Law enforcement influences on HIV prevention for injection drug users:: Observations from a cross-border project in China and Vietnam

Law enforcement activity has had multiple influences on injection drug users’ (IDUs’) participation in a cross-border HIV prevention project in southern China and northern Vietnam. The project has successfully achieved and maintained the official support of police and other government agencies and effectively implemented its interventions. However, analysis of process data, site visit observations, and interviews with project staff, peer educators, IDUs, and police officers reveal the ongoing effects of actual and perceived threats from law enforcement, as well as community stigmatisation, on IDUs’ project participation. These effects are discernible in variations in the monthly numbers of needles/syringes provided, cross-border differences in IDUs’ preferred ways to receive new needles/syringes and retain used needles/syringes for exchange, and geographic patterns of IDUs’ receiving and redeeming pharmacy vouchers. HIV prevention programmes must not only maintain the support of police and other officials but also convince IDUs that it is both beneficial and safe for them to participate in the interventions. Programmes must also be implemented with flexibility, adapting to the potentially changeable preferences, perceptions, and needs of IDUs.     

A qualitative assessment of injection drug use and harm reduction programmes in Kabul, Afghanistan: 2006-2007

BackgroundThe purpose of this paper was to examine the context of injection drug use in Kabul, Afghanistan among injection drug users (IDUs) utilising and not utilising needle and syringe programmes (NSPs).MethodsFollowing identification of themes from eight focus group discussions, free-lists were used for further exploration with both NSP using (n = 30) and non-NSP using (n = 31) IDUs.Results All participants were male, had been injecting for 5 years (mean), and most (95%) had been refugees in the past decade. Main reasons for sharing syringes were convenience and lack of availability and did not vary based on NSP use. Drug users perceived alienation from the community, evidenced by names used for drug users by the community which convey social stigma and moral judgment. Health risks were the principal stated risk associated with drug use, which was mentioned more frequently by NSP users. Harm reduction services available in Kabul are perceived to be insufficient for those in need of services, resulting in under utilisation. The limited scope and distribution of services was frequently cited both as an area for improvement among NSP using IDU or as a reason not to use existing programmes.ConclusionsWhile some positive differences emerged among NSP-using IDU, the current context indicates that both rapid scale-up and increased variety of services, particularly in the realm of addiction treatment, are urgently needed in this setting.     

Barriers to use of Needle and Syringe Programmes in a high drug use area of Sydney,New South Wales

Objective:Most surveillance of injecting drug users (IDUs) in Australia is done with samples of participants drawn from those who attend Needle and Syringe Programmes (NSPs). We investigated the barriers and preferences to NSP access of a group of IDUs who do not use NSPs as their primary source of injecting equipment from a defined geographical area in Sydney, which has been estimated to house the highest number of IDUs in Australia.Method:A cross-sectional, interviewer-administered questionnaire was completed by 294 participants, most of whom were recruited through the personal and extended networks of peer interviewers. Participants were considered in two groups: those who did not use NSPs (non-NSP users) and those who used NSPs infrequently (infrequent NSP users).Results:Infrequent NSP users were more likely than non-NSP users to report reasons of convenience and NSP operation as barriers to access. Non-NSP users reported barriers related to lack of awareness of NSPs and that they did not need to access NSPs. Fixed locations and vending machines were most frequently endorsed by both groups as the “best way” to distribute injecting equipment. However, issues of stigma and maintaining anonymity were concerns for participants in both groups. Compared to non-NSP users, infrequent users were more likely to reside in areas with a large drug user population, obtain safe injecting information from health workers, have injected drugs for longer, have injected alone, have been tested for blood borne viruses, report greater connectedness to drug user networks and be less concerned about contacting NSP staff.Conclusion:Understanding the preferences of IDU, including those who do not attend NSP, is central to providing health services which meet their needs and in developing hepatitis C prevention programmes which reach this target group. The effects of stigma on the health care choices of IDUs must be recognised in planning developments in NSP service, or alternatives to NSPs.     

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.     

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.     

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.     

Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs)

Background

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

Methods

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

Results

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%, n = 28) and satellite NSPs (84%, n = 52) distributed cookers following the dissemination of the document. All core NSPs (100%, n = 32) and nearly all satellite NSPs (97%, n = 60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%, n = 27) distributed glass stems than the core NSPs (16%, n = 5). Commonly cited implementation barriers included funding, senior management and decision-making.

