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.     

Beyond Needle Sharing: Meta-Analyses of Social Context Risk Behaviors of Injection Drug Users Attending Needle Exchange Programs

This study gathered data from U.S. and international needle exchange programs (NEPs). Of particular interest were outcome measures of dependent variables related to behaviors within social contexts of injection drug users (IDUs), an area not well understood. Thirty-one studies, with a total of 86 separate measures of 36 dependent variables were included. Because combining all results into a single meta-analysis would be inappropriate, dependent variables were placed into five categories for five separate meta-analyses: risky contexts, injection frequency, sharing drug paraphernalia, drug preparation, and syringe use. NEP attendance was inversely related to declines in all categorical behaviors except for “risky context.” NEP attenders are slightly more likely to be in a risky circumstance when injecting drugs than non-attenders. While injection frequency declined only slightly among NEP attenders, that result may be interpreted as a positive outcome, given the often-stated criticism that providing clean needles encourages increased drug use. NEP use was weakly associated with a decrease in the sharing of drug paraphernalia. Clean needles alone do not appear to be sufficient motivation to motivate major changes in contextual risk behaviors analyzed herein. Research is needed to assess the impact of interpersonal IDU relationships with other stakeholders (clinic employees, van drivers, medical personnel, nutritionists, sexual partners, etc.) on IDU drug-using behaviors at many levels.     

"Just using old works": injecting risk behaviour in prison

A minority of injecting drug users engage in high risk injecting behaviours when in prison. In the United Kingdom between a quarter and a third of injectors who enter prison inject when in prison, and of these about three-quarters share needles and syringes. In the present study, 44 drug injectors who had been released from prison for no longer than 6 months were recruited and interviewed in three geographical areas in England. Interviewees were asked to recount their experiences of drug use during their most recent period of imprisonment. The majority of interviewees were male (38/44), had a mean age of 28 years, with a mean age of 16 years at first drug use, were primarily opiate users (39) and had multiple imprisonments. All respondents reported drug use when imprisoned and drug injecting was reported by 16 interviewees. Most injected at irregular intervals and at a reduced level, compared with injecting when in the community. Nine reported using needles and syringes that others had previously used. When considering other injecting equipment, more sharing occurred than was actually reported. Much re-use of equipment was viewed simply as “using old works”. The sharing of “cookers” and “filters”, and drug sharing by “backloading” and “frontloading” were common. The concept of “sharing” tended to be understood by respondents as related to the use of tools of injection (needles and syringes rather than other equipment); the use of tools in the act of injection (rather than for mixing drugs); proximity (multiple use of needles and syringes in the presence of others); temporality (shorter time elapse between consecutive use of needles and syringes previously used by another) and source (hired rather than borrowed or bought). We conclude that syringe sharing is an integral part of drug use and drug injecting in prison. Many of those interviewed displayed a restricted understanding of what denotes syringe sharing. Our data reinforce the need for interventions and initiatives to be developed within prisons to deal with the considerable risk posed by continued injecting drug use.     

Secondary exchange of sterile injecting equipment in a high distribution environment: a mixed method analysis in south east Sydney, Australia

BackgroundIn Australia, sterile needles are distributed to people who inject drugs through formal services for the purposes of limiting the transmission of blood borne viruses (BBV). Secondary exchange (SE) involves people acquiring needles from formal services and redistributing them to others. This paper describes the extent, patterns and contexts of SE in south east Sydney, Australia and examines whether SE is independently associated with BBV risk practices.MethodsQuantitative and qualitative data were collected through a cross-sectional study using surveys and in-depth interviews. Respondents were people using community-based pharmacies to obtain sterile needles and syringes.ResultsData were collected from 229 survey respondents, over half of whom (54%) reported SE in the previous month. Of these, 40% engaged in distribution only, 25% in receipt only and 36% in both. Respondents reported passing on 21.7% of their needles to others in the last month, most commonly to friends (51.6%) and partners (27.4%). Recipients of SE were four times more likely than non-secondary exchangers to report borrowing used syringes in the last month. Respondents reported supplying sterile equipment to others to prevent reuse and to reduce risks associated with unplanned drug use.ConclusionSE is a common activity in south east Sydney but does not appear to be highly organised, usually taking place in small networks of friends and/or partners for altruistic reasons. Harm reduction programs could capitalise on the prevalence of SE to reach injecting drug users who do not use formal distribution services.     

