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.     

Harm Reduction in the Hills of Northern Thailand

The human immunodeficiency virus (HIV) pandemic has swept through injecting drug user (IDU) communities around the world. Once HIV is present in an IDU community, seroprevalence rates escalate rapidly unless immediate and comprehensive prevention methods are put in place. Such measures often include providing IDUs with sterile injecting equipment and dispensing methadone or other opiate substitution formulas. These measures fall under the rubric of harm reduction-an attempt to reduce the harm to drug users, their families, and communities, including preventing or limiting the transmission of HIV and other blood-borne viruses. In Thailand, HIV-1 spread rapidly among IDUs with seroprevalence rates jumping from 1 to 40% in the space of a year. Current incidence rates are estimated at 11 per 100 person years. This paper describes the establishment and implementation of needle and syringe exchanges among injecting drug users in nine Hilltribe communities in Northern Thailand. The exchanges have been operating for between 1 and 3 years and have been effective in limiting the transmission of HIV within these small communities. The needle and syringe exchanges are run by indigenous staff widi the cooperation of the community and provide a good example of the feasibility of establishing locally-run, community-based harm reduction programs.     

Minimal uptake of sterile drug preparation equipment in a predominantly cocaine injecting population: implications for HIV and hepatitis C prevention

ObjectiveTo identify factors associated with using sterile drug injection equipment by injection drug users (IDUs).Methods275 IDUs were recruited from syringe exchange programs in Montreal, Canada in 2004–2005. A structured, interviewer-administered questionnaire collected information about demographics, drug injection practices, self-reported HIV and hepatitis C virus (HCV) status, and harm reduction behaviours. Logistic regression was used to model variables in relation to the use of sterile syringes, containers, filters, and drug preparation water.ResultsSterile syringes, containers, filters, and water were used for at least half of injecting episodes by 95%, 23%, 23%, and 75% of subjects, respectively. In multivariate analysis, users of sterile syringes had higher odds of being older and injecting alone, and were less likely to report problems obtaining sterile syringes and requiring or providing help with injecting. Using sterile filters was associated with having at least high school education, injecting heroin, and injecting alone. In addition to the factors associated with filters, users of sterile containers were more likely to be HCV-negative and older. Using sterile water was associated with daily injecting and being HCV-negative.ConclusionsImproving the uptake of sterile drug preparation equipment among IDUs could be aided by considering drug-specific risks, such as drug of choice and injecting context, while reinforcing existing messages on safer injecting. The association between sterile equipment use and HCV-negative status may be representative of an established subgroup of safer injectors who have remained free of infection because of consistent safe injecting practices.     

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.     

Uptake of paraphernalia from injecting equipment provision services and its association with sharing of paraphernalia among injecting drug users in Scotland

Background

There has been a significant increase in the provision of injecting paraphernalia from Scottish injecting equipment provision (IEP) services. However, there is currently a lack of evidence on whether uptake of paraphernalia has any impact on paraphernalia sharing among injecting drug users (IDU). The aim of this study was to examine the factors associated with paraphernalia sharing; in particular, whether uptake of filters, spoons and sterile water from IEPs is associated with a reduction in the sharing of these items.

Methods

A cross-sectional voluntary anonymous survey of 2037 IDUs was administered during 2008–2009. Participants were asked whether they had shared filters, spoons or water (paraphernalia) in the previous 6 months, and their uptake of these items from an IEP during an average week in the previous 6 months.

Results

Self-reported uptake of paraphernalia in an average week during the previous 6 months was associated with reduced odds of sharing paraphernalia: (i) uptake of >30 filters was associated with a reduced odds of sharing filters (adjusted odds ratio (AOR) 0.50, 95% confidence interval 0.32–0.79); (ii) uptake of >30 spoons was associated with a reduced odds of sharing spoons (AOR 0.46, 95% confidence interval 0.28–0.74); and (iii) uptake of sterile water was associated with a reduced odds of sharing water (AOR 0.36, 95% confidence interval 0.22–0.61) compared to no uptake of each of these items.

Conclusions

Uptake of paraphernalia appears to be associated with safer injecting practice. Further research is needed to establish the impact of paraphernalia provision on HCV transmission.     

