPs and elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats posed by receptive syringe sharing.     

Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients

OBJECTIVE: To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal. DESIGN: HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days. RESULTS: Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. CONCLUSIONS: Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.     

Performance and coverage of HIV interventions for injection drug users: Insights from triangulation of programme, field and surveillance data from Pakistan

Introduction

Nearly 20% of the estimated 84,000 injecting drug users in Pakistan are HIV infected. Non-governmental organisations have implemented HIV interventions for IDUs in 7 cities in Pakistan. Here we report on the performance, coverage and costs of these interventions.

Methods

National HIV bio-behavioural surveillance data were used to measure effectiveness of interventions by comparing HIV prevalence and behavioural trends in intervention and non-intervention cities. Coverage was measured by comparing the supply of syringes with the total syringe need and intervention cost per IDU served per year was calculated.

Results

The NGOs registered 20,640 IDUs (original targets: <10,000); provided 66% of new syringes for all registered IDUs and 75% for all estimated street-based IDUs. This compared to a national coverage of about 13%. Intervention cities had higher baseline HIV prevalence, reflecting their choice as intervention sites. More IDUs from intervention cities (59% vs. 27%) reported always using a clean syringe. Condom use with last sexual partner (24% vs. 11%) and HIV prevention knowledge were also higher amongst this group (all at p < 0.001). HIV prevalence in intervention cities remained unchanged in Faisalabad (13%) and Quetta (10%) but increased in Karachi (26-30%) and Lahore (4-7%). Coverage of sterile syringes for intervention cities was 30% compared to 13% nationwide. However within city, coverage varied from 30 to 99%. The costs of services varied widely by NGOs from USD 146 to 403.

Conclusions

IDUs interventions are performing well in some Pakistani cities. However, considerable expansion is needed to increase nationwide coverage.     

Distributive syringe sharing among young adult injection drug users in five U.S. cities

Blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are transmitted most commonly among injection drug users (IDUs) through the sharing of needles and syringes. Distributive syringe sharing (DSS) (i.e., passing on a used needle/syringe to another IDU) poses the potential risk of transmitting HIV and viral hepatitis to others. We studied the prevalence and correlates of DSS among IDUs enrolled in a randomized behavioral intervention trial designed to reduce behaviors associated with HIV and HCV transmission in five U.S. cities. Among 3129 IDUs ages 15-30 years who completed the baseline visit, 1432 (45.8%) engaged in DSS during the 3 months prior to baseline. Significant correlates of DSS were perception that peer norms condone needle sharing, frequent injection, not obtaining most syringes from needle exchange programs or pharmacies, injecting most frequently in shooting galleries and with sex partners, low perceived risk of HIV from sharing syringes, increased anxiety, low self-esteem, and having unprotected sex. Restricting to only those IDUs who reported not injecting with previously used syringes, similar independent correlates of DSS were found. These findings suggest that interventions to reduce ongoing transmission of blood-borne infections should focus on altering peer norms among networks of young IDUs.     

Changes in the "get-off": social process and intervention in risk locales

Because of ongoing resistance in Florida's legislature to interventions involving exchanges of sterile syringes for contaminated ones, Miami/Dade County's population of injection drug users (IDUs) reduce risk of HIV and hepatitis C infection by buying illegal syringes, participating in illegal syringe exchanges, or decontaminating their paraphernalia. Although it is completely legal, wherewithal for decontamination of injection paraphernalia, including sodium hypochlorite (laundry bleach), water, and cotton for filtering drugs, only appears sporadically in Miami/Dade's risk locales (called "get-off" houses). To ensure consistent decontamination, our intervention instituted regular delivery of these goods to known risk locales. In addition, personnel in half of the locales received training in techniques for optimal decontamination. RNA polymerase chain reaction measured impact of this intervention in terms of viral load found on harvested paraphernalia. Regular delivery of cleansing paraphernalia provided opportunities for observation and characterization of adaptations among people who run risk locales. These people may lead highly stable lives or highly changeable ones, but in most cases their roles as regular hosts of injection activities continue with only brief hiatuses due to incarceration, eviction, or familial dissolution. Proprietors of risk locales maintain their roles as facilitators of self-injection because they use that role to make money or to obtain opportunities to inject drugs and also because their clientele demands they continue.     

Changes in the “Get-Off”: Social Process and Intervention in Risk Locales

Because of ongoing resistance in Florida's legislature to interventions involving exchanges of sterile syringes for contaminated ones, Miami/Dade County's population of injection drug users (IDUs) reduce risk of HIV and hepatitis C infection by buying illegal syringes, participating in illegal syringe exchanges, or decontaminating their paraphernalia. Although it is completely legal, wherewithal for decontamination of injection paraphernalia, including sodium hypochlorite (laundry bleach), water, and cotton for filtering drugs, only appears sporadically in Miami/Dade's risk locales (called “get-off” houses). To ensure consistent decontamination, our intervention instituted regular delivery of these goods to known risk locales. In addition, personnel in half of the locales received training in techniques for optimal decontamination. RNA polymerase chain reaction measured impact of this intervention in terms of viral load found on harvested paraphernalia. Regular delivery of cleansing paraphernalia provided opportunities for observation and characterization of adaptations among people who run risk locales. These people may lead highly stable lives or highly changeable ones, but in most cases their roles as regular hosts of injection activities continue with only brief hiatuses due to incarceration, eviction, or familial dissolution. Proprietors of risk locales maintain their roles as facilitators of self-injection because they use that role to make money or to obtain opportunities to inject drugs and also because their clientele demands they continue.     