Changes in the "get-off": social process and intervention in risk locales

Because of ongoing resistance in Florida's legislature to interventions involving exchanges of sterile syringes for contaminated ones, Miami/Dade County's population of injection drug users (IDUs) reduce risk of HIV and hepatitis C infection by buying illegal syringes, participating in illegal syringe exchanges, or decontaminating their paraphernalia. Although it is completely legal, wherewithal for decontamination of injection paraphernalia, including sodium hypochlorite (laundry bleach), water, and cotton for filtering drugs, only appears sporadically in Miami/Dade's risk locales (called "get-off" houses). To ensure consistent decontamination, our intervention instituted regular delivery of these goods to known risk locales. In addition, personnel in half of the locales received training in techniques for optimal decontamination. RNA polymerase chain reaction measured impact of this intervention in terms of viral load found on harvested paraphernalia. Regular delivery of cleansing paraphernalia provided opportunities for observation and characterization of adaptations among people who run risk locales. These people may lead highly stable lives or highly changeable ones, but in most cases their roles as regular hosts of injection activities continue with only brief hiatuses due to incarceration, eviction, or familial dissolution. Proprietors of risk locales maintain their roles as facilitators of self-injection because they use that role to make money or to obtain opportunities to inject drugs and also because their clientele demands they continue.     

Changes in the “Get-Off”: Social Process and Intervention in Risk Locales

Because of ongoing resistance in Florida's legislature to interventions involving exchanges of sterile syringes for contaminated ones, Miami/Dade County's population of injection drug users (IDUs) reduce risk of HIV and hepatitis C infection by buying illegal syringes, participating in illegal syringe exchanges, or decontaminating their paraphernalia. Although it is completely legal, wherewithal for decontamination of injection paraphernalia, including sodium hypochlorite (laundry bleach), water, and cotton for filtering drugs, only appears sporadically in Miami/Dade's risk locales (called “get-off” houses). To ensure consistent decontamination, our intervention instituted regular delivery of these goods to known risk locales. In addition, personnel in half of the locales received training in techniques for optimal decontamination. RNA polymerase chain reaction measured impact of this intervention in terms of viral load found on harvested paraphernalia. Regular delivery of cleansing paraphernalia provided opportunities for observation and characterization of adaptations among people who run risk locales. These people may lead highly stable lives or highly changeable ones, but in most cases their roles as regular hosts of injection activities continue with only brief hiatuses due to incarceration, eviction, or familial dissolution. Proprietors of risk locales maintain their roles as facilitators of self-injection because they use that role to make money or to obtain opportunities to inject drugs and also because their clientele demands they continue.     

Drug use stigma and its association with active hepatitis C virus infection and injection drug use behaviors among community-based people who inject drugs in India

BackgroundAlthough drug use stigma is globally pervasive, quantitative evidence of its role in hepatitis C virus (HCV) transmission is limited. We evaluated the psychometric properties of a drug use stigma scale and examined the association between drug use stigma and active HCV infection among a community-based sample of people who inject drugs (PWID) in India.MethodsBetween 8/2016 and 5/2017, a cross-sectional sample of PWID was recruited from 12 Indian cities (~1000/city) using respondent-driven sampling. Participants were ≥18 years old and reported injection drug use (IDU) in the past 2 years. Multivariable logistic regression with a random-intercept for each city was used to estimate adjusted odds ratios (aOR) of active HCV infection (RNA>30 IU/mL). Analyses incorporated RDS-II weights.ResultsOf 11,663 participants, 73.1% reported IDU in the past 6 months and 33.8% had active HCV infection. Exploratory factor analysis yielded a four-factor solution of enacted, vicarious, felt normative and internalized drug use stigma with high internal consistency (Cronbach's α: 0.85–0.92). In analyses adjusted for age, gender, northeast region, education, homelessness, incarceration, alcohol dependence, HIV status, frequency of IDU, and ever sharing needles/syringes, PWID reporting any enacted stigma had greater odds of active HCV infection (aOR = 1.27 [95% CI = 1.13–1.43]) as did PWID with internalized stigma scores in the highest quartile (vs. lowest quartile; aOR = 1.69 [95% CI = 1.11–2.56]). Among PWID who reported IDU in the past 6 months, multiple forms of stigma were associated with higher frequency of IDU, sharing needles/syringes, having multiple injection partners, and IDU in public spaces.ConclusionUsing a multidimensional drug use stigma scale, various forms of stigma were significantly associated with active HCV infection and injection drug use-related risk behaviors. Collectively, these data suggest that drug use stigma may play a role in HCV transmission and impede efforts to achieve HCV elimination. Strategies to diminish drug use stigma are warranted.     

