Correlates of sharing of needles and syringes among people who inject drugs in Dhaka city, Bangladesh.

INTRODUCTION: This paper examines the correlates of needle and syringe sharing among People Who Inject Drugs in Dhaka city, Bangladesh, which is currently experiencing a steep increase in HIV prevalence despite the ongoing presence of Needle Exchange Programs. METHODOLOGY: This was a retrospective chart review with cross-sectional design that extracted data from 783 male People Who Inject Drugs enrolled into five Opioid Substitution Treatment clinics in Dhaka city between April 2010 and January 2016. Data were retrieved from the program's electronic database. Needle and syringe sharing constituted the borrowing or lending of needles and syringes from others within the past month preceding data collection. RESULTS: Buprenorphine was the preferred injection drug and 44.6% shared needles and syringes within the past month. Multivariate analysis indicated that People Who Inject Drugs who were homeless (OR = 8.1, 95% CI = 1.4-44.9, p < 0.05), living with friends (OR = 6.8, 95% CI = 2.5-18.2, p < 0.001), injecting 2-3 times/day (OR = 4.8, 95% CI = 1.2-19.7, p < 0.05), injecting more than three times/day (OR = 4.8, 95% CI = 1.1-20.0, p < 0.05), not using condom with non-commercial female sex partners (OR = 3.3, 95% CI = 1.8-6.0, p < 0.05), bought sex from female sex workers (OR = 2.9, 95% CI = 1.0-8.3, p < 0.05), and did non-suicidal self-injury (OR = 1.8, 95% CI = 1.0-3.0, p < 0.05) were more likely to share needles and syringes. CONCLUSIONS: This study demonstrates that operating a standalone harm reduction approach that just provides sterile needles and syringes may not adequately curb needle and syringe sharing among People Who Inject Drugs.

French People's positions on supervised injection facilities for drug users.

BACKGROUND: Supervised injection facilities have been set-up in many countries to curb the health risks associated with unsafe injection practices. These facilities have, however, been met with vocal opposition, notably in France. As harm reduction policies can only succeed to the extent that people agree with them, this study mapped French people's opinions regarding the setting-up of these facilities. METHOD: A sample of 318 adults--among them health professionals--were presented with 48 vignettes depicting plans to create a supervised injection facility in their town. Each vignette contained three pieces of information: (a) the type of substance that would be injected in the facility (amphetamines only, amphetamines and cocaine only, or amphetamines, cocaine and heroin), (b) the type of staff who would be working in the facility (physicians and nurses, specially trained former drug users, specially trained current drug users, or trained volunteers recruited by the municipality), and (c) the staff members' mission (to be present and observe only, technical counselling about safe injection, counselling about safe injection and hygiene, or counselling and encouragement to follow a detoxification program). RESULTS: Through cluster analysis, three qualitatively different positions were found: Not very acceptable (20%), Depends on staff and mission (49%), and Always acceptable (31%). These positions were associated with demographic characteristics--namely gender, age and political orientation. CONCLUSION: French people's positions regarding supervised injection facilities were extremely diverse. One type of facility would, however, be accepted by a large majority of people: supervised injection facilities run by health professionals whose mission would be, in addition to technical and hygienic counselling, to encourage patrons to enter detoxification or rehabilitation programs.

Challenges and value of peer outreach workers in needle and syringe exchange programs: Evidence from an HIV prevention program in Yunnan province, China.

We aim to compare the values and challenges of peer outreach workers (POWs) with a history of drug use with non-POWs (NPOWs) in a needle and syringe exchange program (NSEP) in Yunnan, China. Data were abstracted from two independent surveys of 98 outreach workers and 33 program managers in 2014. POWs were more likely than NPOWs to conduct active outreach and to report ease in exchanging needles. Commonly cited concerns from POWs were low wages and frustration with client follow-up. Managers expressed the most concern on high turnover rates and low education levels. POWs seem to be more effective than NPOWs in conducting outreach, though POWs face unique challenges. We call for a recognition of the challenges and needs for more sensitive support for POWs.