Doing the possible: harm reduction, injecting drug use and blood borne viral infections in Australia

Most surveys show that, other than among men who inject drugs and have a history of homosexual contact, the prevalence of HIV infection among injecting drug users (IDUs) in Australia is about 2%. Rates of needle sharing have also declined greatly in the last decade, although the high prevalence and incidence of hepatitis C infection suggest that existing strategies have not yet brought this epidemic under control. Harm reduction has been the major Australian approach to the reduction of blood borne viral infections (BBVIs) in IDUs. Harm reduction strategies include needle distribution schemes, drug substitution therapies and education about safe administration practices. Importantly, with IDUs as with gay men, the infected and affected communities have been brought into partnership with health educators, researchers and policy makers. This paper will review Australia's approach to the prevention of BBVI in IDUs and the effectiveness of current strategies. I will argue that while HIV/AIDS among heterosexual IDUs appears to have been successfully prevented, international experiences of rapidly emerging epidemics demonstrate there is little room for complacency. Moreover, reducing the incidence of hepatitis C and hepatitis B among IDUs remains a major challenge.     

Not All Injection Drug Users Are Created Equal: Heterogeneity of HIV,Hepatitis C Virus,and Hepatitis B Virus Infection in Georgia

Injection drug users (IDU) are widely believed to have accelerated the looming HIV/AIDS epidemic now faced by the Russian Federation and countries of the former Soviet Union. However, IDUs may be heterogeneous with regard to risk behaviors, and a subpopulation may be responsible for the majority of blood-borne pathogen transmission. We studied 926 adult injection drug users (IDU) from the cities of Tbilisi, Batumi, and Poti in Georgia, a small country in the Caucuses region between the Black and Caspian Seas, between 1997 and 1998. Study participants were administered a confidential questionnaire and were tested for antibody to HIV, hepatitis C virus (HCV), hepatitis B virus surface antigen (HBsAg), and hepatitis B core antibody (anti-HBc). Five (0.5%) individuals were positive for HIV; 539 (58.2%), for HCV; 67 (7.2%), for HBsAg; and 475, for (51.3%) anti-HBc. Surveyed individuals, 88.7%, reported sharing needles with others, and needle sharing with more than 10 other individuals versus no sharing was a highly significant predictor (OR: 278.12, 95% CI: 77.57, 997.20) of HCV seropositivity. In adjusted analysis, individuals who usually injected stolen medical/synthetic drugs had significantly lower odds of HCV (OR: 0.38, 95% CI: 0.22, 0.68) and HBV (OR: 0.58, 95% CI: 0.37, 0.90) than individuals most commonly injecting opium. Despite some limitations, these results suggest the presence of substantial heterogeneity between different injection drug-using groups in Georgia. Identification of high-risk IDU subpopulations is vital to efficiently target risk reduction programs and to prevent confounding by risk status in large HIV/AIDS behavioral intervention and vaccine trials.     

Injecting nation: achieving control of hepatitis C in Australia

Since Australia banned heroin in 1953 consumption of illicit drugs, deaths, crime and corruption related to drugs have steadily increased. Injecting drug use (IDU) in Australia is now a significant public health problem linked each year to approximately 500 overdose deaths and more than 6000 hepatitis C infections. At least 85% of prevalent and incident hepatitis C cases in Australia are injecting drug users (IDUs) with annual incidence estimated at 15%. Although poorly documented, increasing numbers of patients with end-stage liver disease from hepatitis C now appear to present in Australia. This reflects a heroin-injecting epidemic commencing a quarter of a century ago, the close association between drug injecting and hepatitis C and the long delay between hepatitis C infection and complications. The overall health and economic burden of hepatitis C may soon exceed HIV. Control is far more difficult to achieve for hepatitis C than HIV because of much higher baseline prevalence levels and far greater infectiousness by blood to blood spread. Transmission appears to follow minimal breaches of infection control guidelines. Hepatitis C has not yet become a priority public health issue in Australia. No national prevention strategy has been proposed. Prevention strategies (such as needle exchange or methadone) which controlled HIV among IDUs should be expanded, with the expectation of some useful reduction of spread but without achieving control of hepatitis C. Other options for control must be considered. Eradicating illicit drug use in Australia is unachievable. Virtually eradicating injecting drug use by facilitating a switch to non-injecting routes of administration (NIROA) is achievable (although difficult) and this could control hepatitis C. NIROA will have the probable additional benefit of reducing drug overdose deaths. NIROA has begun recently to replace injecting in several countries without government intervention. Powerful cultural, pharmacological and economic factors strongly reinforce drug injecting. Economic impediments to NIROA could be reduced by drug policy reform. Facilitating a switch to NIROA carries some risk of increased discrimination directed against an already marginalized population. A major obstacle to harm reduction is the common assumption that any relaxation of drug policy invariably leads to increased consumption. Switching the predominant route of administration of illicit drugs from IDU to NIROA should be the major focus of national efforts to control hepatitis C and overdose deaths in Australia.     

