Needle-syringe Exchange Programs Research Articles

Sexual Dysfunction in Males Receiving Buprenorphine-Naloxone Based Opioid Substitution Therapy

Abuse of opioids and related substances have exerted a tremendous economic, social, legal impact apart from its dire consequences on the individual user’s health. Heroin is a quite common illicit opioid that is covertly made available by illegal traders and has a wide client base. The abuser self-administers heroin by two common methods, namely chasing and intravenous injection. Intravenous administration is associated with high risks of contracting parenterally transmitted infections like hepatitis B, hepatitis C, HIV, as well as infective endocarditis, thrombophlebitis etc. The unsafe injecting practices include sharing of needles, syringes, and other paraphernalia. The National Aids Control Programme, currently in its fourth phase (NACP-IV), makes provisions for strategies known as ‘harm reduction’ to prevent transmission of HIV among intravenous drug users. The harm reduction strategies include needle syringe exchange programme (NSEP), behaviour change communication (BCC), outreach, condom promotion, and substitution therapy (1).

Design, implementation, and monitoring of HIV service packages for people who inject drugs: An assessment of programs supported by the Global Fund in 46 countries

BackgroundPeople who inject drugs (PWID) are at higher risk of acquiring and transmitting HIV, accounting for an estimated 10% of HIV new infections globally. The World Health Organization (WHO) and other international agencies have clearly outlined the comprehensive package of services that should be available for PWID. MethodsThis paper summarizes the data and findings from the PWID service packages assessed in 15 countries across different regions. It also provides data on the design of PWID programs in a further 30 countries that identified PWID as a key population in their national HIV strategic documents. A mixed-method approach was used, including desk reviews, key informant interviews, site observations and group interviews with implementers and PWID focus groups. ResultsDesign of service packages varied considerably between countries while many matched the WHO Comprehensive Package. Only 85% countries (39/46) included needle-syringe exchange programs (NSEP) and 76% included opioid agonist therapy (OAT). Only 17% countries included overdose management in their package design. Across the 46 countries assessed, the average coverage with defined prevention package was 40% among countries for which coverage figures could be derived. ConclusionsDespite some examples of client-based, high-quality services in challenging environments, few countries, which rely primarily on external donor support, are reaching the necessary coverage levels across the full range of PWID HIV prevention, testing and care services. Transition from donor to domestic funding to fund this element of the HIV responses in many countries presents a compelling case to prevent PWID from being further left behind.

Implementation dilemmas of the Needle Syringe Exchange Programme (NSEP): Between the law and prevention

HIV/AIDS is a potentially serious threat to national development. In 2006, the Needle and Syringe Exchange Programme (NSEP) was formally introduced to prevent further spread of HIV/AIDS. However, this programme places many of its clients in a dilemma because they want to access NSEP services but are afraid of being arrested by the police since drug use in is a criminal offense in Malaysia. The primary data for the qualitative study were gathered through in-depth interviews with ten (10) lower ranking police officers from the Penang Narcotics Department. The findings indicated that the majority of the respondents are well-prepared and ready to accept NSEP, while a number still lack a full understanding of the NSEP. This study suggests that improvement in terms of training is important to increase knowledge and understanding among the lower ranking police officers regarding HIV/AIDS in order to ensure the success of the NSEP.

Patterns of substance use and correlates of lifetime and active injection drug use among women in Malaysia

ABSTRACTBackground: While drug use is associated with HIV risk in Southeast Asia, little is known about substance use behaviors among women, including drug injection. Objectives: To describe patterns of substance use among women using alcohol and drugs in Malaysia and identify correlates of lifetime and active drug injection, a risk factor for HIV transmission. Methods: A survey of 103 women who used drugs in the last 12 months assessed drug use history and frequency, including drug injection and drug use during pregnancy, self-reported HIV-status, childhood and adulthood physical and sexual abuse, and access to and utilization of harm reduction services, including needle-syringe exchange programs (NSEP) and opioid agonist maintenance therapy (OAT). Principal component analyses (PCA) were conducted to assess drug use grouping. Results: Amphetamine-type substances (ATS; 82.5%), alcohol (75.7%) and heroin (71.8%) were the most commonly used drugs across the lifetime. Drug injection was reported by 32.0% (n = 33) of participants with 21.4% (n = 22) having injected in the last 30 days. PCA identified two groups of drug users: opioids/benzodiazepines and club drugs. Lifetime drug injection was significantly associated with lower education, homelessness, prior criminal justice involvement, opioid use, polysubstance use, childhood physical and sexual abuse, and being HIV-infected, but not with prior OAT. Conclusion: Women who use drugs in Malaysia report high levels of polysubstance use and injection-related risk behaviors, including sharing of injection equipment and being injected by others. Low OAT utilization suggests the need for improved access to OAT services and other harm reduction measures that prioritize women.