Secondary distribution of injecting equipment obtained from needle and syringe programmes by people injecting image and performance enhancing drugs: England and Wales, 2012-15.

BACKGROUND: People who inject image and performance enhancing drugs (IPEDs) are often the largest group using needle and syringe programmes (NSPs) in the UK. NSP providers report these clients repeatedly collecting large amounts of equipment for others. The extent of secondary distribution of injecting equipment is unknown. METHODS: Data from national surveillance of people injecting IPEDs were used. Participants completed a questionnaire and provided a dried-blood spot sample. Data from two biennial surveys was combined; repeat participants were excluded. Self-reported data was used to explore the extent of secondary distribution. RESULTS: Of the participants, 87% (467) reported NSP use; median age was 31 years; 98% were male. A third (34%, 157) reported collecting equipment for others. Of those collecting for others, 154 reported how many people they had collected for: 55% had collected for one person, 27% for 2-9 people, 5% for 10-19 and 13% for 20 or more (no difference by psychoactive drug use). Those vaccinated for hepatitis B were more likely (22% [15/68] vs 6% [5/86], p = 0.003), and those reporting redness/swelling at an injection site were less likely to collect equipment for at least 20 others (8% [8/106] vs 25% [12/48], p = 0.003). Overall, 154 people collected equipment for 639-1569 people injecting IPEDs. CONCLUSIONS: Secondary distribution of injecting equipment is common among those injecting IPEDs and using NSPs. Whilst not allowing for rotational collection within groups, our analysis suggests that many of those injecting IPEDs are not in direct contact with NSPs. Innovation approaches for harm reduction interventions are needed.

Are there differences in individual-level needle and syringe coverage across Australian jurisdictions related to program policy? A preliminary analysis.

INTRODUCTION AND AIMS: Services provided by needle and syringe programs (NSP) within Australia are easily accessible by international standards. However, important variation in NSP policy remains across Australian jurisdictions. The potential impacts of these variations on program operation for clients have not been systematically analysed in Australia. In this paper we conduct a preliminary examination to compare individual-level syringe coverage between and within Australian capital cities. DESIGN AND METHODS: Participants were 2498 people who inject drugs (PWID) recruited from all Australian capital cities as part of the annual Illicit Drug Reporting System PWID survey over the period 2014-2016. Insufficient coverage was defined when <100% of a participant's injecting episodes were 'covered' by sterile needles and syringes. We report the percentage of insufficient coverage for each capital city for each year, and present descriptive statistics for coverage parameters, and an alternative measure for insufficient coverage, as Supporting Information. RESULTS: Differences in behaviours that have the potential to impact syringe coverage were highly variable over time and place leading to variations in levels of insufficient coverage between and within all cities. Overall, insufficient coverage was most evident in larger cities where insufficient coverage varied between 19% and 23% (Sydney) over time, compared to smaller cities with variation from 9% to 12% (Adelaide). DISCUSSION AND CONCLUSIONS: We found no consistent pattern of differences in individual-level needle and syringe coverage between and within Australian capital cities. Further work is needed to fully evaluate whether policy variation between Australian jurisdictions impacts on NSP coverage.

Relationships, Training, and Formal Agreements Between Needle and Syringe Programs and Police.

Needle and syringe programs (NSPs) are key public health and HIV prevention programs. We sought to compare over time the quality of relationships between NSPs and police, and implementation of best practices. We conducted cross-sectional surveys in 2008 ( n = 32) and 2015 ( n = 28) with NSP managers in Ontario, Canada. Participants were recruited via e-mail to complete an online survey. Over the period studied, self-reported quality of NSP-police relationships did not change-roughly two thirds of NSP managers reported a positive/mostly positive relationship. In 2015, higher proportions of programs offered training to police about the following: the purpose and goals of NSPs (48% vs. 41% in 2008), NSP effectiveness (55% vs. 34%), the health and social concerns of people who use drugs (52% vs. 40%), and needlestick injury prevention (44% vs. 31%). Few managers reported formal conflict resolution procedures with the police (22% in 2015, 9% in 2008). Our findings show that NSP-police relationships did not deteriorate during a time when such programs fell into disfavor with the federal government. More research is needed to understand if and when formal versus informal agreements with police serve the needs of NSPs.

