Needle Exchange Program Attendance Research Articles

Hepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention

BackgroundMeaningful reductions in Hepatitis C Virus (HCV) transmission rates among persons who inject drugs (PWID) require a comprehensive prevention approach, including access to harm reduction measures and to healthcare-related interventions, such as HCV screening, testing and antiviral treatment. Little is known, however, about the role of visiting a primary care physician (PCP) in relation to HCV infection risk among PWID, when integrated within a combined prevention approach. This study assessed the association between PCP visiting and HCV seroconversion among PWID attending needle exchange programs (NEP). MethodsA prospective cohort study, HEPCO, was conducted among active PWID in Montréal (2004–2013). Interviews scheduled at 3- or 6-month intervals included completion of an interviewer-administered questionnaire, and collection of blood samples for HCV antibody testing. HCV-seronegative participants who reported NEP attendance at baseline and had at least one follow-up visit were eligible for this study. HCV incidence was calculated using the person-time method. Time-varying Cox regression modeling was conducted to evaluate the relationship between self-reported recent PCP visiting and HCV incidence. ResultsAt baseline assessment, of 226 participants (80.5% male; median age: 30.6 years), 37.2% reported having recently visited a PCP. During 449.6 person-years of follow-up, 79 participants seroconverted to HCV [incidence rate: 17.6 per 100 person-years, 95% confidence interval (CI): 14.0–21.8]. Covariate-adjusted analyses indicated that visiting a PCP was associated with a lower risk of HCV infection [Adjusted Hazard Ratio: 0.54, 95% CI: 0.31–0.93]. Other independent predictors of HCV infection included unstable housing, cocaine injection and prescription opioid injection. ConclusionAmong PWID attending NEP, visiting a PCP was associated with a lower risk of HCV infection. Yet, only a minority of participants reported PCP visiting. Efforts to intensify engagement with PCP among PWID could potentially contribute to lower HCV transmission when integrated within a combined approach to prevention.

Designing an Institute for Health and Technology: The Amsterdam Living Lab

Background: Despite progress made in halting the global HIV epidemic, new infections among injection drug users (IDU) in Eastern Europe and Central Asia are increasing, and accounted for 10% of all new HIV infections globally in 2010. With 1.8 million IDUs, the Russian Federation (RF) alone contributed to 70% of these infections. Despite ample evidence on effectiveness of needle exchange programs (NEP), the RF is not actively promoting their development. Our project aims to assess the potential health and cost benefits of scaling-up of NEPs in the RF using our advanced modeling tool. Structure/Method/Design: Using standard systematic review methods, we searched and screened studies assessing the direct and indirect effect of NEP on HIV-related outcomes globally. We extracted outcome data from eligible studies, transformed them to standard metric of relative risk reduction (RRR), and calculated summary measures using the random-effects meta-regression model. We developed and calibrated a Markovestate mathematical model to capture the dynamics of the HIV epidemic in the RF and transformed it into our user-friendly, interactive, web-based tool entitled “Global Health Decisions Policy Explorer.” Results (Scientific Abstract)/Collaborative Partners (Programmatic Abstract): Our meta-analysis revealed that NEP attendance is associated with a 57% (52% to 62%) reduction in needle sharing in IDUs. Using this and other data in our model, we estimate that increasing the coverage of NEPs from 6% to 10% of IDUs in the RF will prevent 11,830 HIV infections and 3369 AIDS-related deaths over the next 20 years for approximately $39 million. Scale-up of programs to reach 25% or 50% of IDUs would avert 70,000 or 164,000 infections, respectively, and 20,000 and 46,000 deaths when compared with the baseline scenario for the cost of $233 million and $557 million. Summary/Conclusion: Resource allocation and governance needs to rely on sound evidence that is easy to use. Our project suggests that large gains in HIV prevention can be made in the Russian Federation through scale-up of NEPs.