Cost Effectiveness of Harm Reduction: Comparison Needle and Syringe Exchange Programme

The increasing cases of HIV/AIDs among the women and infants transmitted from the drug abuser through sharing of needles and unsafe sex had forced the Ministry of Health to initiate harm reduction programmes. A group of researchers from Universiti Sains Malaysia (USM) administered two harm reduction programmes: needle & syringe exchange programme (NSEP) and the methadone maintenance programme (MMT). The two programmes were conducted for patients at a local NGO and a public hospital in Kota Bharu, Kelantan. The efforts were not received favourably by many people because it involves the use of public funds. As accounting professionals, the first three authors were invited by USM researchers to review of the costs effectiveness of the programmes. Basically, the drug users who participated in these programmes are mostly youths and young adults who are at their prime age. In this paper the authors discuss the cost effectiveness of the NSEP and MMT intervention programmes. The paper also looks into the quality of life of the clients/patients.

Syringe Exchange in the United States: A National Level Economic Evaluation of Hypothetical Increases in Investment

To examine whether increasing investment in needle/syringe exchange programs (NSPs) in the US would be cost-effective for HIV prevention, we modeled HIV incidence in hypothetical cases with higher NSP syringe supply than current levels, and estimated number of infections averted, cost per infection averted, treatment costs saved, and financial return on investment. We modified Pinkerton's model, which was an adaptation of Kaplan's simplified needle circulation theory model, to compare different syringe supply levels, account for syringes from non-NSP sources, and reflect reduction in syringe sharing and contamination. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion.

At the crossroads: HIV prevention and treatment for people who inject drugs in Ukraine

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Ability to access community-based needle-syringe programs and injecting behaviors among drug users: a cross-sectional study in Hunan Province, China

BackgroundNeedle-syringe exchange programs (NSPs) have been substantially rolled-out in China since 2002. Limited studies reported effectiveness of NSPs in a Chinese setting. This study aimed to assess the association between accessibility to NSPs and drug-use risk behaviors of IDUs by investigating primary (self-reported) data of IDUs recruited from NSP sites, community settings and mandatory detoxification centers (MDCs) in Hunan province, China.MethodsA cross-sectional survey was conducted in Hunan province in 2010. IDU recruits participated in a face-to-face interview to provide information related to their ability to access NSPs, demographic characteristics, and injecting behaviors in the past 30 days.ResultsOf the total 402 participants, 35%, 14% and 51% participants indicated low, medium and high ability to access NSPs in the past 30 days, respectively. A significantly higher proportion of IDUs (77.3%) from the high-access group reported ≤2 injecting episodes per day compared with medium- (46.3%) and low-access (58.8%) groups. Only 29.0% of high-access IDUs re-used syringes before disposal in the past 30 days, significantly lower than those in the medium- (43.1%) and low-access (41.3%) groups. Reported levels of needle/syringe sharing decreased significantly as the ability to access NSPs increased (16.3%, 12.7% and 2.5% in the low, medium and high access groups, respectively). Ninety percent of IDUs recruited from MDCs had low ability to access NSPs.ConclusionsIncreased NSP accessibility is associated with decreased levels of injecting frequency, repetitive use and sharing of injecting equipment among Chinese IDUs. Mandatory detention of IDUs remains as a major barrier for IDUs to access NSPs in China.