Health Equity, Social Justice, and HIV in Rhode Island: A Contemporary Challenge.

From its beginning, HIV has primarily affected marginalized populations, such as injection drug users, gay, bisexual and other men who have sex with men (GBMSM), and minority racial and ethnic groups. HIV is a disease that, from the start, has been strongly influenced by issues related to social justice and health equity due to its intersection with behaviors among at-risk populations. While some of the risks associated with HIV have been successfully mitigated through social justice initiatives related to needle exchange programs and routine HIV testing of pregnant women, Rhode Island remains confronted with the health equity challenges of preventing HIV transmission and ensuring access to HIV care/treatment, especially for Black/African Americans, Hispanics, and GBMSM. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Illicit buprenorphine use, interest in and access to buprenorphine treatment among syringe exchange participants.

Poor access to buprenorphine maintenance treatment (BMT) may contribute to illicit buprenorphine use. This study investigated illicit buprenorphine use and barriers to BMT among syringe exchange participants. Computer-based interviews conducted at a New York City harm reduction agency determined: prior buprenorphine use; barriers to BMT; and interest in BMT. Of 102 opioid users, 57 had used illicit buprenorphine and 32 had used prescribed buprenorphine. When illicit buprenorphine users were compared to non-users: barriers to BMT ("did not know where to get treatment") were more common (64 vs. 36%, p<0.01); mean levels of interest in BMT were greater (3.37 ± 1.29 vs. 2.80 ± 1.34, p=0.03); and more participants reported themselves likely to initiate treatment (82 vs. 50%, p<0.01). Illicit buprenorphine users were interested in BMT but did not know where to go for treatment. Addressing barriers to BMT could reduce illicit buprenorphine use.

Internalized stigma and sterile syringe use among people who inject drugs in New York City, 2010-2012.

BACKGROUND: Little is known on the effect of stigma on the health and behavior of people who inject drugs (PWID). PWID may internalize these negative attitudes and experiences and stigmatize themselves (internalized stigma). With previous research suggesting a harmful effect of internalized stigma on health behaviors, we aimed to determine socio-demographic characteristics and injection risk behaviors associated with internalized PWID-related stigma in New York City (NYC). METHODS: Three NYC pharmacies assisted in recruiting PWID. Pharmacy-recruited PWID syringe customers received training in recruiting up to three of their peers. Participants completed a survey on injection behaviors and PWID-related stigma. Among HIV-negative PWID (n=132), multiple linear regression with GEE (to account for peer network clustering) was used to examine associations with internalized PWID-related stigma. RESULTS: Latinos were more likely to have higher internalized stigma, as were those with lower educational attainment. Those with higher internalized stigma were more likely to not use a syringe exchange program (SEP) recently, although no association was found with the recent use of pharmacies for syringes. Lastly, higher internalized stigma was related to less than 100% use of pharmacies or SEPs for syringe needs. CONCLUSIONS: These data suggest that PWID with higher internalized stigma are less likely to consistently use sterile syringe sources in urban settings with multiple sterile syringe access points. These results support the need for individual- and structural-level interventions that address PWID-related stigma. Future research is needed to examine why PWID with higher internalized stigma have less consistent use of public syringe access venues.

Needle and syringe programs in Yunnan, China yield health and financial return.

