Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis.

OBJECTIVE: From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision. DESIGN: Costing study and longitudinal cohort study. SETTING: Tijuana, Mexico. PARTICIPANTS: Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study. PRIMARY OUTCOME MEASURES: Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal. RESULTS: During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02). CONCLUSIONS: Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.

Rural people who inject drugs: A cross-sectional survey addressing the dimensions of access to secondary needle and syringe program outlets.

OBJECTIVE: To better understand issues related to access to injecting equipment for people who inject drugs (PWID) in a rural area of New South Wales (NSW), Australia. DESIGN: Cross-sectional face-to-face survey using convenience and snowball sampling. SETTING: Six regional and rural population centres in Northern NSW, within the Hunter New England Local Health District. PARTICIPANTS: The sample included 190 PWID who had accessed a needle and syringe program outlet within 4 weeks of the survey. MAIN OUTCOME MEASURES: Data include demographic information, preferred location for accessing injecting equipment, reasons for that preference, whether they obtained enough equipment, travelling distance to an NSP and self-reported hepatitis C virus status. RESULTS: Sixty percent self-identified as Aboriginal people. The median age of respondents was 32 years and 60% were men. A significantly larger proportion (P < 0.05) of the Aboriginal respondents were women (27% versus 11.6%) and younger (37.6 versus 12.7%) compared to non-Aboriginal respondents. Most preferred to access injecting equipment at a community health facility (62.6%), as opposed to other secondary outlets, where they gained enough equipment (67.4%). Just over 80% said they were tested for HCV in the past year, with about 37% told they had tested positive. CONCLUSIONS: There are complex dimensions affecting how rural PWID access secondary NSP outlets. Although access is similarly limited as other rural health services because of the nature of injecting drug use and sensitivities existing in rural communities, there is potential for application of unique access models, such as, promoting secondary distribution networks.

Client satisfaction and risk behaviours of the users of syringe dispensing machines: a pilot study.

INTRODUCTION AND AIMS: The study examines risk behaviours of the users of syringe dispensing machines (SDMs) and evaluates the usefulness of these machines in providing injecting drug users (IDUs) with sterile injecting equipment. DESIGN AND METHODS: Self-administered questionnaires were used among users of SDMs in an Area Health Service of Sydney. RESULTS: The majority of the 167 participants reported being happy with the quality of the SDM services. Problems identified with machines were that they were often broken or jammed (32.8% respondents), not in the right place (21.9%) or require money (16.7%). Just over half (50.9%) of the IDUs use SDMs only from 5 p.m. to 9 a.m., the time when almost all other outlets for accessing sterile injecting equipment remain closed. Relatively young IDUs (age < or = 30 years) were more likely to prefer SDMs over staffed needle syringe programmes (NSPs) compared with older users (age > 30) and to identify stigma (a desire to hide their identity or not liking the way people treat them at staffed NSPs or chemists) as a main reason for using these machines. Primary users of SDMs do not differ from primary users of NSP/chemists in terms of sharing of needles. Those users who had shared in the last month were nearly four times as likely to have never used condoms in sexual encounters over that period (95% confidence interval: 1.2 - 14.5). DISCUSSION AND CONCLUSION: SDMs appear to complement other outlets of NSPs. Providing free-of-cost equipment from SDMs should be considered carefully, as needing money to buy equipment was a reason given for sharing of needles by 35% of those who shared.

Assessing needle exchange operations in a poor Brazilian community.

This article assesses the operations of Porto Alegre, State of Rio Grande do Sul, (southern Brazil) needle exchange program (NEP), a setting where HIV infection rates have been on the rise among injection drug users (IDUs) in recent years, contrasting with substantial declines observed in this population, in major Brazilian cities (located in the southeast and southernmost part of Brazilian northeast). We explored local syringe dynamics, with the exclusive delivery in the local NEP of tagged syringes, and the subsequent monitoring of returned tagged/untagged used syringes from January to September 2002. We further assessed local NEP operations using focus groups and field observation, trying to expose the underlying reasons for the substantial delay in the return of tagged syringes and the continuous and relevant return of untagged syringes throughout the study period. We found that local IDUs reuse, divert, and create caches of syringes at their discretion. All efforts should be made to increase the availability of clean syringes and to fully integrate syringe exchange with comprehensive health education and health screening to effectively curb HIV spread.