Risk factors associated with HIV/HCV infection among entrants in methadone maintenance treatment clinics in China: A systematic review and meta-analysis

Background: Methadone maintenance treatment (MMT) has rapidly expanded in China, from 8 pilot sites to 696 clinics covering 27 provinces, during 2004–2010. This study evaluates the demographic characteristics and drug use behaviors associated with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) infections among MMT entrants through a systematic review and meta-analysis of published literature. Methods: Thirty-nine eligible articles (1 in English and 38 in Chinese) were selected for this review. We extracted the relevant indicator information from all eligible studies and performed meta-analyses, by stratifying according to sex of the participants, age groups and drug use behaviors. Five provinces (i.e., Yunnan, Guizhou, Sichuan, Guangxi and Xinjiang) with the population size of HIV-infected drug users greater than 10,000 were defined as high transmission areas (HTAs) for HIV infection; whereas the remaining twenty-six Chinese provinces were considered as low transmission areas (LTAs). Results: The odds of being infected by HIV among male drug users were significantly higher than for females in high transmission areas (OR=1.49, 95% CI: 1.11–1.99, k=9), while the opposite results were observed in low transmission areas (OR=0.46, 0.27–0.79, k=11). In comparison, no significant differences in risk behaviors were found between sexes in HTAs and LTAs. Younger age was not associated with risk of HIV infection, but was associated with higher risk of HCV infection (<30 years OR=1.88; 30–40 years OR=2.21, compared with >40 years, k=17). Risk of HIV infection was higher among injectors than non-injectors (OR=4.29, 2.70–6.79, k=14) and for those who inject, there was greater risk among sharers than non-sharers (OR=2.47, 1.44–4.23, k=4). Similar patterns were also observed in HCV infection (injectors: OR=10.82, 7.60–15.40; sharers: OR=3.41, 2.56–4.54, k=7). Conclusions: Characteristics of MMT entrants positive for HIV or HCV in China vary by disease types, geographical region, sex, age, and injecting behavior. These factors need to be considered in targeted interventions for MMT participants, such as age-specific health education and psychological treatment, antiretroviral therapy and needle-syringe exchange programs.

The transition to harm reduction: Understanding the role of non-governmental organisations in Malaysia

Background The transition of drug policy from prohibition to harm reduction has never been easy. The deeply entrenched belief in prohibition shared by policy makers and religious leaders provided little room for alternatives, and change came only slowly. The non-governmental organisations (NGOs) in Malaysia played a pivotal role in effecting such a change. Understanding how they did so may be instructive for other similarly placed countries. Methods Data collected via reviews of published secondary sources, media reports and in-depth interviews with pioneers of harm reduction drawn from NGOs, medical practitioners and the police were analysed to construct the paper. Results The policy change was the outcome of competition between three groups in the drug policy subsystem – the state, the Muslim religious lobby and the NGOs. Developments such as the poor outcomes from the prohibition programmes and the outbreak of HIV/AIDS did not change policy but did lead to a rethink of core beliefs in the state alliance and spawned a state-NGO partnership. The subsequent failure to meet the Millennium Development Goal with respect to HIV/AIDS in 2005 – was seen as a failure of the Health Ministry which then led the final charge for a policy change arguing that a health crisis was imminent. The NGOs played a pivotal role in this process by educating their partners in the state coalition, by drawing academics and medical practitioners into advocacy and by engaging the religious lobby (albeit with varying success). They were also frontline players in implementing harm reduction programmes and successfully deflected criticisms from unconvinced Islamic groups away from the state. Conclusion Given their central role in the needle-syringe exchange programme, the NGOs are well positioned to convince injecting drug users to opt for voluntary medical treatment. This can potentially reduce both the harm from drug use and the prevalence of it.