Conclusion

Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.     

Patterns of injection drug use cessation during an expansion of syringe exchange services in a Canadian setting

Background

Needle and syringe programmes (NSPs) have been shown to reduce HIV risk among people who inject drugs (IDUs). However, concerns remain that NSPs delay injecting cessation.

Methods

Individuals reporting injection drug use in the past six months in the greater Vancouver area were enrolled in the Vancouver Injection Drug Users Study (VIDUS). Annual estimates of the proportion of IDU reporting injecting cessation were generated. Generalized estimating equation (GEE) analysis was used to assess factors associated with injecting cessation during a period of NSP expansion.

Results

Between May 1996 and December 2010, the number of NSP sites in Vancouver increased from 1 to 29 (P < 0.001). The estimated proportion of participants (n = 2710) reporting cessation increased from 2.4% (95% confidence interval [CI]: 0.0–7.0%) in 1996 to 47.9% (95% CI: 46.8–48.9%) in 2010 (P < 0.001). In a multivariate GEE analysis, the authors observed an association between increasing calendar year and increased likelihood of injecting cessation (Adjusted Odds Ratio = 1.17, 95% CI: 1.15, 1.19, P < 0.001).

Conclusion

The proportion of IDU reporting injecting cessation increased during a period of NSP expansion, implying that increased NSP availability did not delay injection cessation. These results should help inform community decisions on whether to implement NSPs.     

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.     

What has been achieved in HIV prevention,treatment and care for people who inject drugs, 2010–2012? A review of the six highest burden countries

ObjectiveIn 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an “accountability matrix”, focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress.DesignWe searched peer-reviewed literature, conducted online searches, and contacted experts for ‘grey’ literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews.ResultsPolicy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs.ConclusionsPrevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.     

The changing epidemiology of prevalent diagnosed HIV infections in Taiwan, 1984-2005

By the end of 2005, there were 10,158 reported cases of HIV infections in Taiwan, of them, 2,403 had developed full blown AIDS, and 1,333 had died. It represented an average annual increase of 15% in HIV diagnoses before 2003. The most common route of transmission is through men having sex with men followed by heterosexual contact, while infections through injecting drug use (IDUs) remained low. However, the number of newly reported HIV infections has been rising sharply since 2003, mainly among IDUs. The consequences of this HIV/IDU epidemic include a rapid increase in female HIV/AIDS patients and a decreased mean age of HIV/AIDS cases. Only 2% of patients in the IDU group have been diagnosed with AIDS, suggesting that most IDU cases are in the early stage of HIV infections.HIV/AIDS patients are provided with free medical care by the government in Taiwan, including anti-retroviral treatment. The case fatality rate of AIDS cases declined gradually from 64% in 1996 to 8.9% in 2005. Patients in the IDU group seek medical care less frequently than patients in the sexual contact group. Statistics show that 61.4% of patients in the IDU group did not seek HIV-related medical care, significantly higher compared to the sexual contact group.The Taiwanese government implemented a trial “Harm Reduction Programme,” which involved a needle-syringe programme (NSP) and substitution treatment, in August 2005. After 1 year's pilot study, the HIV incidence in cities with NSP decreased from 13.9 to 13.3 per 100,000 persons compared to an incidence increase from 11.5 to 15.3 per 100,000 persons in cities without NSP. We scaled up the programme to cover the whole of Taiwan in July 2006 and are expecting to see the efficacy in the near future.     

HIV/AIDS and injection drug use in the neighborhoods of Dar es Salaam, Tanzania

This study examines the intersection between needle-sharing practices and HIV recovered from used syringes collected from 73 heroin injection drug users (IDUs) in Dar es Salaam, Tanzania, between October 2003 and January 2004. To extract blood residue, syringes were flushed and 10 microliters of solution mixed with 120 microliters of a latex solution was placed on a Capillus HIV-1/2 slide. Thirty-five (57%) of the useable syringes tested positive for HIV antibodies. Results varied significantly: 90% of syringes tested HIV positive in a mixed-income neighborhood 2 kilometers from the city center: 0% of syringes tested HIV positive in the outlying areas. In addition, semistructured interviews were conducted with 51 IDUs. The interviews were content coded, and codes were collapsed into emergent themes regarding syringe-use practices. Injecting is a recent practice, particularly among heroin users in neighborhoods far from the city center. Sharing syringes has resulted in a high proportion of used syringes containing HIV-positive blood residue. Geographic distance is an indicator of recent adoption of IDU in neighborhoods and correlates strongly with the distribution of syringes containing HIV-positive blood residue.     

