Effectiveness of sterile needle and syringe programmes

This is the first comprehensive international review of the evidence for needle syringe programmes. The major, and now overwhelmingly strong, finding is that needle syringe programmes reduce HIV transmission effectively, safely and cost effectively. The size of the benefit is substantial. There is compelling evidence that needle syringe programmes reduce HIV incidence and HIV prevalence by reducing HIV risk behaviour. The Bradford Hill criteria, generally regarded as the most robust method of assessing public health interventions, were used for the evaluation framework. Conservatively, six of the nine Bradford Hill criteria were fulfilled (strength of association, replication of findings, temporal sequence, biological plausibility, coherence of evidence, and reasoning by analogy). Three of the Bradford Hill criteria were not fulfilled (specificity of association, biological gradient and experimental evidence). Five additional criteria were clearly fulfilled (cost-effectiveness, absence of negative consequences, feasibility of implementation, expansion and coverage, unanticipated benefits, and application to special populations). The findings in this review are consistent with seven published national reviews conducted by, or on behalf of, United States government agencies, which had previously found that needle syringe programmes were effective in reducing HIV infection among injecting drug users and did not increase illicit or injecting drug use. Countries affected or threatened by HIV infection among injecting drug users should carefully consider the convincing evidence now available for the effectiveness and safety of needle syringe programs with a view to establishing or expanding needle syringe programs to scale. Although some research questions still remain unanswered, and areas exist where improved research methodology is needed, the failure to implement needle syringe programmes in time and on a sufficient scale cannot be justified by a lack of available evidence.     

Thinking ethically about needle and syringe programs

Accepting-for the sake of argument-our current legal policies concerning heroin use and its users, what ethical questions are raised for needle and syringe program (NSPs)? Do they weaken drug laws, send the wrong message or obscure the right message, do little to eliminate the harm of drugs, detract from alternatives, and/or constitute a counsel of despair? I suggest that in the absence of established better alternatives, NSPs constitute a morally acceptable and in some cases even desirable option despite the continued criminalization of injecting drug use. Yet they must be conceived and administered in ways that do not reinforce prevailing social prejudices.     

Needle and syringe provision and disposal in an Australian regional centre

The aim of this study was to investigate the provision and disposal of needles and syringes in Geelong, Victoria, supplying a comparison of needles provided to needles returned through needle and syringe programmes (NSPs), needles disposed of in 'Sharpsafe' bins and needles discarded. This study combined quantitative data obtained from a number of sources and qualitative data obtained from 60 interviews. An average of 18,337 (SD = 2796) per month were dispensed from NSPs and an average of 5576 needles are returned to NSP sites in Geelong per month. For the current year, 450 needles and syringes per month were placed in publicly located disposal bins. On average there were 19 callouts to discarded needles per month in the Geelong region and these needles constituted 0.38% of the monthly average of needles provided through NSPs. It was concluded that, while discarded needles are of major community concern, the vast majority of needles and syringes provided in this regional centre are not discarded. Findings are discussed in relation to the current laws surrounding the possession of injecting equipment.     

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.     

Effectiveness of needle and syringe programmes for preventing HIV transmission

Objective: To examine the effectiveness of needle and syringe programmes (NSPs) in preventing HIV transmission among injecting drug users (IDUs).Methods: An ecological study design was used to determine change in HIV prevalence among injecting drug users between cities with and without NSPs. Several data sources, such as electronic journal databases, surveillance reports, websites, and index review of relevant journals, were used to identify studies of HIV seroprevalence among IDUs, and presence of NSPs. The rate of change in HIV prevalence was estimated by regression analysis.Results: There were 778 years of data from 99 cities globally included in the analysis. HIV prevalence decreased by 18.6% per annum in cities that introduce NSPs, and increased by 8.1% in cities that had never introduced NSPs (mean difference −24.7% [95% CI: −43.8, 0.5%], P=0.06). The mean difference was –33% when comparison was weighted to one over the variance of the regression estimator (29% decrease in cities with NSPs and 5% increase in cities without NSPs, P<0.001). When analysis was restricted to cities with first HIV seroprevalence less than 10%, the average annual change in seroprevalence was 18% lower in cities with NSPs (P=0.03).Conclusions: Despite the inherent limitations within an ecological study design, the study provides additional evidence that NSPs reduce transmission of HIV infection. The rapid spread of HIV among IDU populations and increasing rates of injecting in many countries calls for scaling up of NSPs as well as other harm reduction strategies.     

