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.     

Effectiveness of drug dependence treatment in HIV prevention

This review considers the effectiveness of drug dependence treatment in preventing HIV transmission among injecting drug users (IDUs). Substitution programmes using agonist pharmacotherapy (e.g. methadone and buprenorphine maintenance treatment) are available only for drug users who are primarily opioid dependent. There are over half a million people in receipt of methadone maintenance treatment (MMT) and it is estimated that this number will double in the coming decade. There is evidence that MMT is associated with a significant decrease in injecting drug use and sharing of injecting equipment. Data on sex-related risk behaviour change are limited, but suggest that MMT is associated with a lower incidence of multiple sex partners or exchanges of sex for drugs or money, but no change, or only small decreases, in unprotected sex. Studies of seroconversion, which is the toughest and most robust standard for assessing the role of MMT in HIV prevention, suggest that the reductions in risk behaviours do translate into actual reductions in cases of HIV infection. While the data on HIV risk behaviour are limited, there is strong evidence that substitution treatment with either methadone or buprenorphine suppresses illicit opioid use. There is also evidence that substitution treatment for HIV-positive IDUs is associated with better compliance with anti-retroviral treatment and improved health outcomes. The only antagonist being used for opioid dependence relapse prevention treatment is naltrexone. There is currently insufficient evidence to draw firm conclusions as to its effectiveness. Behavioural interventions add to the effectiveness of substitution treatment, while the effectiveness of different types of psychological therapy alone has been found to be variable. There have been few comparative studies of abstinence-based treatment, however, available evidence indicates good outcomes for those who remain in treatment for three months or more. All countries with a population of IDUs should aim to develop a comprehensive range of treatments, including substitution treatment, as a critical component of HIV prevention.     

HIV prevalence among IDUs in Australia: a methodological review

A review was carried out of Australian studies which have measured the prevalence of HIV infection among injecting drug users (IDUs). The review considered published studies which had reported on serologically-determined HIV prevalence. There were five studies reported from specialized sexually-transmissible disease of HIV clinics, five studies reported from health services aimed at IDUs, three studies reported from other health services and one multi-centre behavioural study. The main findings from the studies were that HIV prevalence in IDUs has been low in Australia, apart from in male IDUs who also had homosexual contact. HIV prevalence ranged from 20 to 24% in male IDUs reporting homosexual contact and from 0 to 5% in other IDUs.

The studies, while reflecting a range of research methodologies, are subject to a number of limitations. Most of the studies did not provide detailed analyses of HIV prevalence by age and sex or behavioural factors, and several studies used sampling frames which were not clearly defined. There is little available information on temporal trends in seroprevalence and geographical comparisons are rendered difficult by differences in the study methodology. Adoption of standardized, continuing seroprevalence surveys on IDUs would provide a better means of monitoring the occurrence of HIV infection in this group, which has been a key determinant of the course of the HIV epidemic in a number of Western countries.     

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.     

Socio-demographic factors,health risks and harms associated with early initiation of injection among people who inject drugs in Tallinn,Estonia: Evidence from cross-sectional surveys

AimTo explore socio-demographic factors, health risks and harms associated with early initiation of injecting (before age 16) among injecting drug users (IDUs) in Tallinn, Estonia.MethodsIDUs were recruited using respondent driven sampling methods for two cross-sectional interviewer-administered surveys (in 2007 and 2009). Bivariate and multivariate logistic regression analysis was used to identify factors associated with early initiation versus later initiation.ResultsA total of 672 current IDUs reported the age when they started to inject drugs; the mean was 18 years, and about a quarter of the sample (n = 156) reported early initiation into injecting drugs. Factors significantly associated in multivariate analysis with early initiation were being female, having a lower educational level, being unemployed, shorter time between first drug use and injecting, high-risk injecting (sharing syringes and paraphernalia, injecting more than once a day), involvement in syringe exchange attendance and getting syringes from outreach workers, and two-fold higher risk of HIV seropositivity.ConclusionsOur results document significant adverse health consequences (including higher risk behaviour and HIV seropositivity) associated with early initiation into drug injecting and emphasize the need for comprehensive prevention programs and early intervention efforts targeting youth at risk. Our findings suggest that interventions designed to delay the age of starting drug use, including injecting drug use, can contribute to reducing risk behaviour and HIV prevalence among IDUs.     

Cost of Outreach for HIV Prevention Among Drug Users and Youth at Risk

SUMMARY

Economic evaluation has become an increasingly important component in determining the effectiveness of HIV prevention programs. One type of intervention that governmental and nongovernmental organizations have supported to prevent the spread of HIV is outreach. We conducted a cost analysis at eight sites that provide outreach services to two populations at high risk for HIV infection: injection drug users and street youth. We assessed the potential benefit of HIV prevention through outreach services by comparing outreach costs with the medical costs of treating an HIV infected individual.