Development and implementation of a cross-border HIV prevention intervention for injection drug users in Ning Ming County (Guangxi Province), China and Lang Son Province, Vietnam

This paper describes the background and early implementation of a peer-based HIV prevention intervention involving social marketing of sterile needles and syringes for injection drug users (IDUs) in a border region of northern Vietnam and southern China. Peer educators collect and safely dispose of used needles and syringes and provide IDUs with a choice of new needles/syringes or vouchers redeemable in pharmacies and clinics for new needles/syringes. The project arose from a pattern of changing drug use and increasing HIV infection in the region but its development took 4 years and faced many challenges. Implementation of the intervention posed a new set of challenges for the participating health departments, police, peer educators, pharmacists, injection drug users, and the communities at large. Early implementation of the project has revealed successful multi-sectoral collaboration, and broad acceptance by IDUs of pharmacy vouchers and distribution of new needles/syringes. However, IDUs’ persistent fear of the police, particularly in Vietnam, has required reliance on separate collection by peer educators of used needles/syringes and distribution of pharmacy vouchers and new needles. In China, new needles/syringes and vouchers are largely being provided through exchange. Understanding the development and implementation challenges and the strategies that were successful in overcoming them (including the importance of being flexible and adaptable to contextual factors) may be useful to those interested in launching similar, much-needed interventions in other parts of the world.     

Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales

The aim of this study was to compare demographic and drug use profiles of non-needle and syringe programmes (NSP) attendees with NSP attendees from the same geographic area. Two data sources were used. One was from an annual national survey of injecting drug users (IDU) at NSP and analysis was restricted to survey sites in Kings Cross and Kogarah in 2003 (NSP survey). The other was from a survey of IDU who do not use NSP as their primary source of injecting equipment within the same broad geographical region (Access survey). Of the total 264 survey participants, 102 had never attended a NSP (non-NSP attendees) and 162 had previous experience of NSP (NSP attendees). Compared with NSP attendees, non-NSP attendees were less likely to report severe drug problems and more likely to report lower prevalence of HIV, hepatitis B and hepatitis C infection. Nevertheless, about 20% of non-NSP attendees reported re-use of needles and syringes after someone else in the previous month. Compared to NSP attendees, a lower rate of usage of health services was reported by non-NSP attendees. Strategies to promote access to NSP and harm reduction services, including testing for blood-borne viruses, information provision and consideration of referral to treatment among non-NSP attendees are recommended. [Cao W, Treloar C. Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales. Drug Alcohol Rev 2006;25:439 - 444]     

Optimal provision of needle and syringe programmes for injecting drug users: A systematic review

The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among injecting drug users (IDUs). NSPs incorporating additional harm reduction strategies have been highlighted as an approach that may impact on HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of NSPs are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different NSP settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger IDUs and IDUs with higher risk profiles. Two studies of interventions aimed at encouraging IDUs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in NSPs was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among IDUs. Currently, it is difficult to draw conclusions on ‘what works best’ within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery NSPs impact on effectiveness.     

Syringe Disposal Options for Injection Drug Users: A Community-Based Perspective

This study was a qualitative exploration of syringe disposal interventions for injection drug users (IDUs). Data were collected through in-depth interviews with 26 community members who injected drugs and 32 noninjecting community members in Atlanta, Georgia. Both groups supported syringe exchange programs as syringe disposal interventions, while noninjecting community members favored a one-way drop box. IDUs identified fear of arrest for possession of syringes as the most salient barrier to safe syringe disposal, revealing the negative consequences of drug paraphernalia laws.     

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.     

Syringe disposal options for injection drug users: a community-based perspective.

This study was a qualitative exploration of syringe disposal interventions for injection drug users (IDUs). Data were collected through in-depth interviews with 26 community members who injected drugs and 32 noninjecting community members in Atlanta, Georgia. Both groups supported syringe exchange programs as syringe disposal interventions, while noninjecting community members favored a one-way drop box. IDUs identified fear of arrest for possession of syringes as the most salient barrier to safe syringe disposal, revealing the negative consequences of drug paraphernalia laws.