The effectiveness and safety of syringe vending machines as a component of needle syringe programmes in community settings

Syringe vending machines (SVMs) have been introduced in Europe and Australasia as part of the effort to increase the availability of sterile needles and syringes to injecting drug users (IDUs). This qualitative review of 14 published and grey literature studies examines whether community-based SVMs as a component of a comprehensive needle syringe programme (NSP) assist to reduce the spread of HIV and other blood-borne viruses amongst IDUs. The available evidence suggests that SVMs increase access to sterile injecting equipment, reduce needle and syringe sharing, and are likely to be cost efficient. SVMs also complement other modes of NSP delivery as they are used by IDUs who are less likely to attend staffed NSPs or pharmacies. If installed and properly maintained in a well-chosen location and with the local community well prepared, SVMs can enhance the temporal and geographical availability of sterile injecting equipment.     

Qualitative evaluation of a peer-based needle syringe programme in Vietnam

BackgroundHarm reduction has been identified as an important HIV prevention strategy for injecting drug users (IDUs) in Vietnam. However, to date only small geographically limited formal needle syringe programmes (NSPs) have been implemented; and little attention has been given to assessing the effectiveness of the piloted models. Using data from a qualitative evaluation of an NSP in northern Vietnam, this paper assesses the effectiveness of the intervention, examines barriers to the NSP, and documents lessons which can be applied to replicate and scale up interventions across Vietnam.MethodsData were gathered using key informant interviews, focus group discussions, in-depth interviews, observation and intercept interviews with IDUs and other project stakeholders. IDUs were introduced to the evaluation by peer educators (PEs).ResultsThe project contributed to a shift toward safe injecting practices and safe disposal of used needles and syringes (N&;S) among IDUs. Collection of used N&;S positively influenced community attitudes toward PEs and IDUs. Reduced community discrimination, achieved as a result of project advocacy activities, encouraged IDU to access free needle syringes and other project services provided by PEs. Resistance from the local government officials and community members was turned into support for the programme through intensive advocacy activities. The project highlighted the importance of involving law enforcement in the programme and promoted a public health approach toward working with IDU. However, periodic police campaigns against drug use continued to be an obstacle to successful programme implementation and demonstrated the need for continued efforts to address the issue.ConclusionProgramme success is dependent upon community support. Resistance to NSPs can be overcome through a programme of intensive advocacy with community stakeholders including; local government, mass organizations, local residents, IDUs and their families. Garnering the support of law enforcement officials requires a sustained effort.     

Comparison of automated and manual methods of syringe filling

A study to measure the time and cost associated with an automated and a manual method of syringe filling is reported. A stopwatch was used to measure the time needed by an experienced pharmacy technician to prepare batches of 200 syringes of each of seven drugs by a manual method and an automated method, the Multi-Ad Fluid Dispensing System. For each drug and method, time-and-motion data were collected during the preparation of four batches. The accuracy of each method was determined by dividing the actual by the expected number of syringes filled per batch. Material costs were calculated by summing the contract costs of the necessary equipment. The total cost of each method was determined by adding the labor and material costs. For all the drugs, the mean total time required to prepare one batch of syringes by the automated method was significantly less than that for the manual method. There was no significant difference in accuracy between methods for any of the drugs. The annual labor costs of the automated and manual methods were $4056 and $5761, respectively, and the annual material costs were $3364 and $2260, respectively. The total annual cost of the automated method was $7419, compared with $8021 for the manual method. The Multi-Ad system was significantly faster and somewhat less costly overall than a manual method for batch preparation of syringes of seven drugs.     

Ethnic differences in the psychosocial antecedents of needle/syringe disinfection

This study examined psychosocial antecedents of needle/syringe disinfection by 209 injection drug users in three ethnic groups. Among Whites, high perceived self-efficacy for risk reduction had a positive effect on subsequent disinfection attempts. Among African Americans and Mexican Americans, peer norms favorable to risk reduction had a positive effect on subsequent disinfection attempts, while self-efficacy had no effect. These results suggest that risk-reduction capabilities may be rooted in individualistic perceptions of the self among White drug users, while ‘collective self’ perceptions are more relevant to these capabilities among African American and Mexican American drug users. HIV risk intervention may have more impact in specific ethnic groups if these distinctions are taken into account. Results also demonstrate the importance of comparing models of behavior change across ethnic groups.     