The Transition to Harm Reduction: Understanding the Role of Non-Governmental Organisations in Malaysia

Background: The transition of drug policy from prohibition to harm reduction has never been easy. The deeply entrenched belief in prohibition shared by policy makers and religious leaders provided little room for alternatives, and change came only slowly. The non-governmental organisations (NGOs) in Malaysia played a pivotal role in effecting such a change. Understanding how they did so may be instructive for other similarly placed countries. Methods: Data collected via reviews of published secondary sources, media reports and in-depth interviews with pioneers of harm reduction drawn from NGOs, medical practitioners and the police were analysed to construct the paper. Results: The policy change was the outcome of competition between three groups in the drug policy subsystem - the state, the Muslim religious lobby and the NGOs. Developments such as the poor outcomes from the prohibition programmes and the outbreak of HIV/AIDS did not change policy but did lead to a rethink of core beliefs in the state alliance and spawned a state-NGO partnership. The subsequent failure to meet the Millennium Development Goal with respect to HIV/AIDS in 2005 - was seen as a failure of the Health Ministry which then led the final charge for a policy change arguing that a health crisis was imminent. The NGOs played a pivotal role in this process by educating their partners in the state coalition, by drawing academics and medical practitioners into advocacy and by engaging the religious lobby (albeit with varying success). They were also frontline players in implementing harm reduction programmes and successfully deflected criticisms from unconvinced Islamic groups away from the state. Conclusion: Given their central role in the needle-syringe exchange programme, the NGOs are well positioned to convince injecting drug users to opt for voluntary medical treatment. This can potentially reduce both the harm from drug use and the prevalence of it.

Moving beyond non-engagement on regulated needle-syringe exchange programs in Australian prisons

BackgroundAustralia is at a fork in the road with the possibility of a needle-syringe exchange program (NSP) to be introduced at the new prison in the ACT. However, the current situation is characterised by non-engagement from major stakeholders. We explore why informed discussion will not be enough to convince prison officers, policy makers and the wider community of the benefits of prison-based NSPs. Other methods of engagement and communication will be proposed – in that may provide avenues for "breakthrough".MethodsA review of the literature on needle-syringe exchanges and harm reduction strategies within the context of prisons and prisoner health was conducted. Literature on strategies to change attitudes and move beyond intractable situations was also consulted. In addition, one author, DM, conducted a two-hour interview with an ex-prison officer.ResultsNo studies were found which investigated the potential efficacy of interventions to modify attitudes or behaviours in the specific context of introducing an NSP into a prison. Nonetheless, several theories were identified which may explain the failure of informed discussion alone to create change in this situation and may therefore lead to suggestions for engagement and communication to move towards a resolutionDiscussionCognitive-behavioural therapy highlights the importance of individual cognitions and how they shape behaviours in any change campaign. Social identity theory emphasizes changes to social processes that may open the prison officer workforce to change. Peace studies also suggests socialization strategies such as observing an established and effective prison-based needle-syringe exchange. Social marketing provides suggestions on how to sell an exchange to ensuring the benefits are framed to outweigh the costs.ConclusionPsychology, peace studies and social marketing all agree people's views must be carefully collected and analysed if people are going to be convinced to consider and discuss the issue. By understanding the views and their underlying motivations of those who oppose NSPs, it will be far easier to influence these views. Furthermore, involving all stakeholders, especially prison authorities, will help create a sense of ownership of a solution and therefore increase the chances of that solution succeeding.

Effectiveness of harm reduction programmes for injecting drug users in Dhaka city

This paper provides a brief overview of the harm reduction programme for injecting drug users (IDU) of CARE, Bangladesh in Dhaka city and uses data from surveillance and a focussed research study on a cohort of IDU, to evaluate the programme. The harm reduction programme in Dhaka is run by CARE, Bangladesh and includes needle/syringe exchange, awareness raising on HIV/STI, abscess management, condom distribution and advocacy with different groups of people. The needle/syringe exchange programme (NEP) has been in place since 1998, the 2nd Generation Surveillance in Bangladesh is being conducted since 1998, and an in-depth cohort study, started in 2002, is being conducted in two areas of Dhaka city with approximately 500 IDU under CARE's NEP who are being followed bi-annually to assess risk behaviour, incidence of HIV, hepatitis C and syphilis. As the surveillance and the cohort study are both closely associated with the NEP of CARE, Bangladesh, these data can be used to monitor the NEP.

HIV, hepatitis B and sexual practices in the street-recruited injecting drug users of Calcutta: risk perception versus observed risks.