Collateral damage in the war on drugs: HIV risk behaviors among injection drug users

Objective: To determine whether two key War on Drugs policies, the criminalization of syringes and the disqualification of drug users from the Supplemental Security Income (SSI) program, are associated with injection-related human immunodeficiency virus (HIV) risk behaviors among injection drug users (IDUs). Methods: IDUs were interviewed regarding HIV risk behaviors, drug use, and criminal activities in six San Francisco Bay Area communities in 1996 and followed through 1997 (n=1257). Multivariate analysis was conducted to examine the association between concern about arrest while carrying drug paraphernalia and injection-related risk behaviors. Regarding SSI, respondents were interviewed before (1996) and after (1997) drug and alcohol addicts were disqualified from SSI (n=88). Bivariate analysis was conducted comparing IDUs who lost SSI benefits with those who retained benefits. Results: Among our study sample, 32% of IDUs reported being concerned about possible arrest while carrying drug paraphernalia. In multivariate analysis, concerned IDUs were over one-and-a-half times more likely to share syringes than IDUs not concerned (adjusted odds ratio=1.74; 95% confidence interval =1.24, 2.44). Regarding SSI, 60% (53/88) of baseline SSI recipients had lost benefits by their follow-up interview. IDUs who lost benefits were more likely to participate in illegal activities (48 vs. 27%; P<0.05), more likely to share syringes (17 vs. 0%; P<0.05) and injected drugs on average more (43.8 vs. 36.4 per month; P<0.03) than those who retained benefits. Conclusions: These data suggest that War on Drugs policies which deny injection equipment and federal income support to IDUs also increase their risk for HIV infection, and should be reconsidered.     

Prevalence and Correlates of Needle-Sharing Among New and Long-Term Injection Drug Users in Southwest China

Three community-based surveys recruited 4,310 injection drug users (IDUs) in China from 2004 to 2006. Of the participants, 54.4% were ≤3-year new IDUs; 63.9% reported injecting more than two times daily; 31.5% shared needles in the last six months; 37.4% shared equipments in the last month; 30.2% reported their regular sex partners injected drugs; and 23.5% had commercial sex, with 52.2% reporting no condom use during last sex. The risky injection practices (sharing needles/equipments and high injection frequency) were less frequent among new IDUs, emphasizing that effective prevention needs to identify and intervene with IDUs early on. The study's limitations are noted.     

Modelling the prevalence of HCV amongst people who inject drugs: An investigation into the risks associated with injecting paraphernalia sharing

Background

In order to prevent the spread of the hepatitis C virus (HCV) amongst people who inject drugs (PWID), it is imperative that any injecting risk behaviour which may contribute to the transmission of disease has its role quantified. To inform public health organisations, mathematical modelling techniques were used to explore the risk of HCV infection through the sharing of injecting paraphernalia (including filters, cookers and water).

Methods

A mathematical model was developed for the spread of HCV based on the injecting behaviour of PWID in Scotland, with transmission occurring through the sharing of needles/syringes and other injecting paraphernalia. Numerical simulations were used to estimate the transmission probability for HCV through the sharing of injecting paraphernalia such that the modelled endemic HCV prevalence fitted with that observed amongst PWID in Scotland.

Results

The transmission probability of HCV through injecting paraphernalia was modelled to be over 8 times lower than that through needles/syringes (approximately 0.19–0.30% and 2.5%, respectively), assuming transmission occurs through a combination of at least filters and cookers. In the context of reported needle/syringe and paraphernalia sharing rates in Scotland, it is estimated that 38% and 62% of HCV infections are contributed by these practices, respectively. If needle/syringe sharing rates were to be twice those reported, the contributions would be 70% and 30%, respectively.

Conclusion

Given that the sharing of injecting paraphernalia among PWID is common, HCV transmission through this route could be contributing to the growing healthcare burden associated with this chronic disease. Every effort should therefore be made to establish (a) the contribution that paraphernalia sharing is making to the spread of HCV, and (b) the effectiveness of services providing sterile paraphernalia in preventing infection.     

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.     

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.     

Drug use in business bathrooms: An exploratory study of manager encounters in New York City

BackgroundThough public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses.MethodsA survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches.ResultsMore than half of managers interviewed (58%, n = 50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance.ConclusionThe results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.     

HIV prevention cascades for injection and sexual risk behaviors among HIV-negative people who inject drug in Iran

BackgroundThe HIV prevention cascade complements the HIV treatment cascade and helps evaluate the access to and use of harm reduction programs among HIV-negative individuals at risk for HIV, including people who inject drugs (PWID). This study aimed to estimate the HIV prevention cascades among PWID in Iran.MethodsUsing data from the 2014 national bio-behavioral surveillance survey, 2,391 PWID were recruited from 31 harm reduction facilities and through outreach efforts across 10 major cities. PWID aged ≥18 years who reported drug injection in the past year were interviewed, and information regarding their demographic characteristics, sexual and drug injection practices, and access to services were gathered. PWID were also tested for HIV infection. We examined the prevention cascade framework among HIV-negative PWID.ResultsThe majority of PWID were male (97.6%) and more than half aged ≥ 35 years old (55.5%). Overall, 2,092 (92.5% [95% CI: 90.8, 93.9]) were HIV-negative; 93% of whom knew illicit drug injection could increase the risk of HIV transmission, 54% had access to free-of-charge sterile needles and syringes, 51% used sterile needles and syringes in their last injection practice, and 33% used sterile needles and syringes in all injection practices in the past month. Also, 87.8% (95% CI: 85.1, 90.0) of HIV-negative PWID had sex with any partner in the past year; 88% of whom knew using condoms could reduce the risk of HIV transmission, 35% had access to free-of-charge condoms, 32% used condoms in their last sexual practice, and 18% used condoms in all of their sexual practices in the past month.ConclusionThe majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.     

