Unsafe injecting practices among attendees of syringe exchange programmes in France

Aims. To describe syringe exchange programme attendees and their injection practices. Design. Crosssectional study (one week in 1998). Data were collected through a standardized questionnaire. Setting. 60/74 syringe exchange programmes (SEPs) in France. Participants. Clients requesting syringes in 60 SEPs. Measurements. Self-reports of drug use, injecting behaviour, sexual behaviour, serological status (HIV, HBV, HCV). Prevalence of unsafe injecting practices in the previous month such as: syringe sharing; and sharing other injection paraphernalia. Findings. 1004 questionnaires were collected (response rate: 50%). The mean age of respondents was 30 years, and 70% were males. Among individuals tested, HIV reported prevalence was 19.2%, HCV 58.4% and HBV 20.8%. The mean duration of drug use was 11 years. Eighty-five percent were polydrug users and buprenorphine high-dosage was the substance most used (73%). In the previous month, 45% of the participants had re-used a syringe, 93% injected at least daily (mean 3.6 injections per day), 18% shared a syringe and 71% shared injection paraphernalia. In multivariate analyses, unsafe injecting practices were associated with heroin and cocaine use and with living in a couple. The cluster analysis identified five categories of IDUs: users of buprenorphine-HD (45% of the responders), morphine-sulphate (17%), benzodiazepines and other legal drugs (13%), methadone associated with other legal drugs (13%) and crack-cocaine (13%). The buprenorphine–HD group had better social status and safer injection practices. Conclusions. In France, despite an increase in the accessibility to syringes and substitution treatments, unsafe injecting practices persist among SEP attenders. Interventions should stress the importance of using sterile material for each injection, even with a steady sex partner.     

The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs

Aims To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs). Design Cross‐sectional. Setting A national survey of US SEPs. Participants A total of 111 program managers (representing 59% of all US SEPs). Measurements Program manager self‐report. Findings With overall interference profiles ranging from systematic to totally interference‐free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients' syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction's syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving predominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients. Conclusions Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence‐based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control's new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.     

Cessation of injection drug use and change in injection frequency: the Chicago Needle Exchange Evaluation Study

AIMS: To examine the effect of a needle exchange program (NEP) on incidence of injection cessation and change in injection frequency; to explore predictors for injection cessation and change in injection frequency; and to assess whether injection quitters transitioned to non-injected drug use. DESIGN AND SETTING: Between 1997 and 2002, 901 injection drug users (IDUs) were recruited from an NEP program or an area with no NEP in Chicago, Illinois, interviewed for drug use behaviors, tested for HIV and followed for three annual visits. All participants were exposed to prevention services targeting HIV and drug abuse. MEASUREMENTS: Injection cessation was defined as no injection drug use since the last interview, and changes in the number of injections in a typical month were examined. FINDINGS: Sixteen per cent of study participants reported stopping injection for a median duration of 16 months, and most of them also ceased rather than initiated the use of non-injected drugs. Those who continued injecting reduced their injection frequency by 12% per year, on average. Independent predictors of injection cessation were infrequent injection at baseline, younger age and injecting with others. NEP use was not associated with injection cessation and change in injection frequency. CONCLUSION: These results did not support the hypothesis that NEP use influences the frequency of injection over time. One-sixth of IDUs stopped injection for more than 1 year, providing a substantial window for relapse prevention interventions.     

Unstable Housing as a Factor for Increased Injection Risk Behavior at US Syringe Exchange Programs

Objective

To assess variation in injection risk behavior among unstably housed/homeless injecting drug users (IDUs) across programs in a national sample of US syringe exchange programs.

Methods

About 23 syringe exchange programs were selected through stratified random sampling of moderate to very large US syringe exchange programs operating in 2001–2005. Subjects at each program were randomly sampled. Risk behavior interviews were collected using audio-computer assisted self-interviewing (A-CASI). “Unstable housing/homelessness” was operationally defined as having lived “on the street or in a shanty” or “living in a shelter or single room occupancy hotel (SRO)” at any time in the 6 months prior to the interview. “Receptive sharing” was operationally defined as having injected with a needle or syringe that “had been used by someone else” in the 30 days prior to the interview. Six very large and nine moderate-to-large programs had at least 50 subjects who reported unstable housing, and these 15 programs were used in the analyses. Results: There was considerable variation among the 15 programs in the percentages of unstably housed participants (range from 35 to 74%, P < 0.0001), and in the percentages of unstably housed participants who reported receptive sharing (range from 8 to 52%, P < 0.0001). At each of the 15 programs, unstably housed exchange participants were approximately twice as likely to report receptive sharing than were stably housed participants. The weighted mean odds ratio was 2.02, 95% confidence interval, 1.68–2.41 (random effects model) and there was no statistically significant variation in these odds ratios. Across the 15 programs, receptive sharing among unstably housed participants was highly correlated with receptive sharing among stably housed participants (r = 0.95, P < 0.001, 90% of variance among unstably housed “explained” by variance among stably housed).

