Syringe Exchange Program Clients Research Articles

Contingency Management and SARS-CoV-2 Testing Among People Who Inject Drugs.

People who inject drugs (PWID) are especially vulnerable to morbidity and mortality as a result of SARS-CoV-2 infection because of social and physical health vulnerabilities. Routine testing for SARS-CoV-2 is critical to reduce transmission. Contingency management-the provision of tangible rewards to reinforce positive behavior-can promote the use of health services among PWID. Evidence is scarce on the utility of contingency management to promote SARS-CoV-2 testing. The objective of this study was to evaluate the effectiveness of contingency management to increase testing among PWID. SARS-CoV-2 testing was implemented at 9 syringe exchange program sites in partnership with an Oregon-based nonprofit organization for 5 weeks without contingency management and for 6 weeks with contingency management (a $10 financial incentive for testing) from February 1 through mid-April 2021. We measured rates of testing among syringe exchange program clients before and after implementation of contingency management. Before contingency management, SARS-CoV-2 testing occurred during approximately 131 of 1410 (9.3%) client encounters, and 123 of 997 (12.3%) unique clients were tested. During contingency management, testing occurred during approximately 571 of 1756 (32.5%) client encounters, and 407 of 1151 (35.4%) unique clients were tested. Rates of testing increased from 0.04 (SD, 0.04) before contingency management implementation to 0.25 (SD, 0.15) after implementation (t8 = -3.88; P = .005; Cohen d = 1.46). Contingency management facilitated uptake of SARS-CoV-2 testing among PWID. Contingency management may be an effective strategy for improving communicable disease testing beyond testing for SARS-CoV-2 and for improving vaccine uptake among PWID and warrants additional research.

Interest in Getting Help to Reduce or Stop Substance Use Among Syringe Exchange Clients Who Use Opioids.

Opioid use is a growing problem in the United States. Despite existence of effective treatments (eg, opioid agonist medication), most people with opioid use disorder do not receive treatment. Increasing treatment receipt is an essential component of the response to the opioid crisis. We examined factors associated with interest in getting help to reduce or stop substance use among syringe exchange program (SEP) clients who reported using opioids. Surveys were administered at 17 SEPs across Washington State during 2015; 436 respondents who reported recent opioid use and not receiving current treatment were eligible for this analysis. Multivariable logistic regression was conducted to examine factors associated with being somewhat or very interested in getting help, including sociodemographic characteristics, substance use behaviors and outcomes, and use of health care services. Most participants reported interest in getting help (77.5%). Factors positively associated with interest included female gender (adjusted odds ratio [AOR] = 1.79; 95% confidence interval [CI]: 1.03, 3.11), having an abscess (AOR = 1.87; 95% CI: 1.02, 3.40), and having received treatment (AOR = 4.83; 95% CI: 1.77, 13.14) or other services (AOR = 3.01; 95% CI: 1.06, 8.54) in the past year. Recent methamphetamine use was negatively associated with interest in getting help (AOR = 0.49; 95% CI: 0.26, 0.91). In this survey of SEP clients, interest in getting help to reduce or stop substance use was prevalent and varied across subpopulations of persons using opioids. Findings point to SEPs as an important venue for treatment engagement, and suggest subgroups who may be targeted for engagement interventions.

Increasing methamphetamine injection among non-MSM who inject drugs in King County, Washington

BackgroundIn King County, Washington, the HIV prevalence among men who have sex with men (MSM) who inject methamphetamine is high, while it is low among other people who inject drugs (PWID). Local drug problem indicators suggest that methamphetamine use is increasing. The extent to which this increase affects MSM and non-MSM, and whether MSM and non-MSM networks are connected through injection equipment sharing, is unknown. MethodsWe used data from two serial cross-sectional surveys of PWID including five biannual surveys of Public Health–Seattle and King County Needle and Syringe Exchange Program clients (NSEP, N=2135, 2009–2017) and three National HIV Behavioral Surveillance IDU surveys (NHBS, N=1709, 2009–2015). ResultsThe proportion of non-MSM PWID reporting any recent methamphetamine injection increased significantly from approximately 20% in 2009 to 65% in 2017. Most of this increase was attributable to injecting methamphetamine in combination with heroin (goofballs). PWID who injected goofballs were more likely to be younger, homeless or unstably housed, report daily injection, and self-report an opioid overdose in the past year than other PWID. The majority of PWID who injected methamphetamine reported sharing any injection equipment. Among these PWID, 43% of MSM had last shared injection equipment with a non-MSM. Eight percent of non-MSM men and 15% of women had last shared equipment with an MSM. ConclusionsGiven non-trivial rates of sharing injection equipment with methamphetamine-using MSM, a population with an HIV prevalence of 40%, non-MSM who inject methamphetamine could be an emerging population at risk for acquiring HIV.