Emerging Risks Due to New Injecting Patterns in Hungary During Austerity Times

As a consequence of the massive restructuring of drug availability, heroin injection in Hungary was largely replaced by the injecting of new psychoactive substances (NPS) starting in 2010. In the following years in our sero-prevalence studies we documented higher levels of injecting paraphernalia sharing, daily injection-times, syringe reuse, and HCV prevalence among stimulant injectors, especially among NPS injectors. Despite the increasing demand, in 2012 the number of syringes distributed dropped by 35% due to austerity measures. Effects of drug market changes and the economic recession may have future epidemiological consequences. Study limitations are noted and future needed research is suggested.     

Incarceration, addiction and harm reduction: inmates experience injecting drugs in prison

Within Canadian prisons HIV/AIDS is becoming more common among inmates. While injection drug use in correctional facilities is documented to be a problem, qualitative research into the HIV risks faced by inmates is lacking. The goal of this research was to qualitatively examine HIV risk associated with injecting inside British Columbia prisons. A sample of 26 former male inmates who had recently used drugs within correctional facilities were recruited from a ongoing cohort study of injection drug users in Vancouver, Canada. Data for this study were collected through in-depth interviews conducted in 2001/2002. Analysis of these data involved identifying emergent themes and then exploring these central concepts in further interviews to confirm the accuracy of interpretation. The harms normally associated with drug addiction, and injection drug use are exacerbated in prison. Interpersonal relationships and the possession of exchangeable resources determine access to scarce syringes. The scarcity of syringes has resulted in patterns of sharing amongst large numbers of persons. Continual reuse of scarce syringes poses serious health hazards and bleach distribution is an inadequate solution. The findings of this study emphasize the need for effective harm reduction programs that provide an appropriate response to the problem of injection drug use among inmates.     

Incarceration,Addiction and Harm Reduction: Inmates Experience Injecting Drugs in Prison

Within Canadian prisons HIV/AIDS is becoming more common among inmates. While injection drug use in correctional facilities is documented to be a problem, qualitative research into the HIV risks faced by inmates is lacking. The goal of this research was to qualitatively examine HIV risk associated with injecting inside British Columbia prisons. A sample of 26 former male inmates who had recently used drugs within correctional facilities were recruited from a ongoing cohort study of injection drug users in Vancouver, Canada. Data for this study were collected through in-depth interviews conducted in 2001/2002. Analysis of these data involved identifying emergent themes and then exploring these central concepts in further interviews to confirm the accuracy of interpretation. The harms normally associated with drug addiction, and injection drug use are exacerbated in prison. Interpersonal relationships and the possession of exchangeable resources determine access to scarce syringes. The scarcity of syringes has resulted in patterns of sharing amongst large numbers of persons. Continual reuse of scarce syringes poses serious health hazards and bleach distribution is an inadequate solution. The findings of this study emphasize the need for effective harm reduction programs that provide an appropriate response to the problem of injection drug use among inmates.     

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.     

Acceptance of HIV-antibody testing by persons seeking outpatient treatment for cocaine abuse

One hundred of 101 applicants for outpatient treatment for cocaine abuse consented to voluntary HIV-antibody testing when the testing was offered as an option within the medical assessment at intake. Twelve applicants tested HIV-antibody positive; eight of these had injected drugs parenterally with syringes and needles used by other addicts and four had never taken drugs intravenously. There were no significant differences between HIV-antibody positive and negative applicants regarding the percentages who completed the evaluation, began treatment, and completed four weeks of treatment. A subgroup of 48 patients were interviewed regarding their knowledge of HIV infection, AIDS, and risk factors associated with transmission of HIV. All 48 patients had heard of HIV, AIDS, and recommendations that they use condoms as well as clean syringes and needles. None of the 48 patients reported that they used condoms; 10 reported reduced sexual activity and number of sexual partners; and none of those who shared needles reported that they had discontinued sharing other addicts' drug paraphernalia. The authors conclude that on-site, voluntary HIV-antibody testing for drug abusing patients entering treatment appears feasible and is not a deterrent to persons entering and continuing in treatment for drug abuse. The finding that persons at risk for HIV infection have knowledge of risk factors and have not changed risk-taking behaviors associated with HIV contagion points out the urgent need for further education and counseling.