Ten years of experience with needle and syringe exchange programmes in European prisons

Results of needle and syringe exchange programmes (SEPs) in prisons based on 10 years experience in Switzerland, Germany, Spain and Moldova are presented. SEPs have been introduced in 46 European prisons, predominantly as pilot projects. Forty-three of these projects were still operating at the time of writing. In 11 prisons, SEPs were evaluated to assess feasibility and efficacy. Results did not support fears that commonly arise in the start-up of implementation of SEPs. Syringe distribution was not followed by an increase in drug use or injection drug use. Syringes were not misused, and disposal of used syringes was uncomplicated. Sharing of syringes among drug users reduced. Based on these experiences, it can be concluded that in these settings harm reduction measures, including syringe exchange, were not only feasible but efficient. Despite these positive results, syringe exchange in prison is far from general acceptance. However, a governmental decree released in Spain in 2001 that all prisons in the country are required to provide drug users with sterile injection equipment may lead to a breakthrough of this harm reduction measure in the future. The discrepancy concerning the success of SEPs in prisons on the one hand and its low acceptance on the other hand is striking. Suggestions for the installation of SEPs in prison are given to assist a more objective discussion.     

Correlates of unsafe syringe acquisition and disposal among injection drug users in Baltimore, Maryland

Because multi-person syringe use is the most common vehicle for HIV and hepatitis C virus transmission among injection drug users (IDUs), safe sources of sterile syringes and safe methods of disposal are necessary to curb these epidemics. We examined syringe acquisition and disposal in a cohort of IDUs in Baltimore. Between January 1, 1998 and December 31, 2001, 1034 participants reported on syringe acquisition at 3492 visits, and 953 reported on disposal at 2569 visits. Participants were 69.9% male, 93.9% African-American, and median age was 44. Syringes were acquired exclusively from unsafe sources at 32.3% of visits, while exclusively unsafe disposal was reported at 59.3% of visits. Significant correlates of unsafe acquisition were: attending shooting galleries, anonymous sex, sharing needles, smoking crack, and emergency room visits. Significant correlates of unsafe disposal were: injecting speedball, no methadone treatment, acquiring safely, and frequent injection. Having a primary source of medical care was associated with safe acquisition, but unsafe disposal. IDUs continue to acquire safely but dispose unsafely, especially among those with a primary source of care; this suggests that messages about safe disposal are not being disseminated as widely as those about acquisition. These data suggest the need for a more active program involving pharmacists, an expanded syringe access program, and better efforts to enhance safe disposal.     

Development of an enhanced needle and syringe programme: the First Step programme pilot

The First Step programme is a new approach to needle and syringe exchange services established to help intravenous drug users reduce harmful drug use behaviours, provide psychoeducation and act as a point of transition enhancing access to other health and community services. The First Step assertive treatment approach was implemented in a medium-sized community area health service and evaluated over an 18-month period. A pilot evaluation of staff training was also conducted, demonstrating a significant improvement in staff skills in assertive outreach, needs assessment, engagement, psychoeducation and referral. Measures of drug-related harm showed the benefits of new early engagement-enhancing psychoeducational interventions, with increases in needles distributed and returned and greater referrals to drug and alcohol and other health services. Training needle and syringe workers towards a more assertive community outreach role gives them the ability to provide psychoeducation and harm minimization strategies and act as a conduit for intravenous drug users to enter treatment. [Hudoba M, Grenyer BFS, O'Toole M. Development of an enhanced needle and syringe programme: the First Step programme pilot. Drug Alcohol Rev 2004;23:295-297]     

Public opinion on needle and syringe programmes: avoiding assumptions for policy and practice

Despite evidence for their effectiveness, harm reduction services such as needle and syringe programmes (NSPs) are highly vulnerable to perceptions of community disapproval. This paper reviews Australian research on community attitudes to harm reduction services and its impact on research, policy and practice. The literature on community attitudes to NSPs in Australia comprises a small number of representative national samples and surveys of local communities affected by specific services. Despite these extremely limited data, negative community attitudes are often cited by policy-makers and health professionals as a primary constraint on policy-making. The main finding of this literature review is that community perceptions of NSPs are largely positive. Also, support for NSPs was not synonymous with condoning drug use. The failure of policy-makers and politicians to recognise positive community attitudes to NSPs has led in some instances to hasty political responses to adverse media reports, including the closure of services. This literature review showing positive community attitudes to harm reduction services should embolden researchers, practitioners and policy-makers to challenge such reactionary responses. Further, this evidence should be used in countering negative publicity surrounding these services. [Treloar C, Fraser S. Public opinion on needle and syringe programmes: avoiding assumptions for policy and practice. Drug Alcohol Rev 2007;26:355 - 361]     