Access to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU (\u201cI do\u201d) Care Collaborative

BackgroundLittle is known about access to health insurance among people who inject drugs (PWID) who attend syringe exchange programs (SEPs). The goal of the current study was to assess perceptions of SEP staff, including health navigators and program managers, on access to health insurance and healthcare access among SEP clients following implementation of state and federal policies to enhance universal healthcare access in Massachusetts.MethodsBetween December 2014 and January 2015, we conducted in-depth interviews (n = 14) with SEP staff, including both program managers and health navigators, to assess knowledge, attitudes, and beliefs related to health insurance enrollment and access to enhanced referrals among SEP clients. We developed a preliminary coding scheme from the interview guide and used a grounded theory approach to guide inclusion of subsequent thematic codes that emanated from the data. We analyzed the coded data thematically in an iterative fashion using a consensus-based approach.ResultsWe identified five primary themes that emerged from the qualitative interviews, including high levels of health insurance enrollment among SEP clients; barriers to enrolling in health insurance; highly needed referrals to services, including improved access to substance use disorder treatment and hepatitis C virus treatment; barriers to referring clients to these highly needed services; and recommendations for policy change.ConclusionsWhile barriers to enrollment and highly needed referrals remain, access to and enrollment in healthcare insurance plans among PWID at SEPs in Massachusetts are high. With the uncertain stability of the Affordable Care Act following the US presidential election of 2016, our findings summarize the opportunities and challenges that are connected to health insurance and healthcare access in Massachusetts. SEPs can play an important role in facilitating access to health insurance and enhancing access to preventive health and primary care.

Reduction in Injection Risk Behaviors After Institution of an Emergency Syringe Exchange Program During an HIV Outbreak Among Persons Who Inject Drugs, Indiana 2015

Background. On April 6, 2015, an emergency syringe exchange program (SEP) was implemented in response to an unprecedented HIV outbreak linked to injection drug use in a small rural Indiana community. To assess impact of the SEP, we compared injection-related risk behaviors reported over time. Methods. At each SEP visit, clients received sterile syringes, a wound kit, harm reduction education, and referrals to health and substance abuse services. Returned syringes were safely disposed and clients were surveyed about current risk behaviors. We analyzed data on clients with >2 SEP visits ≥7 days apart through June 6, 2015. Differences in medians and percentages between clients' first and most recent visit were assessed using the Kruskal-Wallis test, or χ2 or Fisher exact test. Results. We evaluated data from 100 qualifying SEP clients who contributed a total of 361 visits (median: 3) and received 19,376 syringes: 55% were male, median age was 33 years (interquartile range [IQR]: 26–40). The median interval between first and most recent visit was 27 days (IQR: 16–40). Sharing syringes to inject declined significantly by 85% between the first and most recent visits (table). The frequency of reusing the same syringe also declined significantly. The number of syringes returned and distributed both increased significantly. Decreases in sharing syringes to divide drugs and sharing other injection equipment were not statistically significant. Conclusion. Among clients enrolled during the first two months of an emergency SEP, many injection-related risk behaviors declined significantly. Emergency SEPs can rapidly reduce risk behaviors capable of transmitting HIV in an outbreak setting. Risk Behaviors Reported by Emergency Syringe Exchange Program Clients, by Visit, Scott County Indiana, April 6–June 6, 2015 (n = 100) First Visit Most Recent Visit P Value Sharing syringes to inject, n (%) 34 (34%) 5 (5%) 0.04 Median frequency of syringe reuse, n (interquartile range [IQR]) 4 (2–15) 1 (1–1) <0.001 Median syringes returned, n (IQR) 0 (0–1) 47 (27–80) <0.001 Median syringes given, n (IQR) 35 (21–56) 42 (30–70) 0.004 Sharing syringes to divide drugs, n (%) 38 (38%) 10 (10%) 0.17 Sharing other injection equipment, n (%) 44 (44%) 11 (11%) 0.52 View it in a separate window Disclosures. All authors: No reported disclosures.