Injecting drug users (IDUs) were recruited from the streets of Calcutta to obtain a baseline biological and behavioural data on risk practices. One-fifth of them (mostly using buprenorphine) tested positive for hepatitis B surface antigen (HBsAg); 4% were reactive to serologic test for syphilis (VDRL: Venereal Disease Research Laboratory). Condom use was insignificant while 74% reported sex with female sex workers and 15% of male IDUs also reported having sex with men. Although, sharing of injecting equipment ('works') was perceived as dangerous by the IDUs, majority of them (90/103) reportedly shared it; cleaning of works before sharing was a concern for intravenous but not for intramuscular drug injecting. Half of the IDUs reported suffering ever from abscess; a proportion (12%) of which had had superadded attack of maggots in it. They were also found to be infected with HIV (1%, 95% CI 0.028-5.97%) at a low prevalence that prompted subsequent launching of needle syringe exchange programme, establishment of cleaning norms before sharing of works, cleaning of injecting site on the body and condom promotion.

Risk factors for hepatitis C virus infection among injecting drug users in Sydney.

To study risk factors for hepatitis C virus (HCV) infection in injecting drug users (IDUs) from central Sydney. All IDUs attending a primary health care facility in central Sydney between December 1991 and November 1992 who underwent HCV antibody testing. Information was obtained retrospectively from client forms routinely completed at the time of medical consultation. Additional information on injecting history and practice was obtained from the registration forms of subjects who also attended the needle syringe exchange programme at the same health care facility. Of the 201 IDUs tested, 118 (59%) had HCV antibodies, which did not differ significantly between males and females. HCV prevalence increased significantly with age, being highest in IDUs who were aged 35 years or more (93%) and lowest in IDUs aged under 20 years (17%). HCV prevalence increased significantly with time since first injecting, from 26% for IDUs who had injected for less than 3 years to 94% for those who had injected for more than 10 years. HCV prevalence was also significantly higher in heterosexual IDUs as compared with homosexual male IDUs, and in opiate users as compared with stimulant users, even after adjustment for age and duration of injecting. HCV prevalence was strongly associated with exposure to hepatitis B virus, but was not associated with exposure to HIV. Recent HCV transmission indicates ongoing injecting risk behaviour despite HIV prevention efforts, and underlies the potential for increased transmission of HIV through the sharing of injecting equipment. Within the population of IDUs, those who are heterosexual or inject heroin appear to be at increased risk of HCV infection.

Controlling the HIV Epidemic Among Drug Injectors

About 50% of iv drug users in Madrid Spain may be HIV infected. 52% are prisoners. HIV prevalence rates among iv drug users are also high in Barcelona and Bilbao. Many of these iv drug users do not use condoms likely resulting in sizable heterosexual transmission. The possibility of resurgent tuberculosis (TB) among HIV-infected iv drug users looms since most receive no treatment. HIV-infected persons with multidrug-resistant TB almost always die. It is also difficult and expensive to treat in HIV seronegatives. Faulty cost-benefit estimations leading to reduced TB-oriented care and prevention and programs that did not provide effective iv drug user-oriented harm reduction and medical care account for the spread of TB in New York City. Evidence suggests that HIV epidemics have stabilized in many cities. Yet mathematical models show that once epidemics reach 50% among iv drug users they spread quite quickly. Many people believe that iv drug users are unable to practice risk reduction behavior but research in Bangkok and Rio de Janeiro shows that they can indeed modify their behavior. Needle-syringe exchange programs result in risk behavior reduction and subsequent reduction of HIV seroconversion and of new infections with hepatitis B. They should include street-based outreach and fixed-site exchanges. They also effectively increase the number of iv drug users who seek drug abuse treatment. Some countries have legalized the sale of syringes thus reducing syringe sharing among iv drug users. Iv drug users must have access to confidential HIV counseling and testing and user-friendly medical treatment. Drug abuse treatment should be expanded with minimal documentation or bureaucratic procedure. Methadone treatment protects iv drug patients against HIV infection. Other programs need to emphasize abstinence from drug use. New iv drug users tend to be less likely to be HIV infected thus they are a prime target group but it is difficult to locate them.