A matter of convenience: factors influencing secondary syringe exchange in Baltimore, Maryland, USA

Distribution of sterile syringes to reduce the circulation of HIV-infection among injection drug user (IDU) communities is vital in curbing the spread of HIV among IDUs. In addition to other methods of distribution, syringe exchange programmes (SEPs) have been shown to be necessary in the dissemination of sterile syringes. Secondary syringe exchange (SSE) is an organic process by which IDUs distribute syringes to other IDUs and is an important complement to SEPs. This paper examines the motivations for people who provide SSE to other IDUs and the reasons why some IDUs do not use the Baltimore Needle Exchange Program (BNEP). Approximately 5000 individuals had obtained clean syringes from the BNEP between 1994 and 1997. In 1997, qualitative interviews were conducted in Baltimore with 20 providers of SSE and 10 SSE recipients who had never used the BNEP. Data from qualitative interviews were transcribed, coded and compiled. SSE providers reported economic gain and altruism as incentives. SSE recipients reported privacy, convenience of location and time, force of habit, and concern for carrying paraphernalia around as reasons influencing them to obtain syringes from secondary syringe exchangers rather than the needle exchange programme. Results from this study illuminate the social context in which SSE occurs and indicate the importance of SSE as a method for distributing sterile syringes.     

A brief intervention for hazardous drinkers in a needle exchange program

Active injection drug users (IDUs) who are also hazardous alcohol users are at particularly high risk for HIV transmission due to sharing of injection equipment. We recruited AUDIT-positive injectors from the Providence, RI needle exchange program for a randomized clinical trial testing the effect of a brief motivational intervention (MI) on frequency of injection-related HIV risk behavior (IRRB). HIV drug risk behavior was measured as the number of days on which subjects reported sharing works using the 30-day Timeline Followback Method. Overall, 109 subjects reported a mean reduction of IRRB days of 9.1 days from baseline to 6-month follow-up (p <.001). When compared to controls, there was a trend in reduction of IRRB days to zero at follow-up for MI subject (OR = 2.1; 95% CI = 0.9-4.5), and strongly significant reductions in IRRB days across a range of alternative improvement thresholds. Results from this study demonstrate that MI reduces drug-related HIV risk behaviors among active IDUs. As a brief intervention, MI may be a useful adjunct to existing services intended to reduce harm.     

HIV prevalence and correlates of receptive needle sharing among injection drug users in the Mexican-U.s. border city of Tijuana

Injection drug use is a growing but understudied problem in Tijuana, a city situated on the northwestern Mexico-U.S border. The authors studied factors associated with receptive needle sharing in an effort to inform prevention activities. In 2003, street-recruited injection drug users (IDUs) in Tijuana underwent interviews on injection risk behaviors and rapid HIV antibody tests. Logistic regression was used to identify correlates of receptive needle sharing at the last injection episode. Of 402 IDUs, 87.6% were male; the median age was 34. HIV prevalence was 4.01% (95% CI: 2.29-6.51). One third reported receptive needle sharing at last injection. Factors independently associated with receptive needle sharing were years living in Tijuana (Adjusted Odds Ratio [AdjOR]= 0.97 per year, 95% CI: 0.96-0.99), being bisexual/homosexual (AdjOR=2.12; 95% CI: 1.30 - 3.44), unemployed (AdjOR=2.5; 95% CI: 1.52-4.10), never having an HIV test (AOR: 4.02; 95% CI: 2.44-6.60), having friends who placed importance on avoiding HIV (AdjOR: 0.36; 95% CI: 0.19-0.68) and last injecting in a shooting gallery (AdjOR=1.98; 95% CI: 1.21-3.24). These results underscore the need to increase access to voluntary HIV testing and counseling to IDUs and migrants in Tijuana, as well as expand access to sterile syringes in an effort to avert widespread HIV transmission.     

云南四川部分城市注射毒品人群高危行为的快速需求评估

目的 :评估云南省和四川省部分城市注射毒品人群感染HIV的高危险行为。方法 :采用随机抽样和“滚雪球”的方法 ,对云南省和四川省四个地区注射毒品人群进行高危行为的流行学调查 ,并将结果做分析比较。结果 :四川省的吸毒者主要以静脉注射毒品和烫吸毒品为主 ,而云南省的吸毒者则更多以静脉注射毒品为主。 4个城市吸毒者共用注射器的比例分别为 :昆明市 74 5 % ,西昌市 5 8 8% ,绵阳市 34 1%和保山市 2 8 8%。这些吸毒者都很少消毒注射器 ,平均每天的吸毒次数云南 2 - 3次 ,四川 2次。安全套使用率都比较低 ,特别是在与非固定性伴的性行为中 ,昆明市吸毒者安全套的使用率为 2 7% ,保山市为 4 1 7% ,绵阳市和西昌市分别为 33 3%和 30 8%。结论 :四川省和云南省被调查的吸毒者都存在有不同程度的与HIV传播相关的高危险行为     

