Should Pharmacists have a Role in Harm Reduction Services for IDUs? A Qualitative Study in Tallinn,Estonia

Despite the high number of injecting drug users (IDUs) in Estonia, little is known about involving pharmacies into human immunodeficiency virus (HIV) prevention activities and potential barriers. Similarly, in other Eastern European countries, there is a need for additional sources for clean syringes besides syringe exchange programmes (SEPs), but data on current practices relating to pharmacists’ role in harm reduction strategies is scant. Involving pharmacies is especially important for several reasons: they have extended hours of operation and convenient locations compared to SEPs, may provide access for IDUs who have avoided SEPs, and are a trusted health resource in the community. We conducted a series of focus groups with pharmacists and IDUs in Tallinn, Estonia, to explore their attitudes toward the role of pharmacists in HIV prevention activities for IDUs. Many, but not all, pharmacists reported a readiness to sell syringes to IDUs to help prevent HIV transmission. However, negative attitudes toward IDUs in general and syringe sales to them specifically were identified as important factors restricting such sales. The idea of free distribution of clean syringes or other injecting equipment and disposal of used syringes in pharmacies elicited strong resistance. IDUs stated that pharmacies were convenient for acquiring syringes due to their extended opening hours and local distribution. IDUs were positive toward pharmacies, although they were aware of stigma from pharmacists and other customers. They also emphasized the need for distilled water and other injection paraphernalia. In conclusion, there are no formal or legislative obstacles for providing HIV prevention services for IDUs at pharmacies. Addressing negative attitudes through educational courses and involving pharmacists willing to be public health educators in high drug use areas would improve access for HIV prevention services for IDUs.     

Comparison of injecting drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia

Background  

Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn.     

Greater Drug Injecting Risk for HIV, HBV, and HCV Infection in a City Where Syringe Exchange and Pharmacy Syringe Distribution are Illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004–2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU’s used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs. Neaigus, Zhao, Gyarmathy, and Cisek are with the Institute for International Research on Youth at Risk, National Development and Research Institutes, New York, NY, USA; Neaigus is with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Gyarmathy is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Friedman is with the Institute for AIDS Research, National Development and Research Institutes, New York, NY, USA; Friedman is with the Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Baxter is with the North Jersey Community Research Initiative, Newark, NJ, USA.     

HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services

OBJECTIVES: We sought to estimate HIV incidence among injection drug users (IDUs) in New York City from 1990 to 2002 to assess the impact of an expansion of syringe exchange services. Syringe exchange increased greatly during this period, from 250,000 to 3,000,000 syringes exchanged annually. METHODS: Serum samples were obtained from serial cross-sectional surveys of 3,651 IDUs. HIV-positive samples were tested with the Serologic Test Algorithm for Recent HIV Seroconversion (STARHS) assay to identify recent HIV infections and to estimate HIV incidence. Consistency with other incidence studies was used to assess strengths and limitations of STARHS. RESULTS: HIV incidence declined from 3.55/100 person-years at risk (PYAR) from 1990-1992, to 2.63/100 PYAR from 1993-1995, to 1.05/100 PYAR from 1996-1998, and to 0.77/100 PYAR from 1999-2002 (P<.001). There was a very strong negative linear relationship (r= -.99, P<.005) between the annual numbers of syringes exchanged and estimated HIV incidence. These results were highly consistent with a large number of shorter incidence studies among IDUs conducted during the time period. CONCLUSIONS: STARHS testing of samples from large serial cross-sectional surveys can provide important data for the assessment of community-level HIV prevention.     