Needle exchange and the HIV epidemic in Vancouver: Lessons learned from 15 years of research

During the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injection drug users (IDU) and many questioned how this could occur in the presence of a high volume needle exchange program (NEP). Specific concerns were fuelled by early research demonstrating that frequent needle exchange program attendees were more likely to be HIV positive than those who attended the NEP less frequently. Since then, some have misinterpreted this finding as evidence that NEPs are ineffective or potentially harmful. In light of continuing questions about the Vancouver HIV epidemic, we review 15 years of peer-reviewed research on Vancouver's NEP to describe what has been learned through this work. Our review demonstrates that: (1) NEP attendance is not causally associated with HIV infection, (2) frequent attendees of Vancouver's NEP have higher risk profiles which explain their increased risk of HIV seroconversion, and (3) a number of policy concerns, as well as the high prevalence of cocaine injecting contributed to the failure of the NEP to prevent the outbreak. Additionally, we highlight several improvements to Vancouver's NEP that contributed to declines in syringe sharing and HIV incidence. Vancouver's experience provides a number of important lessons regarding NEP. Keys to success include refocusing the NEP away from an emphasis on public order objectives by separating distribution and collection functions, removing syringe distribution limits and decentralizing and diversifying NEP services. Additionally, our review highlights the importance of context when implementing NEPs, as well as ongoing evaluation to identify factors that constrain or improve access to sterile syringes.

Mexico's evolving HIV epidemic.

Mexico's evolving HIV epidemic.

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.

Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: Results from a community-based behavioral intervention trial

We evaluated a case management intervention to increase treatment entry among injecting drug users referred from a needle exchange program (NEP). A randomized trial of a strengths based case management (intervention) versus passive referral (control) was conducted among NEP attenders requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD. Logistic regression identified predictors of treatment entry within 7 days, confirmed through treatment program records. Of 247 potential subjects, 245 (99%) participated. HIV prevalence was 19%. Overall, 34% entered treatment within 7 days (intervention: 40% versus control: 26%, p = 0.03). In a multivariate “intention to treat’ model (i.e., ignoring the amount of case management actually received), those randomized to case management were more likely to enter treatment within 7 days. Additional ‘as treated’ analyses revealed that participants who received 30 min or more of case management within 7 days were 33% more likely to enter treatment and the active ingredient of case management activities was provision of transportation. These findings demonstrate the combined value of offering dedicated treatment referrals from NEP, case management and transportation in facilitating entry into drug abuse treatment. Such initiatives could be implemented at more than 140 needle exchange programs currently operating in the United States. These data also support the need for more accessible programs such as mobile or office-based drug abuse treatment.

Characteristics and HIV Risk Behaviors among Injection Drug Users in St. Petersburg, Russia: A Comparison of Needle Exchange Program Attenders and Nonattenders

The purpose of this descriptive study was to compare young Russian NEP attenders (N = 209) and nonattenders (N = 207) on a multitude of dependent variables related to drug and sexual knowledge, attitudes, and behaviors. Questionnaire data found NEP attenders were more likely to be female, inject more frequently, use heroin heavily, be in long-term relationships, use clean needles, have more unprotected vaginal sex acts, and have drug-using friends with positive safer sex attitudes. Comparisons were also made between male and female NEP attenders, male NEP attenders and nonattenders, female NEP attenders and nonattenders, and male and female NEP nonattenders. Significant differences between those subgroups were found. A logistic regression was run to determine which variables served to predict NEP attendance. Four variables accounted for 17% of the variance and predicted NEP attendance in two thirds of the cases: safer sex attitudes of drug-using friends, heroin use, using new needles to inject, and relationship status.

Risky Sexual Behaviors and HIV/Disease Knowledge of Injection Drug Users Attending Needle Exchange Programs

ABSTRACT A meta-analysis of worldwide Needle Exchange Program research was conducted with fourteen studies, looking at the impact of needle exchange programs (NEPs) on the sexual risk behaviors and HIV/disease knowledge of injection drug users. Based on the limited data available to date (a total of 14 studies), two conclusions were drawn. First, HIV/disease knowledge does increase with NEP attendance. Second, risky sexual behaviors do not appear to decrease with NEP attendance, and may in fact increase. Neither of these areas has been investigated nearly as often as risky drug behaviors among NEP attend-ers. Focusing on disease knowledge and reducing risky sexual behaviors of NEP clients are both key areas for AIDS Service Organization staff to consider when developing HIV risk reduction interventions for injection drug users (IDUs).