Drug use,AIDS Knowledge,and HIV Risk Behaviors of Cuban-, Mexican-, and Puerto-Rican-Born Drug Injectors who are Recent Entrants into the United States

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

Injecting Equipment Provision in Australia: The State of Play

Injecting equipment provision measures in Australia can be judged reasonably successful as HIV prevention measures. In the capital cities of all Australian States and Territories, access to needles and syringes is easy, at least during the day in at least some areas. In conjunction with peer education and other activities, needle and syringe supply appears to have led to a change in norms away from the sharing of needles and other injecting equipment among at least older heroin injectors in large population centers. However, in many other areas, and in many subpopulations-particularly further marginalized groups such as Aboriginal and Vietnamese-Australian injectors-messages about HIV/AIDS risk are either not penetrating or are being ignored, and needle and other equipment sharing still appears to be common. The strategy of providing access to needles and syringes as a separate activity from peer education among injecting drug users (IDUs) needs to be reconsidered in the light of the widespread epidemic of hepatitis C among Australian IDUs. The level of supply of all injecting equipment also needs to be increased to assist all IDUs in learning and carrying out an aseptic injecting technique given the lack of an effective disinfection technique to prevent the spread of hepatitis C, and me problems surrounding both the promotion of disinfection and the promotion of noninjecting routes of administration.     

Measuring Attitudes Toward Injecting Drug Users and People with Hepatitis C

Preexisting scales used to measure attitudes toward human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and homosexuals were adapted to assess attitudes toward people with hepatitis C (HCV) and injecting drug users (IDUs). In 2005, 110 undergraduate psychology students completed these scales, and abbreviated versions of the IDU and HCV scales were then administered to 61 health care workers to establish their relevance in the field. Results indicated that the new scales have good reliability and validity with undergraduates and with health care workers in an applied setting.     

The impact of an HIV prevention intervention for injecting drug users in Svetlogorsk,Belarus: model predictions

Background: From the mid-1990s there has been a rapid spread of HIV infection amongst injecting drug users (IDUs) in Svetlogorsk, Belarus. In 1997, when the IDU HIV prevalence had reached 74%, two needle and syringe exchange points (NEPs) were established in the town. These interventions have been operating since then, with some interruptions due to a lack of funding 1998. Methods: This article presents a deterministic epidemiological model ‘IDU 2.4’ that simulates the transmission of HIV among IDUs sharing injecting equipment, and between IDUs and their sexual partners. The model incorporates the impact of the interrupted distribution of clean syringes and condoms, is validated against data from Svetlogorsk, and is used to estimate the impact of the intervention on HIV transmission. Results: The model predicts that between 1997 and 2000 the intervention averted 414 HIV infections in Svetlogorsk (95% CI, 180–690) and caused a 6.5% decrease in IDU HIV prevalence compared to if there had been no intervention. The analysis also suggests that the gap in funding between 1998 and 1999 resulted in a 35% reduction in the number of HIV infections averted among IDUs during that period, and that the IDU HIV prevalence is 3% higher in 2000 (95% CI, 1.9–4.6%) than if there had been no gap in funding. Conclusions: Even though the HIV prevalence and incidence amongst the IDUs remained high, the findings suggest that the intervention had an important affect on HIV transmission in Svetlogorsk, Belarus. The findings reinforce the importance of strengthening existing projects and replicating similar projects in the region, and highlight the detrimental impact of gaps in intervention funding.     

HIV Among Drug Users at Beth Israel Medical Center,New York City,the First 25 Years

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.     

Social Context of Needle Selling in Baltimore,Maryland

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

Injection Risk Behavior among Women Syringe Exchangers in San Francisco

Women who inject drugs in cities where syringe exchange programs (SEPs) are well established may have different risks for HIV infection. In 1997, we interviewed 149 female syringe exchangers in San Francisco, CA, a city with high rates of injection drug use that is home to one of the largest and oldest SEPs in the United States. In this report, we describe their sociodemographics, health, and risk behavior, and we examine factors associated with recent syringe sharing. Fifty percent of respondents were women of color and the median age was 38 years. Most (86%) injected heroin and nearly half were currently homeless or had recently been incarcerated. One-third of all women reported needle sharing in the prior month. This was higher than the rate of needle sharing reported by a mixed gender sample of San Francisco exchangers in 1993, although it resembled the rate reported by a mixed gender sample in 1992. In a multivariate analysis, syringe sharing was associated with age, housing status, and sexual partnerships. Syringe sharers were more likely to be young, homeless, or have a sexual partner who was also an injection drug user. While wide access to sterile syringes is an important strategy to reduce HIV transmission among injection drug users (IDU), syringe exchange alone cannot eradicate risky injection by female IDU. Additional efforts to reduce risky injection practices should focus on younger and homeless female IDU, as well as address selective risk taking between sexual partners.     