BACKGROUND: As a harm reduction strategy in response to HIV epidemics needle and syringes programs (NSPs) were initiated throughout China in 2002. The effectiveness of NSPs in reducing the spread of infection in such an established epidemic is unknown. In this study we use data from Yunnan province, the province most affected by HIV in China, to (1) estimate the population benefits in terms of infections prevented due to the programs; (2) calculate the cost-effectiveness of NSPs. METHODS: We developed a mathematical transmission model, informed by detailed behavioral and program data, which accurately reflected the unique HIV epidemiology among Yunnan injecting drug users (IDUs) in the presence of NSPs. We then used the model to estimate the likely epidemiological and clinical outcomes without NSPs and conducted a health economics analysis to determine the cost-effectiveness of the program. RESULTS: It is estimated that NSPs in Yunnan have averted approximately 16-20% (5,200-7,500 infections) of the expected HIV cases since 2002 and led to gains of 1,300-1,900 DALYs. The total $1.04 million spending on NSPs from 2002 to 2008 has resulted in an estimated cost-saving over this period of $1.38-$1.97 million due to the prevention of HIV and the associated costs of care and management. CONCLUSION: NSPs are not only cost-effective but cost-saving in Yunnan. Significant scale-up of NSPs interventions across China and removal of the societal and political barriers that compromise the effects of NSPs should be a health priority of the Chinese government.

Harm reduction product distribution in British Columbia.

OBJECTIVES: The British Columbia Centre for Disease Control (BCCDC) tracks the distribution of all harm reduction products subsidized by the BC government, including needles and syringes, sterile water vials, alcohol swabs, condoms, and lubricant. This study measures the distribution of harm reduction products in BC, identifies regional variation in distribution, and estimates the supply/demand ratio for needle and syringe units. METHODS: Using three years of administrative data (2004-2006) from the BCCDC, the quantity of harm reduction products distributed was calculated by Health Service Delivery Area (HSDA). Regional hepatitis C virus (HCV) case report rates were calculated to reflect potential variation in IDU populations at the HSDA-level and the number of needle and syringe units distributed per reported case of HCV was calculated and ranked by HSDA. To compare the demand for sterile injecting equipment to the distribution, the number of illicit drug injections per year was approximated using established estimates of IDU populations in BC and Vancouver. RESULTS: Marked regional variation exists in the rates of harm reduction product distribution per 100,000 residents aged 15-64. The average number of needle and syringe units distributed annually in BC from 2004-2006 was 5,382,933. The estimated number of injections per year in BC is 24,951,144, suggesting the province distributed 21.5% of the units required to cover all illicit drug injections in the province. DISCUSSION: Harm reduction product distribution is not equitable between BC HSDAs. The current level of distribution of sterile injecting equipment is inadequate to provide a clean needle for every injection.

Descentralização, AIDS e redução de danos: a implementação de políticas públicas no Rio de Janeiro, Brasil / Decentralization, AIDS, and harm reduction: the implementation of public policies in Rio de Janeiro, Brazil

O artigo avalia como a descentralização dos recursos e ações do Programa Nacional de DST e AIDS influenciou as transferências de recursos para os programas de prevenção ao HIV/AIDS entre usuários de drogas injetáveis no Rio de Janeiro, Brasil (1999-2006). Foram avaliados os efeitos da política de descentralização sobre as transferências de recursos para os Programas de Redução de Danos (PRD) no Rio de Janeiro. A descentralização das transferências para os PRD no Rio de Janeiro se efetivou em 2006, com a virtual supressão do financiamento federal direto, obrigando estes programas a buscarem fontes alternativas de financiamento. Constata-se uma fragilidade dos PRD no Estado, agravada pela redução recente do volume de recursos. Dos 22 programas, existentes em 2002, o Estado passou a contar, em 2006, com apenas dois programas, financiados pelo Estado e por um município. A descontinuidade dessas ações pode vir a favorecer a reemergência da epidemia de AIDS nesta população, o que reclama um processo de descentralização mais gradual e melhor pactuado dessas iniciativas.

This paper assesses how decentralization of resources and initiatives by the Brazilian National SDT/AIDS Program has impacted the transfer of funds for programs to prevent HIV/AIDS among injecting drug users in Rio de Janeiro, Brazil (1999-2006). The effects of the decentralization policy on Rio de Janeiro's Syringe Exchange Programs (SEPs) are assessed in detail. Decentralization effectively took place in Rio de Janeiro in 2006, with the virtual elimination of any direct transfer from the Federal government. The elimination of direct transfers forced SEPs to seek alternative funding sources. The structure of local SEPs appears to be weak and has been further undermined by current funding constraints. Of 22 SEPs operating in 2002, only two are still operational in 2006, basically funded by the State Health Secretariat and one municipal government. The current discontinuity of SEP operations may favor the resurgence of AIDS in the IDU population. A more uniform, regulated decentralization process is thus needed.