Conclusions

The programs clearly differ in the extent to which they are attracting unstably housed IDUs as participants. The consistency of more frequent injection risk behavior among unstably housed exchange participants and the lack of significant variation in the odds ratios for increased injection risk suggests that none of the programs were “better” or “worse” at reducing injection risk behavior among unstably housed participants. Reduction in injecting risk behavior among syringe exchange participants may require greater efforts to provide stable housing or the development of dramatically new interventions to reduce injecting risk behavior among IDUs with persistent unstable housing.

     

Long-term effects of syringe exchange on risk behavior and HIV prevention.

The purpose of this study was to assess stability of population-level injection risk behavior over time among participants in a syringe exchange program and compare factors affecting syringe sharing at two points in time. Participants of the Tacoma Syringe Exchange Program were interviewed in 1997 and 2001 using audio computer assisted self-interviewing technology. In each wave of data collection, a random cross section of participants was recruited and interviewed, with no attempt made to follow respondents over time. Rates of injection risk behavior remained stable across the 4-year period, despite increases in factors associated with syringe sharing. Homelessness, rates of depression symptoms, and injection of amphetamines all increased from 1997 to 2001. The central factors associated with syringe sharing in both 1997 and 2001 were depression symptoms and the interaction of younger age with amphetamine injection. The data indicate that the exchange has been able to stabilize risk among a high-risk population for a substantial period of time. This study confirms previous findings that SEPs can play a significant role in the prevention of HIV in marginal and impoverished communities in the United States.     

Long-term improvement in unsafe injection practices following community intervention.

BACKGROUND: A study in 1994 identified frequent unsafe injections as the cause of widespread hepatitis C virus infection in Hafizabad, Pakistan. A simple low cost community education program was assessed to see if it improved injection safety. METHODS: A local health organization developed educational materials on hepatitis C including advice on how to avoid unnecessary injections and, when injections were necessary, to use a new syringe and needle. Beginning in 1995, this advice was communicated through multiple channels including health education meetings, announcements in mosques, and via pamphlets. In 1998 study workers revisited controls from the 1994 case-control study (along with three of their neighbors of a similar age) to collect information on injection practices in the previous 12 months. RESULTS: Thirty-three percent of the study's participants in 1998 received >or=5 injections in the preceding 12 months compared to 40% of the hepatitis C virus negative controls reported in the year prior to the 1994 study (p=0.85). In 1998 52 persons (34%) brought their own syringe for their most recent injection, a practice that was unreported in 1994. Overall, in 1998 59% of patients received their most recent injection with a new syringe and needle compared to 24% in 1994 (p=0.003). CONCLUSIONS: Following this low cost health communication effort, community members took steps to protect themselves from unsafe injections.     

The effect of syringe exchange use on high-risk injection drug users: a cohort study

OBJECTIVE: To determine whether syringe exchange program use is associated with cessation of syringe sharing among high-risk injection drug users. DESIGN AND METHODS: Between 1992 and 1996, street-recruited injection drug users were interviewed and received HIV testing and counseling semi-annually, as part of a dynamic cohort study. We examined a cohort of 340 high-risk injection drug users for whom two observations, 6-months apart, were available and who reported syringe sharing at the first interview. Multivariate logistic regression analysis was performed to determine the relationship between syringe exchange program use and cessation of syringe sharing, while controlling for confounding factors. RESULTS: At follow-up interview, 60% (204 of 340) reported quitting syringe sharing. High-risk injection drug users who began using the syringe exchange program were more likely to quit sharing syringes [adjusted odds ratio (AOR), 2.68; 95% confidence interval (CI), 1.35-5.33], as were those who continued using the syringe exchange program (AOR,1.98; 95% CI, 1.05-3.75) in comparison with non-syringe exchange program users, while controlling for confounding factors. CONCLUSIONS: The initiation and continuation of syringe exchange program use among high-risk injection drug users is independently associated with cessation of syringe sharing. Syringe exchange program use can be an important component in reducing the spread of blood-borne infectious diseases among high-risk injection drug users.     

Residual injection risk behavior, HIV infection, and the evaluation of syringe exchange programs.