The Role of Physician and Nurse Attitudes in the Health Care of Injecting Drug Users

In 2005, 60 health care workers were recruited through services that attract injecting drug users (IDUs) and asked to complete attitude measures regarding IDU clients. Mediation analyses indicated that conservative health care workers displayed more negative attitudes toward their IDU clients because they believe that injecting drug use is within the control of the IDU. Negative attitudes toward IDU clients, in turn, were associated with worry about IDU clients’ behavior in the clinic and with beliefs that IDU clients should disclose their hepatitis C status to their health care worker. Perceptions of controllability of drug use were also associated with the belief that IDU clients’ ailments were caused by their IDU status. The study's limitations are noted.     

Not all injection drug users are created equal: heterogeneity of HIV, hepatitis C virus, and hepatitis B virus infection in Georgia

Injection drug users (IDU) are widely believed to have accelerated the looming HIV/AIDS epidemic now faced by the Russian Federation and countries of the former Soviet Union. However, IDUs may be heterogeneous with regard to risk behaviors, and a subpopulation may be responsible for the majority of blood-borne pathogen transmission. We studied 926 adult injection drug users (IDU) from the cities of Tbilisi, Batumi, and Poti in Georgia, a small country in the Caucuses region between the Black and Caspian Seas, between 1997 and 1998. Study participants were administered a confidential questionnaire and were tested for antibody to HIV, hepatitis C virus (HCV), hepatitis B virus surface antigen (HBsAg), and hepatitis B core antibody (anti-HBc). Five (0.5%) individuals were positive for HIV; 539 (58.2%), for HCV; 67 (7.2%), for HBsAg; and 475, for (51.3%) anti-HBc. Surveyed individuals, 88.7%, reported sharing needles with others, and needle sharing with more than 10 other individuals versus no sharing was a highly significant predictor (OR: 278.12, 95% CI: 77.57, 997.20) of HCV seropositivity. In adjusted analysis, individuals who usually injected stolen medical/synthetic drugs had significantly lower odds of HCV (OR: 0.38, 95% CI: 0.22, 0.68) and HBV (OR: 0.58, 95% CI: 0.37, 0.90) than individuals most commonly injecting opium. Despite some limitations, these results suggest the presence of substantial heterogeneity between different injection drug-using groups in Georgia. Identification of high-risk IDU subpopulations is vital to efficiently target risk reduction programs and to prevent confounding by risk status in large HIV/AIDS behavioral intervention and vaccine trials.     

在静脉吸毒者中开展降低危害干预项目的效果分析

目的探索在静脉吸毒者中开展以针具交换和同伴教育为主的降低危害干预项目的有效模式。方法在宁明县边境乡镇社区寻找并通过＂滚雪球＂的方式发展静脉吸毒者,在进行需求调查的基础上,对其开展针具交换、同伴教育、自愿咨询检测、安全套发放等降低危害的活动。并通过横断面调查了解静脉吸毒者行为的改变情况及干预的效果。结果项目当地的静脉吸毒者HIV感染率有下降趋势,由基线调查的17.32%下降到13.1%;共针吸毒行为从47.0%下降到3.4%;最近一次性行为不使用安全套从71.4%下降到31.3%;静脉吸毒者艾滋病知识知晓率明显提高。结论在静脉吸毒者中开展以针具交换和同伴教育为主的干预模式降低危害是可行的,效果是显著的。     

Reaching the unreached: targeting hidden IDU populations with clean needles via known user groups.

Needle exchange is a practical and important part of the Dutch prevention strategy to check the spread of HIV among injecting drug users (IDUs). However, needle-exchange programs are often tied to drug treatment programs that only reach a limited number of IDUs. To overcome this limitation, alternative designs are considered and initiated. This article describes a community-based approach to needle exchange that is built on empowerment of, and intense participation by, known IDUs to target unknown IDUs for delivery of clean needles. The needle-exchange patterns of the IDUs participating in this collective scheme are compared to those of other users who exchanged needles on an individual basis. It was found that this approach extended the reach of the program to a great degree and that it was well received in the IDU community. However, the results were negatively influenced by police activities aimed at closing down places where drugs were used and sold. It is concluded that engaging IDUs in peer-group-directed prevention efforts is both feasible and promising.