[Decentralization, AIDS, and harm reduction: the implementation of public policies in Rio de Janeiro, Brazil]. / Descentralização, AIDS e redução de danos: a implementação de políticas públicas no Rio de Janeiro, Brasil.

This paper assesses how decentralization of resources and initiatives by the Brazilian National SDT/AIDS Program has impacted the transfer of funds for programs to prevent HIV/AIDS among injecting drug users in Rio de Janeiro, Brazil (1999-2006). The effects of the decentralization policy on Rio de Janeiro's Syringe Exchange Programs (SEPs) are assessed in detail. Decentralization effectively took place in Rio de Janeiro in 2006, with the virtual elimination of any direct transfer from the Federal government. The elimination of direct transfers forced SEPs to seek alternative funding sources. The structure of local SEPs appears to be weak and has been further undermined by current funding constraints. Of 22 SEPs operating in 2002, only two are still operational in 2006, basically funded by the State Health Secretariat and one municipal government. The current discontinuity of SEP operations may favor the resurgence of AIDS in the IDU population. A more uniform, regulated decentralization process is thus needed.

Evaluation of a needle social marketing strategy to control HIV among injecting drug users in China.

OBJECTIVE: To evaluate the effectiveness of a needle social marketing strategy to reduce needle sharing and hepatitis C Virus (HCV)/HIV transmission among injecting drug users (IDU) in China. DESIGN: Two-armed, prospective, community-randomized prevention trial. SETTING: Four counties/townships in Guangxi and Guangdong provinces; one randomized to intervention the other to control in each province. PARTICIPANTS: Injecting drug users: 823 (443 intervention, 382 control) at baseline and 852 (415 intervention, 407 control) at the second cross-sectional survey 12 months later. INTERVENTION: A needle social marketing programme, including promotion of safe injection norms and increased access to clean needles over a 12 month period. MAIN OUTCOME MEASURES: Cross sectional surveys at baseline and follow-up compared changes in drug using behaviours and HIV and HCV rates in the intervention and control communities. RESULTS: Needle sharing behaviours were similar in the two groups at baseline (68.4 vs. 67.8%), and dropped significantly to 35.3% in the intervention community and remained relatively stable in the control community (62.3%; P < 0.001). In a subset of cohort of new injectors, the incidence of HCV was significant lower in intervention than in control in both provinces (P < 0.001, P = 0.014) and overall (P < 0.001) but HIV was only significantly lower in intervention in Guangdong (P = 0.011). CONCLUSION: Needle social marketing can reduce risky injecting behaviour and HIV/HCV transmission among injecting drug users in China and should be expanded.

Effectiveness of needle/syringe exchange program in Tbilisi.

IDUs are under the high risk of HIV and other blood born diseases. In Georgia injecting drug use is associated with two third of registered HIV/AIDS cases. Majority of them are also infected with B and C Hepatitis. One of the main components of HIV/AIDS prevention among drug users is considered to be harm reduction programs, among them syringe exchange program. We conducted observational cohort study and performed interviewing participants of syringe exchange program using structured questionnaire. The interviewing was conducted at intake, after 3 months and at the end of the program. During interviewing we used risk assessment questionnaire which we have little adapted (Risk Assessment Battery, Navaline, et al, 1994). The data were statistically analysed using SPPS-11, 5 program. The aim of the study was to assess the efficacy of outreach and needle exchange programs in terms of reduction of HIV risk behavior of injection drug users in Tbilisi. The results of the study show visible reduction in injection risk behavior for clients being in the program for at least three months. There was not seen any significant change in the level of sexual risk behavior, which might suggest the need for targeting this behavior during the further interventions. The results of the study suggest a visible potential benefit to drug users and communities that could be gained through the wide scale implementation of harm reduction programs in Georgia.