Injecting behaviour of injecting drug users at needle and syringe programmes and pharmacies in Australia

Objective: To compare demographic and injecting characteristics of clients collecting needle syringes from needle syringe programmes (NSPs) and pharmacies. Methods: Clients obtaining needle syringes from three NSPs and one pharmacy in the same geographic area during one and four weeks, respectively were asked to complete a self-administered questionnaire. Results: Approximately half the 336 NSP (56%) and 63 pharmacy (49%) respondents reported using both NSPs and pharmacies in the past month. NSP and pharmacy respondents were similar on many characteristics: male gender (60 and 62%, respectively); median age (30 years for both groups); median age at first injection (18 years both groups); history of methadone treatment (62 and 53%); and heroin as the last drug injected (60 and 59%). NSP respondents were more likely than pharmacy respondents to report imprisonment in the previous year (20% versus 8%, P=0.05), daily injection (67% versus 56%, P=0.09) and re-use of more than one other person’s needle syringe in the previous month (27% versus 7% of 52 and 15 reporting needle syringe re-use). Pharmacy respondents were more likely than NSP respondents to report amphetamine use (32% versus 10%, P<0.001), shared use of tourniquets (24% versus 12%, P=0.01), spoons (43% versus 32%, P=0.09), filters (22% versus 15%, P=0.1), or drug mix (16% versus 9%, P=0.1), and difficulty finding a vein (73% versus 26%, P<0.001). Conclusion: The risk profile of IDUs (Injecting Drug Users) recruited at various sites provides important information for behavioural surveillance and health promotion efforts. Increased convenience of needle syringe access enhances HIV prevention efforts, however, appropriate education is required for people obtaining needle syringes at pharmacies to reduce sharing of injecting equipment other than needle syringes.     

糖尿病患者使用胰岛素笔用针头护理干预分析

目的：分析护理干预对糖尿病患者正确使用胰岛素笔用针头的影响。方法：对82例糖尿病患者进行胰岛素笔用针头的护理干预,比较干预前后患者胰岛素笔用针头的使用情况。结果：护理干预前后糖尿病患者使用胰岛素情况比较差异有统计学意义（P〈0.05）。结论：护理干预可显著提高糖尿病患者胰岛素笔用针头正确使用率,提高治疗效果。     

Point-of-care hepatitis C testing from needle and syringe programs: An Australian feasibility study

BackgroundAchieving hepatitis C elimination requires novel approaches to engage people at highest risk of infection into care pathways. Point-of-care-tests may help to overcome some of the barriers preventing people who inject drugs (PWID) accessing testing and progressing to treatment for hepatitis C virus (HCV). We assessed the feasibility and acceptability of HCV point-of-care testing at needle and syringe exchange programs (NSPs) co-located in three community health clinics in Melbourne, Australia.MethodsNSP clients were offered an oral fluid point-of-care test for HCV antibody by NSP staff. Positive HCV antibody tests were followed by a point-of-care test for HCV RNA alongside standard-of-care laboratory testing for hepatitis C treatment work-up. Participants were offered same-day point-of-care results on site, via phone or text message, or upon return to the service. Participants were scheduled for follow-up review with the study nurse for assessment and linkage to treatment.ResultsA total of 174 participants completed HCV antibody point-of-care test; 150 (86%) had a reactive result. Of these, 140 (93%) underwent a HCV RNA point-of-care test and 76 (54%) tested positive; few participants (5%) waited on site for results delivery, but the majority of RNA positive (63%) attended a follow-up visit for treatment work-up (median time to follow-up visit = 11 days; IQR = 7–20 days). The majority of participants reported a preference for point-of-care tests (66%) and supported NSP staff involvement in testing (90%).ConclusionProvision of HCV point-of-care tests, follow-up and linkage to treatment services through NSPs was feasible and acceptable to PWID. Despite few participants waiting to receive same-day results, there was effective linkage to care, suggesting value in further evaluation of this approach.     

Five years of needle syringe exchange in Manipur, India: programme and contextual issues

This paper reviews the performance of the syringe exchange programmes (SEPs) in Manipur, northeast India, with the objective of identifying good practice, and areas that require improvement. The paper also examines contextual and structural factors in Manipur that inhibit optimal functioning of SEPs and hinder behaviour change, and argues that these factors need to be addressed as part of any endeavour aimed at improving services and programme coverage in the future.