Harmonizing disease prevention and police practice in the implementation of HIV prevention programs: Up-stream strategies from Wilmington, Delaware

IntroductionImproving access to sterile injection equipment is a key component in community-based infectious disease prevention. Implementation of syringe access programs has sometimes been complicated by community opposition and police interference.Case descriptionIn 2006, the Delaware legislature authorized a pilot syringe exchange program (SEP). A program designed to prevent, monitor, and respond to possible policing and community barriers before they had a chance to effect program implementation and operation. A program designed to prevent, monitor, and respond to these barriers was planned and implemented by a multidisciplinary team of legal practitioners and public health professionals.DiscussionWe report on an integrated intervention to address structural barriers to syringe exchange program utilization. This intervention employs community, police and client education combined with systematic surveillance of and rapid response to police interference to preempt the kinds of structural barriers to implementation observed elsewhere. The intervention addresses community concerns and stresses the benefits of syringe exchange programs to officer occupational safety.ConclusionsA cohesive effort combining collaboration with and educational outreach to police and community members based on the needs and concerns of these groups as well as SEP clients and potential clients helped establish a supportive street environment for the SEP. Police-driven structural barriers to implementation of public health programs targeting populations engaged in drug use and other illicit behavior can be addressed by up-stream planning, prevention, monitoring and intervention strategies. More research is needed to inform the tailoring of interventions to address police-driven barriers to HIV prevention services, especially among marginalized populations.

Getting the message straight: effects of a brief hepatitis prevention intervention among injection drug users

To redress gaps in injection drug users' (IDUs) knowledge about hepatitis risk and prevention, we developed a brief intervention to be delivered to IDUs at syringe exchange programs (SEPs) in three US cities. Following a month-long campaign in which intervention packets containing novel injection hygiene supplies and written materials were distributed to every client at each visit, intervention effectiveness was evaluated by comparing exposed and unexposed participants' self-reported injection practices. Over one-quarter of the exposed group began using the novel hygiene supplies which included an absorbent pad ("Safety Square") to stanch blood flow post-injection. Compared to those unexposed to the intervention, a smaller but still substantial number of exposed participants continued to inappropriately use alcohol pads post-injection despite exposure to written messages to the contrary (22.8% vs. 30.0%). It should also be noted that for those exposed to the intervention, 8% may have misused Safety Squares as part of pre-injection preparation of their injection site; attention should be paid to providing explicit and accurate instruction on the use of any health promotion materials being distributed. While this study indicates that passive introduction of risk reduction materials in injection drug users through syringe exchange programs can be an economical and relatively simple method of changing behaviors, discussions with SEP clients regarding explicit instructions about injection hygiene and appropriate use of novel risk reduction materials is also needed in order to optimize the potential for adoption of health promotion behaviors. The study results suggest that SEP staff should provide their clients with brief, frequent verbal reminders about the appropriate use when distributing risk reduction materials. Issues related to format and language of written materials are discussed.

Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client‐level syringe coverage among injection drug users

To determine whether syringe exchange programs' (SEPs) dispensation policy is associated with syringe coverage among SEP clients. Cross-sectional samples of SEPs and their clients. SEPs in California, USA. Twenty-four SEPs and their injection drug using (IDU) clients (n = 1576). Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self-reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange. Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Using propensity scoring methods, we compared syringe coverage by dispensation policies while controlling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits. Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. SEPs should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage.

Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients

Objective To determine if adequate syringe coverage – “one shot for one syringe” – among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal. Design HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days. Results Participants were divided into four groups based on syringe coverage: <50%, 50–99%, 100–149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR] = 2.3; 95% confidence interval [CI] = 1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR = 0.5; 95%CI = 0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100–149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Conclusions Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

The Impact of Legalizing Syringe Exchange Programs on Arrests Among Injection Drug Users in California

Legislation passed in 2000 allowed syringe exchange programs (SEPs) in California to operate legally if local jurisdictions declare a local HIV public health emergency. Nonetheless, even in locales where SEPs are legal, the possession of drug paraphernalia, including syringes, remained illegal. The objective of this paper is to examine the association between the legal status of SEPs and individual arrest or citation for drug paraphernalia among injection drug users (IDUs) in California from 2001 to 2003. Using data from three annual cross-sections (2001-03) of IDUs attending 24 SEPs in 16 California counties (N = 1,578), we found that overall, 14% of IDUs in our sample reported arrest or citation for paraphernalia in the 6 months before the interview. Further analysis found that 17% of IDUs attending a legal SEP (defined at the county level) reported arrest or citation for drug paraphernalia compared to 10% of IDUs attending an illegal SEP (p = 0.001). In multivariate analysis, the adjusted odds ratio of arrest or citation for drug paraphernalia was 1.6 [95% confidence interval (CI) = 1.2, 2.3] for IDUs attending legal SEPs compared to IDUs attending illegal SEPs, after controlling for race/ethnicity, age, homelessness, illegal income, injection of amphetamines, years of injection drug use, frequency of SEP use, and number of needles received at last visit. IDUs attending SEPs with legal status may be more visible to police, and hence, more subject to arrest or citation for paraphernalia. These findings suggest that legislative efforts to decriminalize the operation of SEPs without concurrent decriminalization of syringe possession may result in higher odds of arrest among SEP clients, with potentially deleterious implications for the health and well-being of IDUs. More comprehensive approaches to removing barriers to accessing sterile syringes are needed if our public health goals for reducing new HIV/HCV infections are to be obtained.

Secondary Syringe Exchange Among Users of 23 California Syringe Exchange Programs

This article describes the secondary syringe exchange (SSE) practices of injection drug users (IDUs) attending 23 syringe exchange programs (SEPs) in the state of California during 2002 (n = 539). The sample was primarily heroin injecting, about two thirds male, half White and half other racial/ethnic groups. Participants were interviewed with a structured questionnaire that included items on sociodemographic factors, drug use practices, sexual practices, use of SEP and other social services, and satisfaction with SEP services. Interviews lasted about 30 minutes. SSE was highly prevalent: 75% of IDUs reported participating in SSE in the 6 months before interview. Program characteristics, such as legal status, SSE policy, and exchange policy, did not affect the prevalence of SSE among SEP clients. Infectious disease risk behaviors were significantly more common among SSE participants than nonparticipants. SSE participants were more likely to share syringes (p <. 001) and cookers (p <. 001) in the previous 6 months. SSE was significantly associated with being stuck with another person's syringe (needle-stick), a little-discussed “occupational hazard” of this practice. In multivariate analysis, the adjusted odds ratio of needle-stick among SSE participants was 2.8 (95% confidence interval, 1.3, 6.0). The high prevalence of SSE and the infectious disease risk associated with it warrant additional research to determine the causality of these associations. In the interim, SEPs should consider reinforcing HIV prevention education messages and training IDUs who engage in SSE in safe handling of biohazardous materials.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: Implications for quality improvement

Background Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California. Methods Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews. Results On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients. Conclusions SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Syringe Acquisition and Use of Syringe Exchange Programs by Puerto Rican Drug Injectors in New York and Puerto Rico: Comparisons Based on Quantitative and Qualitative Methods

Quantitative and qualitative data are used to compare alternative sources of syringes, including syringe exchange programs (SEPs), accessed by 165 Puerto Rican injection drug users (IDUs) in East Harlem, New York (NY), and 115 in Bayamon, Puerto Rico (PR). IDUs in PR obtained, on average, 45.2% of their syringes from “syringe sellers,” 18.0% from pharmacies, and 17.6% from a SEP. By contrast, IDUs in NY obtained 55.0% of their syringes from SEPs and 22.9% from “syringe sellers.” Compared to their island counterparts, IDUs in NY received significantly more syringes from SEPs (NY, 104.5; PR, 9.2) in the prior 30 days, and were more likely to be referred by SEPs to drug treatment and HIV/TB-testing services. The results of this study suggest the need in Puerto Rico to eliminate restrictive syringe exchange policies, reform drug paraphernalia laws to protect SEP clients, and address police harassment related to carrying syringes.