Demographic, risk, and spatial factors associated with over-the-counter syringe purchase among injection drug users

Since 2005, California law allowed over-the-counter (OTC) syringe sales pending local authorization. Although pharmacy sales of OTC syringes are associated with reduced injection-mediated risks and decreases in human immunodeficiency virus infection rates, little is known about the factors associated with syringe purchase among injection drug users (IDUs). Using a cross-sectional design, the authors applied targeted sampling to collect quantitative survey data from IDUs (n = 563) recruited in San Francisco, California, during 2008. They also compiled a comprehensive list of retail pharmacies, their location, and whether they sell OTC syringes. They used a novel combination of geographic information system and statistical analyses to determine the demographic, behavioral, and spatial factors associated with OTC syringe purchase by IDUs. In multivariate analyses, age, race, injection frequency, the type of drug injected, and the source of syringe supply were independently associated with OTC syringe purchases. Notably, the prevalence of OTC syringe purchase was 53% lower among African-American IDUs (adjusted prevalence ratio = 0.47, 95% confidence interval: 0.33, 0.67) and higher among injectors of methamphetamine (adjusted prevalence ratio = 1.35, 95% confidence interval: 1.07, 1.70). Two neighborhoods with high densities of IDUs had limited access to OTC syringes. Increased access to OTC syringes would potentially prevent blood-borne infectious diseases among IDUs.     

Syringe exchange programs --- United States, 2008

Persons who inject drugs should use a new, sterile needle and syringe for each injection. Syringe exchange programs (SEPs) provide free sterile syringes and collect used syringes from injection-drug users (IDUs) to reduce transmission of bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus (HCV). As of March 2009, a total of 184 SEPs were known to be operating in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2009). Of these, 123 (67%) SEP directors participated in a mail/telephone survey conducted by NASEN and Beth Israel Medical Center (New York, New York) that covered program operations for the calendar year 2008. To characterize SEPs in the United States, this report summarizes the findings from that survey and compares them with previous SEP survey results from the period 1994-2007. In 2008, the 123 SEPs reported exchanging 29.1 million syringes and had budgets totaling $21.3 million, of which 79% came from state and local governments. Most of the SEPs reported offering preventive health and clinical services in addition to basic syringe exchange: 87% offered HIV counseling and testing, 65% offered hepatitis C counseling and testing, 55% offered sexually transmitted disease screening, and 31% offered tuberculosis screening; 89% provided referrals to substance abuse treatment. Providing comprehensive prevention services and referrals to IDUs, such as those offered by many SEPs, can help reduce the spread of bloodborne infections and should increase access to health care and substance abuse treatment, thus serving as an effective public health approach for this population.     

Methadone maintenance treatment and HIV risk-taking behaviour among injecting drug users in Berlin.

STUDY OBJECTIVE: To determine whether methadone maintenance treatment (MMT) is effective in reducing the levels of HIV risk-taking behaviour (borrowing and lending of injection equipment, irregular condom use) among injecting drug users (IDUs), and to identify independent predictors of the borrowing of used syringes. DESIGN: Cross sectional study of IDUs in MMT and not in MMT, using standardised interviews for collection of sociodemographic and behavioural data, and laboratory tests for detecting HIV antibodies. SETTING AND PARTICIPANTS: The 612 IDUs were recruited at different services for drug users such as treatment centres, walk in agencies, a hospital, and on the streets. MAIN RESULTS: Of all IDUs, 41% had borrowed and 34% had passed on used injection equipment in the previous six months. In univariate analysis, IDUs receiving MMT had injected less frequently and were significantly less likely to borrow and lend syringes. In logistic regression analysis, MMT was protective against the borrowing of syringes (adjusted odds ratio 0.36, 95% confidence interval 0.2, 0.8), but not against syringe lending nor against sexual risk behaviour (i.e., numbers of sex partners, lack of condom use). Important independent predictors of the borrowing of syringes were injecting drug use in prison, use of sedatives, and sex with another IDU in the previous six months. CONCLUSIONS: MMT may play a significant role in reducing the levels of borrowing of syringes among IDUs. However, additional prevention measures are needed which should specifically address sexual risk behaviour and target subgroups of IDUs with high levels of needle sharing, such as IDUs who have been in prison and and those who are sedative users.