Telephone survey of Alaskan pharmacists' nonprescription needle-selling practices.

OBJECTIVES: To determine the availability of nonprescription needles and syringes (NS) through pharmacy sales and to assess the impact of pharmacy policies and municipal paraphernalia laws on pharmacists' selling practices. DESIGN: Telephone survey of all pharmacies in Alaska's four largest cities. SETTING: Anchorage, Fairbanks, Juneau, and Ketchikan, Alaska. SUBJECTS: A single pharmacist from each pharmacy represented in the cities' phone books. MAIN OUTCOME MEASURES: Reports of (1) pharmacies' policies and individual pharmacists' procedures regarding the nonprescription sale of NS, (2) pharmacists' selling practices, and (3) identification of conditions that may affect pharmacists' decisions to sell nonprescription NS. RESULTS: Response rate of 86% (37/43); 77% of pharmacists reported selling at least one nonprescription NS in the last month. Store policy was related to selling practices; however, there was no difference in selling practices between a city with a paraphernalia law and cities without such laws. Logistic regression revealed pharmacists were more likely to sell NS if they worked in chain pharmacies and estimated that a high number of other local pharmacists sell nonprescription NS. CONCLUSION: NS are available through nonprescription sales in Alaskan pharmacies. The majority of pharmacies have store policies that permit pharmacists to sell nonprescription NS, either in all cases or at their discretion. Municipal paraphernalia laws do not determine the selling practices of individual pharmacists.

The role of policy in community pharmacies' response to injection-drug use: results of a nationwide Canadian survey.

The response rate to this survey reflects the salience of the topic and the professional concern about and interest in issues presented by HIV. The HIV/AIDS epidemic has presented pharmacists with one of the greatest challenges to their professional training, ethics, and practice. It further expedites a current re-examination that is occurring among community pharmacies concerning their roles in community health practices. In response to HIV there have been dramatic and unprecedented changes in pharmacy policy and practices. Clearly, some community pharmacies have led the way and influenced policy and practices. In view of the recent introduction of many of these policies and practices, it is likely that change will continue. Survey respondents were, in general, very comfortable with an expanded role involving counseling, health promotion, and disease prevention, consistent with a broader role for community pharmacies in general that has been recently advocated. Community pharmacies serve all areas of the country, in communities large and small; many are open seven days a week, and some provide extended hours of service. Community pharmacies may provide an important complement to community outreach programs as a source of clean needles and syringes for IDUs in most communities, and as an alternative service in some communities where more elaborate programs are not feasible. Safer needle use, as part of a health-promotion approach, is divergent from conventional practice. While major changes have occurred, it appears that there has been some polarization of attitudes and response. The explanation for this is not simple, and further analysis is required to determine the full impact from several ethical perspectives that include professional, business, and public health viewpoints. We have highlighted the role that policy has in moving toward preventive and harm-reduction approaches. From a policy perspective, we have found that support from the federal government, regulatory bodies, and professional associations may be an important catalyst to pharmacists' participation in programs. Further, it does not appear to be possible to implement such policies without professional development and continuing education, and collaboration with the community. Based on data on knowledge and educational need, we believe that our study population's lowest levels of information were in such areas as the role of methadone in HIV prevention and the availability of needle-exchange programs. As with other health-promotion campaigns, additional skills training may be important. Movement forward with expanded preventive and harm-reduction strategies by pharmacies will require careful planning. It is anticipated that change in this area will be incremental in nature, and that it is necessary to introduce programs and services into community pharmacies gradually. Successful implementation will require extensive community development and collaboration with other health professionals, public health officials, police, groups who represent IDUs, and persons living with HIV/AIDS. Careful monitoring and evaluation of these programs will be necessary to enhance their effectiveness.

