Comparison of injection drug users accessing syringes from pharmacies,syringe exchange programs,and other syringe sources to inform targeted HIV prevention and intervention strategies

ObjectiveTo describe injection drug users (IDUs) who access syringes through different outlets to help inform the prevention needs of IDUs who underuse safe syringe sources in New York City (NYC), where syringe availability is high compared with other U.S. cities.DesignCross sectional.SettingNYC, 2005–2007.Participants285 IDUs.InterventionParticipants were recruited using random street-intercept sampling in 36 socioeconomically disadvantaged neighborhoods.Main outcome measuresIDUs using syringe exchange programs (SEPs), pharmacies, or other outlets as a primary syringe source were compared based on sociodemographic characteristics, injection practices, and medical service use.ResultsChi-square tests and polytomous logistic regression were used to compare IDUs with different self-reported primary syringe sources used in the 6 months preceding study entry. Compared with IDUs using other syringe sources, those primarily using SEPs were less likely to be black (adjusted odds ratio 0.26 [95% CI 0.11–0.57]), more likely to inject daily (3.32 [1.58–6.98]), and more likely to inject with a new syringe (2.68 [1.30–5.54]). Compared with IDUs using other syringe sources, those primarily using pharmacies were less likely to be black (0.39 [0.17–0.90]).ConclusionThese data suggest that pharmacies and SEPs may be reaching different populations of IDUs and highlight a subpopulation of highly marginalized IDUs (i.e., black race, infrequent injectors) who are underusing safe syringe sources in NYC. Targeted interventions are needed to reduce racial disparities and increase use of safe syringe outlets.     

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.     

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.     

Public Health Interventionists,Penny Capitalists,or Sources of Risk?: Assessing Street Syringe Sellers in Hartford,Connecticut

Improved access to sterile syringes decreases risks related to blood-borne transmission of HIV and hepatitis among injection drug users (IDUs). While syringe exchange programs and pharmacy sales of over-the-counter syringes have received considerable attention from researchers and interventionists during the past decade, little is known about informal economy street syringe sellers. In Hartford, CT, as well as other regions throughout the United States a large percentage of IDUs utilize street sellers to facilitate their injection activities. A qualitative and ethnographic study was conducted in Hartford between 1999 and 2001 to help elucidate the public health risks and benefits of street syringe sellers.     

Public health interventionists,penny capitalists,or sources of risk?: assessing street syringe sellers in Hartford,Connecticut

Improved access to sterile syringes decreases risks related to blood-borne transmission of HIV and hepatitis among injection drug users (IDUs). While syringe exchange programs and pharmacy sales of over-the-counter syringes have received considerable attention from researchers and interventionists during the past decade, little is known about informal economy street syringe sellers. In Hartford, CT. as well as other regions throughout the United States a large percentage of IDUs utilize street sellers to facilitate their injection activities. A qualitative and ethnographic study was conducted in Hartford between 1999 and 2001 to help elucidate the public health risks and benefits of street syringe sellers.     

Syringe exchange programs: Impact on injection drug users and the role of the pharmacist from a U.S. perspective

ObjectiveTo present a summary of the existing literature on syringe exchange programs (SEPs) and to discuss the potential role of pharmacists in providing support for injection drug users (IDUs) and such programs.Data sourcesTo identify relevant articles published since 2000, a search of PubMed and Medline was conducted using syringe exchange programs and needle exchange programs as search terms. A manual review of each article's citation list was also conducted.Data extractionBy the authors.Data synthesisInformation is presented in four categories: state and federal support of SEPs, characteristics of SEP users, epidemiological studies, and social reluctance for SEP support. The information summarized in these sections is then used as a foundation for a review of the potential role of the pharmacist.ConclusionSEPs have demonstrated a clear effect in improving the health outcomes of IDUs by decreasing the transmission of blood-borne disease and lowering high-risk injecting behaviors. Despite conflicting support for SEPs at both the federal and local levels, pharmacists can play a pivotal role in the health of IDUs by providing sound medical advice and, in some states, acting as an alternative channel for obtaining clean syringes. Efforts should continue to focus on educating pharmacists about this role and how their individual actions can benefit the health of the entire population.     

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.     

Practices surrounding syringe acquisition and disposal: effects of Syringe Exchange Programmes from different Brazilian regions—the AjUDE-Brasil II Project

The study describes practices relating to syringe acquisition and disposal by Syringe Exchange Programme (SEP) participants. A cross-sectional multi-city study enrolled 857 injection drug users (IDUs) from six SEPs in different Brazilian regions, and assessed self-reported acquisition and disposal behaviours. Seven hundred and nine males (82.9%) and 146 females (17.1%) were recruited through outreach and interviewed, most from the streets or their neighbourhoods (54.1%). The average age was 28.5 years; 76.4% reported injecting cocaine in the past 6 months. Sources for acquiring new syringes differed significantly between time of injection drug use debut and the 6 months prior to interview. Fifty-three percent of IDUs reported acquiring their syringes in pharmacies when they initiated injection drug use, whereas most reported acquiring new syringes in the 6 months before interview from several simultaneous sources: 69% through SEPs; 58% through pharmacies; 36% from friends and/or sexual partners; and 17% from other health services. Across SEPs, acquisition and disposal varied widely. Most interviewees discarded their syringes on the streets, in open fields, or in the garbage or sewage. Restrictions on syringe availability and unsafe practices may be functioning as barriers to the public health recommendation of one-time use of sterile syringes for IDUs and discouraging community support to SEPs. Further increase in access to legal, inexpensive and timely sterile syringes, as well as counselling about the merits of one-time use and safer disposal must be reinforced as part of efforts to minimise high-risk behaviours and curb the spread of blood-borne infections.     

Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach

BackgroundNew York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs’ needs are required. A HCV strategic plan has stressed integration.MethodsHCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development.ResultsIDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain.DiscussionA comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV–HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.     

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.     

Needle syringe acquisition and HIV prevention among injecting drug users: a treatise on the "good" and "not so good" public health practices in South Asia

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and "friends" continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.     

Needle Syringe Acquisition and HIV Prevention Among Injecting Drug Users: A Treatise on the “Good” and “Not So Good” Public Health Practices in South Asia

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and “friends” continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.