The average cost of outreach services was $13.30 per contact. The cost per contact for services to street youth was 78% higher than for drug users. Comparing the cost per contact with HIV treatment costs, if only two in 10,000 contacts reduce their high-risk behavior so as to avoid transmission of HIV, outreach would yield a net benefit. These results provide evidence that outreach programs compare favorably to other HIV prevention strategies in terms of cost.     

Topic-Focused Bibliography: Syringe Exchange: HIV Prevention,Key Findings,and Future Directions

HIV among injecting drug users (IDUs) has now been documented in over 60 countries in the world, and there are an additional 40 countries where injecting drug use has been reported including widespread epidemics in Southeast and southern Asia and in Latin America. At present HIV infection is almost always fatal, and there is no promise that a preventive vaccine will become available soon. Given the enormity of the HIV epidemic among IDUs and the critical need to reduce the spread of HIV transmission to and from IDUs, prevention efforts are essential. Syringe-exchange programs have become a major component of HIV prevention strategies in most developed countries and work within the philosophy of harm reduction. Increasing access to sterile syringes has been met with considerable controversy. Opponents of syringe exchange have generally argued that increasing access to sterile syringes would simultaneously increase the number of injecting drug users, increase the frequency of injection for already active IDUs, and appear to “condone” an illegal behavior. To date many research studies and four major reviews of syringe exchange literature have been conducted. All studies thus far have shown no increase in illicit drug injection associated with syringe exchanges, and significant decrease in drug risk behaviors.     

四川省凉山地区静脉吸毒人群药物滥用及其行为特征调查

目的:了解四川省凉山地区静脉吸毒人群药物滥用及行为特征情况,为采取有针对性的戒毒干预措施预防艾滋病病毒的传播提供数据.方法:以社区为基础招募了379名静脉吸毒人员,调查其人口学特征,艾滋病病毒感染情况,药物滥用的种类、吸毒方式和频率,口吸和静脉吸毒时间,共用注射器具情况等.结果:静脉吸毒人群艾滋病病毒感染率为11.3%(43/379).379名被调查者全部为海洛因滥用者,其中247人(65.2%)单独使用过海洛因,297人(78.4%)混合注射过海洛因与安定,滥用过的其他药物有安定(8.2%)和鸦片(1.3%).300人(79.2%)每天静脉注射吸毒一次及以上;曾经共用注射器具静脉吸毒的为247人(65.2%),87人(35.2%)首次静脉注射吸毒即与他人共用注射器具;初次口吸吸毒和静脉注射吸毒的平均年龄分别为22.37岁和25.35岁,口吸吸毒和静脉注射吸毒的平均时间分别为6.41年和3.42年.结论:加强青少年、吸毒人员关于毒品危害和拒绝毒品的健康教育活动,以及开展美沙酮或丁丙诺啡口服治疗海洛因依赖者,降低静脉注射吸毒行为,控制艾滋病病毒的传播.     

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.     

Impact of HIV risk and infection and the role of prevention services

Blood-borne infection associated with injection drug use is a significant cause of morbidity and mortality. Over the last decade, HIV infection and its clinical sequelae have had a significant impact on research and interventions involving injecting drug users (IDUs) in the United States and elsewhere. Discussed are some of the major intervention options for reducing blood-borne infections in general and HIV in particular. The use of multiple interventions is considered within the community context in which both IDUs and service providers operate. Intervention options discussed include treatment for drug dependence; voluntary and confidential HIV testing and counseling; community health outreach; bleach distribution; and easy, legal access to needles and syringes through pharmacy sales and needle exchange programs. Many surveillance and evaluative studies have examined multiple intervention efforts that include all or some of these program components and suggest positive outcomes. However, these studies tend to be limited by experimental designs that restrict attribution of causal inference. Examples of such programs in the United States and abroad are examined in terms of their potential for reducing HIV risk behaviors and averting new infections. The article concludes that diversity among AIDS prevention programs, rapid deployment (at earlier stages of epidemics), and effective coordination (minimization of interagency conflicts) are important factors in successful AIDS prevention programming and attaining disease prevention objectives.     

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.     

Success and Failure of LAAM Maintenance: Selected Case Studies

Abstract

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 limit ation, 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 IOU 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.     

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.     