The syringe in the machine.

This paper is a report on focus-group discussions with Western Australian and South Australian injecting drug users and South Australian drug workers, about the feasibility of and issues surrounding the introduction of needle-and-syringe vending machines in Australia. Injecting drug users and workers supported the idea of introducing vending machines in Australia to complement existing services that provide sterile injecting equipment. The participants emphasised that the machines should be provided in addition to existing services. Possible adverse effects of their introduction included concerns for the safety of minors who are not drug users. The potential benefits to public health includes further reducing that proportion of the sharing of injecting equipment that is related to unavailability of sterile equipment (usually at times when other services do not operate).

[Distribution of free equipment to intravenous drug addicts in Copenhagen]. / Udlevering af gratis "vaerktøj" til intravenøse stofmisbrugere i København.

Since HIV-infection was recognized in Denmark in the middle of the 80'ies, the authorities have tried to prevent spread of the infection by common educational information. Besides this, special interest was focussed on transmission between members in certain subgroups at high risk. Amongst these are intravenous drug users because of their common needle-sharing. Intravenous drug users constitute the second largest group of HIV infected individuals in Denmark as well as abroad, and it is from this primary high risk group that heterosexual transmission is most feared. In order to prevent this, the urgent need in stopping transmission among the members of the subpopulation itself as early as possible was realized. In order to achieve this, the municipalities of Copenhagen, Frederiksberg and Copenhagen County have distributed free needles and syringes from pharmacies during the past five years. The free needle arrangement is described in figures as well by interviews with a number of intravenous drug users seen as customers at Pharmacy of Istedgade, Copenhagen V. A total of 3 million needles and syringes have been distributed through the period and the arrangement seems to have been a success, although difficulties are great outside normal opening hours and for the imprisoned. Further and expanded distribution possibilities and new ways of thinking are recommended in order to achieve greater compliance amongst intravenous drug addicts.

The needle-borne HIV epidemic: causes and public health responses.

Needle sharing among intravenous drug users is fueling the modern HIV epidemic. A public health approach to needle-borne infection has three components: prevention and education, availability of sterile injection equipment, and drug treatment. This essay examines the most controversial aspect of this strategy--sterile needle distribution and exchange. The sharing of drug injection equipment is the critical factor in the transmission of HIV in the drug using population. Sharing is not merely a learned response, but is also the result of a limited supply of needles and syringes. Limiting the supply of sterile equipment results from a policy choice which includes: (i) the adoption of drug paraphernalia statutes which criminalize the possession of equipment with the intention of using it for drug injection; (ii) the adoption of needle prescription statutes which criminalize the sale of needles and syringes without a medical prescription; and (iii) the failure to adopt a comprehensive program for the distribution, exchange, or sterilization of equipment. A public health approach to reduce the needle-borne HIV epidemic would repeal needle prescription laws, limit drug paraphernalia laws so they apply only to illicit sellers, and establish needle exchange programs with an array of education and drug treatment services attached.

Recommendations for control and prevention of human immunodeficiency virus (HIV) infection in intravenous drug users.

Considerable evidence indicates that intravenous drug users are emerging as the group at greatest risk for both acquiring and spreading human immunodeficiency virus (HIV) infection. Thus, all possible methods to control the spread of HIV infection in intravenous drug users should be explored. Key recommendations are that HIV antibody testing of intravenous drug users should be voluntary, because mandatory testing is counterproductive; free distribution of needles and syringes to intravenous drug users should occur only in carefully controlled circumstances to determine its effectiveness in decreasing infection rates; and drug-free and methadone maintenance treatment programs should be available on demand to all intravenous drug users as a means of reducing the spread of HIV infection. At present, the primary strategy for prevention must be education resulting in behavioral change. Education is currently the only definitive means for controlling the spread of HIV infection among intravenous drug users, their sex contacts, and to fetuses.