A meta-analysis of needle sharing, lending, and borrowing behaviors of needle exchange program attenders.

This study used meta-analysis to examine cumulatively needle exchange program (NEP) change/comparison data from 47 studies between 1988 and 2001, based on data collected between 1986 and 1997. The research question posed was: Is NEP attendance associated with reductions in risky needle-related behaviors? Results indicated that needle sharing (r = -.189), variations on the outcome measure of needle sharing (r = -.161), and needle lending/borrowing (r = -.194) consistently declined among NEP attenders, suggesting the NEPs are effective in reducing risky needle-related behaviors of IDUs. The meta-analytic results lend support to the harm-reduction philosophy often used as the rationale for the establishment and maintenance of NEPs.

Readiness for Cessation of Drug Use Among Recent Attenders and Nonattenders of a Needle Exchange Program

Needle exchange programs (NEPs) represent a bridge to drug abuse treatment. NEP attenders tend to have more severe drug problems, however, and may be less ready to reduce their drug use than other drug users. This study investigated the relationship between NEP attendance and readiness for cessation of drug use. Since the period from 1988 through 1989, a community-based sample of injection drug users (IDUs) in Baltimore has undergone semiannual interview-administered questionnaires and HIV testing. A total of 288 IDUs completed a questionnaire on readiness for cessation of drug use. Readiness for drug use cessation was assessed from a 28-item validated scale of problem drug use and intention to quit, based on the "stages of change" model. Logistic regression was used to determine factors associated with readiness for cessation of drug use, including sociodemographics, drug use behaviors, and NEP attendance. Thirty percent of respondents attended the NEP in the past month. Stage of change in readiness for cessation of drug use did not differ between NEP attenders and nonattenders (OR = 0.9; 95% CI: 0.5-1.6). Similar proportions of persons recently attending and not attending the NEP were classified as ready to stop drug use (about 30%). In multivariate analysis, readiness for cessation of drug use was associated with speedball injection and previous enrollment in drug treatment but not with NEP attendance. NEP attenders, although exhibiting characteristics consistent with more severe drug dependence, were as motivated for cessation of drug use as were nonattenders. These findings suggest that formal collaboration between NEPs and drug treatment programs could increase the proportion of IDUs in treatment.

Feasibility of referring drug users from a needle exchange program into an addiction treatment program: Experience with a mobile treatment van and LAAM maintenance

We evaluated program entry, retention, and early treatment response of needle exchange program (NEP) attenders referred to a drug treatment program using levomethadyl acetate hydrochloride (LAAM). Of 163 referrals, 114 (70%) entered the program, and 84% were retained for at least 90 days. Comparing baseline and follow-up visits after 1 month, there were significant reductions in the Addiction Severity Index subscale scores for drug and alcohol use and legal situation. We observed a 31% and 22% reduction in heroin- and cocaine-positive urine tests, respectively ( p < .0001). Although LAAM is no longer considered a first line treatment for heroin addiction, these results demonstrate the feasibility of utilizing long-acting agonist therapies such as LAAM to treat opioid dependence among NEP attenders.

Validity of self-reported needle exchange attendance among injection drug users: implications for program evaluation.