This study assessed relationships between residual risk behavior (risk behavior among persons participating in effective HIV prevention programs) and HIV infection. Structured interviews and HIV tests were obtained from participants in six large U.S. syringe exchange programs. Program characteristics were obtained through interviews with the directors. Findings indicated that injection risk behaviors varied significantly across the six programs--from 10% to 27% of the participants at each program reported receptive sharing of needles and syringes in the 30 days prior to the interview. HIV prevalence ranged from 2.5% to 22.2% across the six programs. HIV prevalence among new injectors was strongly related to HIV prevalence among long-term injectors across the programs (r = .869). There was a consistent pattern of negative relationships between injection risk behaviors and HIV infection across the six programs (higher rates of risk behavior at a program associated with lower HIV infection). As a result, appropriate evaluation of HIV prevention programs may require not only information on continuing risk behavior and HIV infection among program participants but also historical information on the epidemiology of HIV in the local community.     

Doing harm reduction better: syringe exchange in the United States

Objective   To trace the growth of syringe exchange programs (SEPs) in the United States since 1994–95 and assess the current state of SEPs.
Methods   Annual surveys of US SEPs known to North American Syringe Exchange Network (NASEN). Surveys mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996.
Results   The numbers of programs known to NASEN have increased from 68 in 1994–95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment, human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counseling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of SEPs in 2007.
Conclusions   While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing SEPs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of SEPs in the United States.     

Hospital- versus community-based syringe exchange: a randomized controlled trial.

This study examined the effect of syringe exchange program setting on the injection practices, health status, and health service utilization patterns of injection drug users (IDUs) recruited from a public urban hospital. One hundred sixty-six participants were randomized to either community- or hospital-based syringe exchange services. Poisson regression models were used to compare service utilization between groups. In both conditions, risky drug use practices decreased, and physical health functioning improved over time. Hospital-based syringe exchange program (SEP) attendees had 83% more inpatient admissions (p < .0001) and 22% more ambulatory care visits (p < .0001) than those assigned to the community-based SEP condition. Syringe exchange services that are integrated into public hospital settings may serve as a valuable strategy to engage hard to reach IDU populations in behavioral interventions designed to reduce HIV risk transmission behaviors and increase access to, or engagement in, the use of secondary and tertiary preventive medical care.     

NEP advocates urged: set up needle exchange

The Point Defiance AIDS Projects, founded in 1988, is a successful needle exchange program (NEP) in Tacoma, WA. Program director David Purchase's approach to potential community resistance is based on the theory that it is better to seek forgiveness than to beg permission. Since its inception, the program has faced two legal battles that have been resolved in favor of Point Defiance. The Washington State Supreme Court ruled that exchange programs should be exempted from state paraphernalia laws. Point Defiance employs three full-time staff members experienced with the drug-using community to conduct on-site exchanges. HIV seroprevalence among injection drug users has remained below five percent over the last five years.     

Lower injection-related HIV-1 risk associated with participation in a harm reduction program in Kazan, Russia.

This study was carried out to investigate the extent of unsafe practices associated with participation in a harm reduction program in Kazan, Russian Federation. In this cross-sectional study a convenience sample of active drug injectors encountered by the field outreach teams was interviewed. Demographic data and information on injection drug use were obtained using a structured survey instrument. Comparisons between program clients and newly encountered individuals not yet engaged by the program were made. Clients were divided into four groups based on the duration and intensity of their interaction with the program. Clients were found to be less likely than newly encountered injectors to give away or use previously used syringes, more likely to have used a new syringe the last time they injected with others, and more likely to be able to anticipate their need to acquire new syringes. However, the sharing of nonsyringe injection paraphernalia was no different between clients and newly encountered injectors. Despite the limitations of a cross-sectional study, it appears that engagement with the harm reduction program in Kazan was associated with reduction in many aspects of unsafe injecting.     

A Randomized Trial to Evaluate the Efficacy of a Computer-Tailored Intervention to Promote Safer Injection Practices Among Drug Users

The aim of this study was to evaluate the efficacy of a theory-based intervention to increase the use of a new syringe for each injection among injection drug users (IDUs). Users of two needle exchange programs (NEPs) were involved. At both sites, participants were assigned at random to either the experimental or the control group. Once a week for four weeks, users reported to the NEPs where they logged onto a computer and received an audiovisual message. A total of 260 IDUs were recruited. At baseline, 52.3% of participants reported that they had not always used new syringes in the previous week. The results indicate that it is possible for IDUs to adopt safer injection practices. One month after the intervention began, participants in the experimental group were using fewer dirty syringes compared to the control group (RR: 0.47 CI_95% 0.28–0.79; P = .004). This short-term effect was no longer present 3 months later.     