Women injecting drug users in London: the extent and nature of their contact with drug and health services

Improved access to drug treatment and other health services remains central to HIV prevention and other harm reduction strategies among injecting drug users (IDUs) in the UK. Efforts have therefore been focused upon making such services more accessible and 'user friendly'. Women who use drugs are considered a 'hard to reach' population. This is largely based on data from a variety of official sources which have suggested that women are under-represented as clients of drug services. While current literature provides numerous explanations for this, there have been few empirical studies exploring the nature and extent of women's contact with such services. This paper presents findings from an European Community funded survey of women IDUs in London. Data from this survey suggest that women IDUs have surprisingly high levels of contact with a range of specialist and generic health services in relation to their drug use.     

African-American injection drug users: tensions and barriers in HIV/AIDS prevention.

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs.     

Characteristics of High-Risk HIV-Positive IDUs in Vietnam: Implications for Future Interventions

The HIV epidemic in Vietnam is concentrated primarily among injecting drug users (IDUs). To prevent HIV-1 superinfection and to develop effective HIV prevention programs, data are needed to understand the characteristics of high-risk HIV-positive IDUs. In , we conducted a community-based cross-sectional study among predominately male, out-of-treatment IDUs, aged 18–45, in the Bac Ninh Province, Vietnam. Among 299 male participants, 42.8% were HIV-positive, and among those, 96.9% did not know their status prior to the study. Furthermore, 32% were HIV-positive and had high HIV behavioral risk (having unprotected sex or having shared injecting equipment in the past 6 months). Injecting for ≥3 years, younger age, and pooling money to buy drugs were independently associated with being at high risk for transmitting HIV. IDUs who purchased more than one syringe at a time were less likely to have high HIV behavioral risk. Structural interventions that increase syringe accessibility may be effective in reducing HIV risk behavior among HIV-positive IDUs. Study limitations are noted in the article.     

AFRICAN-AMERICAN INJECTION DRUG USERS: TENSIONS AND BARRIERS IN HIV/AIDS PREVENTION

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs. [Translations are provided in the International Abstracts Section of this issue.]     

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.     

Interventions to reduce the sexual risk behaviour of injecting drug users

Reducing the risk of sexual HIV transmission by injecting drug users (IDUs) is important for controlling the HIV epidemic among all drug users and for controlling the larger epidemic. Over the past few years, several qualitative and meta-analyses reviews have been published. Most of these reviews involved numerous studies conducted in resource-rich countries, while a few covered the smaller number of studies undertaken in resource-constrained countries. In order to make greater strides in controlling the HIV epidemic, we assessed the generalisability of the results of the major studies and reviews for use in developing programmes in resource-constrained countries. We also discuss the implications for global research efforts and public health practice.The reviews show that IDUs in both resource-rich and resource-constrained countries have changed their sexual risk behaviours, reflecting rational and altruistic responses to a major health threat. Findings show that IDUs changed their sexual risk behaviour to avoid becoming infected with HIV and to avoid transmitting HIV to their sexual partners. Although the risk-reduction effect is moderate, it is important to implement programmes to reduce the sexual risk behaviour of IDUs in all countries. Providing evidence-based interventions is ethically responsible compared to providing no interventions. As interventions are implemented in different settings, it is important to bear in mind that stigmatisation of HIV/AIDS, or drug or condom use may limit an intervention's effectiveness. There is a need for research on adapting interventions to different cultural or national settings, and to develop and evaluate new interventions that may produce greater reductions in sexual risk behaviours.     

Predictors of risky needle use following interventions with injection drug users in Ukraine

This study was designed to assess factors associated with change in needle-related risk behaviors as well as predictors of continued high-risk behavior following intervention efforts among injection drug users (IDUs) in Ukraine. In each of three locations--Kiev, Odessa, and Makeevka/Donesk--100 IDUs were recruited using modified targeted sampling methods. Following a baseline interview, participants were offered free HIV testing and, over the course of the next 5 months, individualized interventions focusing on reducing HIV-related risk behaviors. Former IDUs conducted interventions through street outreach. The intervention model was based on the Indigenous Leader Outreach Model (ILOM) and stressed assessing an individual's unique risks and developing strategies by which to minimize those risks. Follow-up assessments showed significant reductions in every risk behavior measured. Following the intervention, however, approximately one of four participants reported front- or backloading, using drugs obtained from a common container or injecting with a used needle/syringe. Although the sample as a whole averaged only 28 years of age, those who were younger were significantly more likely to engage in each of these behaviors than those who were older. In light of the overall young age of the Ukrainian IDUs observed in this study, the consistent finding that younger IDUs were at highest risk foreshadows a worsening HIV epidemic in Ukraine.