Some studies have indicated that needle exchange programs (NEPs) can be effective in reducing drug-related risks for human immunodeficiency virus (HIV) seroconversion; however, others have reported higher HIV incidence rates among NEP attendees. Since many studies rely on self-reports of NEP attendance, the authors investigated the extent to which differential misreporting of NEP attendance could bias risk estimates. Over a 3-year period from 1994 to 1997, self-reports of NEP attendance from participants in a prospective study in Baltimore, Maryland, were compared with NEP records. Of 1,315 participants, 459 (35%) had registered with the Baltimore NEP. There was 86.7% concordance between self-reported and actual NEP use; 11.0% reported NEP attendance but did not attend (overreported), and 2.2% reported not attending NEP but did attend (underreported). In multivariate analyses using generalized estimating equations, persons who overreported NEP attendance were more likely to have injected frequently (adjusted odds ratio (AOR) = 1.29, 95% confidence interval (CI): 1.04, 1.61), denied needle sharing (AOR = 0.69; 95% CI: 0.52, 0.89), and been an HIV seroconverter (AOR = 1.83, 95% CI: 1.11, 3.01). With Poisson regression to model predictors of HIV seroconversion, models that included measures of NEP attendance based on self-reports compared with actual program data underestimated a protective association by 18%. These findings have important implications for evaluations of NEPs.

HEALTH SERVICES UTILIZATION BY INJECTION DRUG USERS PARTICIPATING IN A NEEDLE EXCHANGE PROGRAM

Objective: To determine the characteristics associated with health care and drug treatment utilization among a distinctly high-risk sub-population of injectors participating in a needle exchange program (NEP). Methods: Between June 1998 and May 1999, study staff collected demographic and health services utilization data on participants of the Baltimore NEP. Odds ratios and logistic regression were used to identify the participant characteristics associateds with utilizing primary health care and drug treatment during the prior 3 years. Results: Among 269 participants, 81% were African–American and 66% were male. Over half (56%) had not graduated from high school, 89% were unemployed, 70% did not have health insurance, and the median age was 39 years. Fifty-eight percent of the participants reported utilizing primary care (i.e., visited a physician or other health care provider) and 44% had utilized drug treatment during the prior 3 years. Primary care utilization was associated with age≥39 [adjusted odds ratio (AOR)=1.82], having health insurance (AOR=2.16), and exchanging a higher volume of syringes per NEP visit (AOR=2.45). Recent drug treatment utilization was associated with African–American race (AOR=0.41), unemployment (AOR=2.72), having health insurance (AOR=2.05), and exchanging a higher volume of syringes per NEP visit (AOR=0.60). Conclusions: Health insurance was significantly associated with the recent utilization of both primary care and drug treatment, yet only one-third of NEP attenders were insured. Facilitating the uptake of health insurance services at NEP sites may improve the access to health care for drug users who are currently not utilizing the health care system.

Patterns of Needle Acquisition and Sociobehavioral Correlates of Needle Exchange Program Attendance in Baltimore, Maryland, U.S.A.

Objectives: This study examined factors associated with obtaining syringes from a needle exchange program (NEP) and other safer sources in Baltimore, Maryland, U.S.A. Design and Methods: A cross-sectional face-to-face survey was administered to 741 current drug injectors recruited by snowball sampling techniques. A brief openended interview was conducted on a subsample. Results: Most (85%) participants obtained needles from street needle sellers. Only 8% obtained their needles exclusively from safer sources (NEPs, pharmacies, hospitals, or patients with diabetes). Cocaine use was associated with obtaining needles from the NEP but not from exclusively safer sources. Obtaining needles from only safer sources was associated with being female and less frequent needle sharing and shooting gallery attendance. Among HIV-seropositive participants, those who were diagnosed before the year that the NEP began were more likely to obtain needles from safer sources. Participants who sold needles reported that it was easy to make used needles appear to be unused, and some admitted to selling used syringes as new. Conclusions: Street needle sellers are an important source of needles for drug injectors, and few injectors appear able to determine whether these needles are clean. Individual sealing of diabetic syringes may reduce the risk of blood-borne infections by enabling both drug injectors and patients with diabetes to better judge the sterility of the needles they purchase.

Patterns of needle acquisition and sociobehavioral correlates of needle exchange program attendance in Baltimore, Maryland, U.S.A.