Overview of injection practices in two governorates in Egypt

OBJECTIVE: To describe the extent and characteristics of injection use and injection providers in Egypt, given that unsafe injections are associated with blood-borne pathogen transmission. METHODS: Household surveys of a population-based sample of residents in the Nile Delta and in Upper Egypt; focus group discussions and in-depth interviews with community target groups, formal and informal medical providers. RESULTS: Of 4197 persons interviewed, 26.2% reported receiving an injection in the past 3 months. Of these, 77% reported it was for therapeutic indications. The age-sex specific prevalence of injections was highest among children 0-2 years of age and among older adults. Women were more likely to report having an injection than men, particularly at the age above 20 years. Overall, respondents reported receiving on average 4.2 injections per year, indicating that up to 281 million injections are provided per year in Egypt. Injection administrators were public and private sector physicians, pharmacists, barbers, doctor assistants, housekeepers, relatives and friends. Injection prescribers were mostly private and public sector physicians. Of the 1101 respondents who received an injection in the past 3 months, 92 (8.4%) reported that the provider did not use a syringe taken from a closed sealed packet. CONCLUSION: The frequency of therapeutic injection use is high in Egypt and may contribute to blood-borne pathogen transmission. The Ministry of Health and Population (MOHP) is developing interventions targeted towards promotion of injection safety and reduction of injection overuse on community basis as part of a comprehensive strategy to prevent blood-borne pathogen transmission in Egypt.     

Syringe exchange, injecting and intranasal drug use

Objective   To assess trends in injecting and non-injecting drug use after implementation of large-scale syringe exchange in New York City. The belief that implementation of syringe exchange will lead to increased drug injecting has been a persistent argument against syringe exchange.
Methods   Administrative data on route of administration for primary drug of abuse among patients entering the Beth Israel methadone maintenance program from 1995 to 2007. Approximately 2000 patients enter the program each year.
Results   During and after the period of large-scale implementation of syringe exchange, the numbers of methadone program entrants reporting injecting drug use decreased while the numbers of entrants reporting intranasal drug use increased ( P  < 0.001).
Conclusion   While assessing the possible effects of syringe exchange on trends in injecting drug use is inherently difficult, these may be the strongest data collected to date showing a lack of increase in drug injecting following implementation of syringe exchange.     

Potential for HIV transmission through unsafe injections

We tested for HIV in discarded needles and syringe washes from 191 HIV-infected patients receiving injections in rural Cameroon. HIV-1 RNA was amplified from 34 of 103 intravenous injection syringes and two of 88 intramuscular injection syringes. All 36 strains were HIV-1 group M. The majority belonged to the circulating recombinant form CRF02 (IbNg). Our data support a role for unsafe injections in the spread of HIV-1 in Africa, in contrast to recent studies.     

Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users

AIM: To determine whether syringe exchange programs' (SEPs) dispensation policy is associated with syringe coverage among SEP clients. DESIGN: Cross-sectional samples of SEPs and their clients. SETTING: SEPs in California, USA. PARTICIPANTS: Twenty-four SEPs and their injection drug using (IDU) clients (n = 1576). MEASUREMENTS: Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self-reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange. FINDINGS: Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Using propensity scoring methods, we compared syringe coverage by dispensation policies while controlling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits. CONCLUSION: Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. SEPs should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage.     

Psychosocial and Behavioral Differences Among Drug Injectors who Use and do not Use Syringe Exchange Programs

Most research on the benefits of syringe exchange programs (SEPs) has focused on assessing program effectiveness and identifying risk profiles of SEP customers. To our knowledge, no empirical studies have considered the psychosocial characteristics of IDUs who do and do not use SEPs. To determine whether IDUs who do and do not use SEPs differ along demographic, psychosocial, and HIV risk characteristics and behaviors, we analyzed data from a three-city (Chicago, IL; Hartford, CT; Oakland, CA) observational study of how HIV prevention messages and supplies diffuse from SEPs. The study sample consisted of 350 participants with no reported history of HIV, hepatitis B or C virus infection. Self-efficacy was the only psychosocial factor to differentiate SEP customers from all non-customers groups; injecting others and pre-injection cleaning of the injection site differentiated some non-customers from customers. Implications for future interventions are discussed.     

Decline in Self-Reported High-Risk Injection-Related Behaviors Among HIV-Seropositive Participants in the Baltimore Needle Exchange Program

This study was conducted to determine whether enrollment in a needle exchange program (NEP) was associated with reduction(s) in high-risk injection practices among HIV-seropositive drug users. Between August 1994 and August 1997 HIV-seropositive individuals who underwent baseline and 6-month follow-up visits in the Baltimore NEP evaluation were studied. Chi-square statistics and paired t tests were used to compare reported injection-related behaviors between visits. One hundred and twelve HIV-seropositive NEP participants completed baseline and follow-up visits. Between visits self-reported lending of used syringes to others decreased (34.0% vs. 15.5%, p = .001), borrowing syringes from others decreased (23.2% vs. 11.1%, p = .002), and reported participation in drug treatment increased (8.0% vs. 18.8%, p = .01). A decrease in the mean number of injections per syringe was reported, 11.4 vs. 4.7 (p < .001). These data suggest that NEP attendance can contribute to significant reductions in risky drug-use behaviors in HIV-seropositive drug users.