Social Context of Needle Selling in Baltimore,Maryland

Although much of the debate surrounding the distribution of sterile syringes to injection drug users (IDUs) has focused on needle exchange programs (NEPs), IDUs acquire their syringes from three major sources: NEPs, pharmacies, and secondary exchangers or needle sellers. The purpose of the present study is to examine types and frequencies of social interactions among drug injectors who sell needles, most of which come from NEPs, compared with individuals who do not sell needles. Specifically, we compared engagement in drug-related behaviors, roles in the drug economy, and social network membership. Data were collected as part of the SHIELD study, an HIV prevention intervention targeted at drug users and their social networks (n = 910) from February 2001 through September 2003 in Baltimore, Maryland (USA). In this sample, 56 participants reported selling needles. Needle sellers had higher levels of engagement in drug-related social interactions, including using drugs with others, giving or receiving drugs from others, and buying drugs with other users. Participants who sold needles had a significantly higher number of roles in the drug economy. Also, they had more social network members who were injectors, with whom they talked about risky drug behaviors, gave needles to, and shared cookers and bleach with. Compared with nonselling injectors, needle sellers engage in HIV risk-related behaviors, such as injecting daily and sharing injection equipment, more frequently. The study's findings may be useful to determine whether secondary exchangers should be targeted for HIV prevention activities both to reduce their own risk and to diffuse risk reduction information throughout the drug using community.     

Social context of needle selling in Baltimore, Maryland

Although much of the debate surrounding the distribution of sterile syringes to injection drug users (IDUs) has focused on needle exchange programs (NEPs), IDUs acquire their syringes from three major sources: NEPs, pharmacies, and secondary exchangers or needle sellers. The purpose of the present study is to examine types and frequencies of social interactions among drug injectors who sell needles, most of which come from NEPs, compared with individuals who do not sell needles. Specifically, we compared engagement in drug-related behaviors, roles in the drug economy, and social network membership. Data were collected as part of the SHIELD study, an HIV prevention intervention targeted at drug users and their social networks (n=910) from February 2001 through September 2003 in Baltimore, Maryland (USA). In this sample, 56 participants reported selling needles. Needle sellers had higher levels of engagement in drug-related social interactions, including using drugs with others, giving or receiving drugs from others, and buying drugs with other users. Participants who sold needles had a significantly higher number of roles in the drug economy. Also, they had more social network members who were injectors, with whom they talked about risky drug behaviors, gave needles to, and shared cookers and bleach with. Compared with nonselling injectors, needle sellers engage in HIV risk-related behaviors, such as injecting daily and sharing injection equipment, more frequently. The study's findings may be useful to determine whether secondary exchangers should be targeted for HIV prevention activities both to reduce their own risk and to diffuse risk reduction information throughout the drug using community.     

Secondary Syringe Exchange Among Users of 23 California Syringe Exchange Programs

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.     

Sources of injecting equipment for drug users in Moscow, Russia

Syringe exchange programmes (SEPs) were approved in Moscow in 2002 and studies to evaluate access to sterile syringes are now needed. Clients of a non-governmental organisation (NGO) providing outreach to IDUs were interviewed concerning behaviours within the previous 30 days. Of 232 IDUs, 64% were male, mean age was 25 and mean duration of injection drug use was 5.8 years. Twelve percent reported injecting with used syringes and using prefilled syringes; 6% passed syringes to others and 91% shared paraphernalia. Seventy nine per cent admitted that they had never had a sterile syringe every time they needed it. Among women, 45% used pharmacies as their only source of injecting equipment. Out of 10 potential syringe sources, pharmacies were the major source, especially for women. The other two major sources were other drug users and drug dealers. NGOs offering syringe exchange were mentioned by 9%, whereas medical institutions were reported as the least popular source. Almost all (99%) reported that syringes are not expensive and their procurement is not difficult, but 83% mentioned that buying syringes at pharmacies often involves a risk of being examined by law enforcement staff. These results indicate that significant barriers for procurement and use of sterile syringes exist in Moscow.     

Quantitative and Qualitative Methods to Assess Behavioral Change Among Injection Drug Users

SUMMARY

The risk injecting drug users (IDUs) have for contracting the human immunodeficiency virus (HIV) led to governmental requests for interventions to prevent its spread. At the same time there was an urgent need to evaluate the effectiveness of these proposed interventions. We believe that both quantitative and qualitative research methods should be employed in this effort. In this paper we discuss the differences between the two approaches, how they can complement one another, and present findings derived from their joint application to a particular risk behavior, needle sharing. Despite behavioral changes in a number of high risk activities, significant reductions in borrowing syringes were not reported by participants in structured interviews. Evidence obtained through participant observation and open-ended interviews indicated Colorado's paraphernalia law may have played a major role in encouraging this behavior.