This study examined factors associated with obtaining syringes from a needle exchange program (NEP) and other safer sources in Baltimore, Maryland, U.S.A. A cross-sectional face-to-face survey was administered to 741 current drug injectors recruited by snowball sampling techniques. A brief open-ended interview was conducted on a subsample. Most (85%) participants obtained needles from street needle sellers. Only 8% obtained their needles exclusively from safer sources (NEPs, pharmacies, hospitals, or patients with diabetes). Cocaine use was associated with obtaining needles from the NEP but not from exclusively safer sources. Obtaining needles from only safer sources was associated with being female and less frequent needle sharing and shooting gallery attendance. Among HIV-seropositive participants, those who were diagnosed before the year that the NEP began were more likely to obtain needles from safer sources. Participants who sold needles reported that it was easy to make used needles appear to be unused, and some admitted to selling used syringes as new. Street needle sellers are an important source of needles for drug injectors, and few injectors appear able to determine whether these needles are clean. Individual sealing of diabetic syringes may reduce the risk of blood-borne infections by enabling both drug injectors and patients with diabetes to better judge the sterility of the needles they purchase.

Correlates of enrollment in methadone maintenance treatment programs differ by HIV-serostatus.

To identify correlates of enrollment in methadone maintenance treatment programs (MMTP) among a prospective cohort of injection drug users (IDUs) in Baltimore, Maryland. A total of 1480 IDUs undergoing semi-annual HIV tests and interviews were studied between 1994 and 1998, during which time a needle exchange program was introduced. Longitudinal analysis using generalized estimating equations was used to identify correlates of MMTP participation over time. Although similar proportions of HIV-seropositive and -seronegative IDUs enrolled in MMTP during follow-up (26 versus 22%, respectively), correlates of enrollment differed by HIV-serostatus. Among HIV-seropositive participants, older age [adjusted odds ratio (AOR, 1.37)] was associated with enrollment in MMTP. Among HIV-seronegative IDUs, factors associated with not enrolling in MMTP were being African American (AOR, 0.22) and having been recently incarcerated (AOR, 0.62) or homeless (AOR, 0.72). In both groups, females were twice as likely to be enrolled in MMTP, and those with Medicaid were 1.5 times more likely to be enrolled. When behavioral factors were lagged one visit, needle exchange program attendance was positively associated with MMTP enrollment among HIV-negative IDUs (AOR, 2.10); however, this association diminished significantly over time as dedicated treatment slots for needle exchange program participants became saturated. These findings underscore the need to improve access to MMTP, especially to certain subgroups such as African-Americans, the homeless, incarcerated and uninsured. Our data suggest that health care providers and needle exchange programs can facilitate enrollment into MMTP provided that adequate treatment slots are consistently available to this particularly vulnerable population.

HIV Prevalence Remains Low Among Calgary’s Needle Exchange Program Participants

To determine the demographic characteristics, risk behaviours and prevalence of HIV-1 among injection drug users (IDU) attending Calgary's needle exchange program (NEP). A survey was conducted from June through September 1998 among IDU attending Calgary's NEP. Demographic and behaviour characteristics were determined by personal interview and saliva was tested for HIV antibody. There were 278 participants providing 272 saliva specimens. Nine were positive for HIV-1 (3.3%, 95% C.I. 1.6-6.4%). Sexual and injecting practices, cities where drugs had been used, incarceration, addiction treatment and demographic characteristics were described, and a subanalysis for women, youth and Aboriginals was carried out. HIV prevalence remains low among NEP attenders in Calgary, although high-risk behaviours are common. Women, youth and Aboriginals have unique risk behaviour profiles. Many IDU want to participate in addiction treatment, and strategies should be made to provide accessible, appropriate treatment services.

Decline in self-reported high-risk injection-related behaviors among HIV-seropositive participants in the Baltimore needle exchange program

This study was conducted to determine whether enrollment in a needle exchange program (NEP) was associated with reduction(s) in high-risk injection practices among HIV-seropositive drug users. Between August 1994 and August 1997 HIV-seropositive individuals who underwent baseline and 6-month follow-up visits in the Baltimore NEP evaluation were studied. Chi-square statistics and paired t tests were used to compare reported injection-related behaviors between visits. One hundred and twelve HIV-seropositive NEP participants completed baseline and follow-up visits. Between visits self-reported lending of used syringes to others decreased (34.0% vs. 15.5%, p = .001), borrowing syringes from others decreased (23.2% vs. 11.1%, p = .002), and reported participation in drug treatment increased (8.0% vs. 18.8%, p = .01). A decrease in the mean number of injections per syringe was reported, 11.4 vs. 4.7 (p < .001). These data suggest that NEP attendance can contribute to significant reductions in risky drug-use behaviors in HIV-seropositive drug users.

Factors associated with frequent needle exchange program attendance in injection drug users in Vancouver, Canada.

The objective of this study was to identify factors associated with frequent needle exchange program (NEP) attendance by injection drug users (IDUs) in Vancouver, Canada. Data were examined from a case control study of recent HIV infection. IDUs with documented HIV seroconversion after January 1, 1994 (n = 89) and seronegative controls with two documented HIV-negative test results in the same period (n = 192) were asked about demographic and social information, drug injection and sexual behavior, and NEP attendance. Logistic regression was used to examine the effect of multiple variables on NEP attendance while adjusting for HIV status and other potential confounders. Frequent (> 1 time/week) versus nonfrequent (< or = 1 time/week) NEP attenders did not differ with respect to gender, age, ethnicity, education, or HIV serostatus. For men, multivariate analysis showed that frequent cocaine injection was the only variable independently associated with NEP attendance (adjusted odds ratio [AOR] = 3.9; 95% confidence interval [CI] = 1.8-8.3); for women, independently associated variables were frequency of any drug injection (AOR = 5.5; 95% CI = 1.7-17), shooting gallery attendance (AOR = 11.5; 95% CI = 2.2-66), and having a nonlegal source of income (AOR = 3.4; 95% CI = 1.0-12). Borrowing used needles was associated with frequent NEP attendance in the univariate analysis. The NEP in Vancouver attracts IDUs who are frequent injectors (especially men using cocaine) and who have high-risk behaviors or an unstable lifestyle. This finding reinforces the role of NEPs as potential focal points for intervention in this hard-to-reach population.

High Rates of HIV Infection among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results of a Cohort Study

Needle exchange programs (NEPs) are designed to prevent human immunodeficiency virus (HIV) transmission among injection drug users. Although most studies report beneficial effects in terms of behavior modification, a direct assessment of the effectiveness of NEPs in preventing HIV infection has been lacking. A cohort study was conducted to assess the association between risk behaviors and HIV seroprevalence and seroincidence among injection drug users in Montreal, Canada. The association between NEP use and HIV infection was examined in three risk assessment scenarios using intensive covariate adjustment for empirical confounders: a cross-sectional analysis of NEP use at entry as a determinant of seroprevalence, a cohort analysis of NEP use at entry as a predictor of subsequent seroconversion, and a nested case-control analysis of NEP participation during follow-up as a predictor of seroconversion. From September 1988 to January 1995, 1,599 subjects were enrolled with a baseline seroprevalence of 10.7%. The mean follow-up period was 21.7 months. The adjusted odds ratio for HIV seroprevalence in injection drug users reporting recent NEP use was 2.2 (95% confidence interval 1.5-3.2). In the cohort study, there were 89 incident cases of HIV infection with a cumulative probability of HIV seroconversion of 33% for NEP users and 13% for nonusers (p < 0.0001). In the nested case-control study, consistent NEP use was associated with HIV seroconversion during follow-up (odds ratio = 10.5, 95% confidence interval 2.7-41.0). Risk elevations for HIV infection associated with NEP attendance were substantial and consistent in all three risk assessment scenarios in our cohort of injection drug users, despite extensive adjustment for confounders. In summary, in Montreal, NEP users appear to have higher seroconversion rates then NEP nonusers.