Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries An Assessment of the Evidence (2007) / Chapter Skim
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3 Sterile Needle and Syringe Access and Outreach and Education
3 Sterile Needle and Syringe Access and Outreach and Education
Pages 137-186
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From page 137... ...
To properly reflect this, the Committee refers to such programs as multi-component HIV prevention programs 1Needle and syringe exchange refers broadly to supplying clean needles and syringes to IDUs and collecting used injecting equipment. While some programs require exchange of used needles for clean ones, need-based programs allow unlimited distribution of needles and syringes.
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From page 138... ...
Outreach and education are sometimes part of multi-component HIV prevention programs, as they are often used to direct drug users to services such as needle and syringe exchange. They can also stand alone as a means of educating IDUs on HIV prevention, and can also be used to refer drug users to drug treatment and other health and social services.
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From page 139... ...
Another limitation is that the study designs generally do not allow separate examination of program elements, so the independent contribution of improving access to sterile needles and syringes cannot be assessed. For example, NSE is often one component of a multi-component HIV prevention program, making it difficult to isolate the exact effects of NSE alone.
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From page 140... ...
Negative outcomes may include more frequent injection among participants, new initiates to injecting drug use, greater drug use in the community, and more needles discarded in public places. In the following sections, BOX 3-1 Potential Outcomes from Needle and Syringe Exchange Drug-related risk behavior Sex-related risk behavior Frequency of drug use Number of sexual partners Frequency of injection Frequency of unprotected sex Frequency of equipment sharing Sale of sex for drugs or money Use of disinfectant Number of injecting partners Unintended consequences Links to health and social services Recruitment of new IDUs Referral to services Increase in unsafe disposal of needles Extent of use of services Increase in prevalence or frequency of Referral to drug treatment drug use Incidence/prevalence HIV Hepatitis C Hepatitis B
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From page 141... ...
Thirteen found that participation in multi-component programs that include needle and syringe exchange reduced self-reported needle sharing. (Sharing is defined as lending or borrowing used needles or syringes.)
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The study found no change in selfreported frequency of injection, but did find a decline in self-reported frequency of unsafe injection. Based on this evidence, the Committee concludes: Conclusion 3-1: Nearly all programs included in our literature search combine needle and syringe exchange with other compo nents such as outreach, risk reduction education, condom distri bution, bleach distribution and education on needle disinfection, and referrals to substance abuse treatment and other health and social services.
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From page 143... ...
Des Jarlais et al., 2000, New York City Injection risk behaviors declined (ecological) significantly in presence of NSE.
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From page 144... ...
Conclusion 3-2: Moderate evidence from a large number of stud ies and review papers -- most from developed countries -- shows that participation in multi-component HIV prevention programs that include needle and syringe exchange is associated with a reduction in drug-related HIV risk behavior. Such behavior in cludes self-reported sharing of needles and syringes, safer inject ing and disposal practices, and frequency of injection.
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From page 145... ...
However, this issue has not been well studied, and the existing modest evidence is insufficient to deter mine the effectiveness of needle and syringe exchange in reducing sex-related risk. Effects of NSE on HIV Incidence/Prevalence Few site-specific studies have explored the relationship between NSE participation and HIV incidence, although several ecological studies have found positive associations between the introduction or presence of NSEs and reduced HIV prevalence and incidence (see Table 3-3)
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From page 146... ...
. The analyses employed methodologies to control for a range of confounders, including drug of choice and frequency of injecting drug use in the previous month.
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From page 147... ...
After adjusting for confounders, the authors found that the adjusted odds ratio for HIV infection status among NSE users compared with non-NSE users was 1.68. The authors noted that cocaine was the drug of choice among 72 percent of HIV-seropositive IDUs, and that cocaine puts IDUs at elevated risk because it is associated with more frequent injection (Anthony et al., 1991; Chaisson et al., 1989)
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From page 148... ...
found initial reductions in risk behavior after NSE and other interventions began, but no further reductions over time. These studies also found that NSE was not associated with an increase in injecting drug use, and attributed declines in injecting to cultural and ecological factors.
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From page 149... ...
Conclusion 3-5: Moderate evidence indicates that multi component HIV prevention programs that include needle and sy ringe exchange reduce intermediate HIV risk behavior. However, evidence regarding the effect of needle and syringe exchange on HIV incidence is limited and inconclusive.
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From page 150... ...
More recently, a variant of this mathematical framework has been used to assess the impact of extending coverage of needle distribution programs on HIV transmission among injecting drug user populations of Belarus and the United Kingdom when injectors share needles in the confines of small sub-groups of the population (Vickerman et al., 2006)
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From page 151... ...
Moreover, models can highlight some common areas of concern such as how the relatively high probability of transmission of HCV from a single unsafe injection means that even if needle exchanges achieved high coverage rates, they would be much less efficacious in preventing HCV than HIV. Unintended Consequences of Needle and Syringe Exchange This section reviews evidence regarding the effect of NSE on the frequency of drug use, the recruitment of new injecting drug users, unsafe disposal of needles, and trends in crime.
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From page 152... ...
. Based on this evidence, the Committee concludes: Conclusion 3-7: Few studies have specifically evaluated whether HIV prevention programs that include needle and syringe ex change lead to unintended consequences, such as increases in new drug users, more frequent injection among established users, ex
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Thirty-nine percent of the sample used at least one service besides needle exchange, with most of these participants using services that did not require outside follow-up. Twenty-eight percent had heard of at least one service beyond needle and syringe exchange, but had not used the additional service.
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From page 154... ...
However, none of the studies had comparison or control groups, so the overall use of such services among drug users who do not use NSE is unknown. Summary Conclusion and Finding on Multi-Component HIV Prevention Programs that Include NSE Summary Conclusion: Moderate evidence from developed coun tries points to a beneficial effect of multi-component HIV preven tion programs that include needle and syringe exchange on injection-related HIV risk behavior, such as self-reported needle sharing and frequency of injection.
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From page 155... ...
. Relaxation of such laws and regulations governing pharmacy sales of syringes has improved attitudes toward selling to injecting drug users, and increased the number of IDUs who turn to pharmacies for clean injecting equipment (Coffin et al., 2002; Deren et al., 2006)
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From page 156... ...
. Some pharmacists fear that IDUs will discard syringes unsafely, and that the presence of IDUs in their pharmacy will be bad for business, while others view syringe access as an HIV prevention method, and see drug dependence as a disease.
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From page 157... ...
. Characteristics of IDUs Using Pharmacies for Sterile Needle and Syringe Access Studies show that IDUs who use pharmacies tend to have lower risk profiles.
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From page 158... ...
SIFs prohibit drug dealing and provide sterile injecting equipment, referrals to health care and drug treatment, and other services such as meals and showers. SIFs have long existed in Europe, particularly in the Netherlands, Germany, Switzerland, and Spain (Dolan et al., 2000)
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From page 159... ...
Similarly, no studies have linked SIFs to HIV transmission, but reductions in risk behavior such as needle sharing and condom use have occurred among SIF clients. Vending Machines Syringe vending machines work like other types of vending machines, except that they accept contaminated syringes and dispense sterile syringes in exchange (Obadia et al., 1999)
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From page 160... ...
Conclusion 3-10: The evidence regarding supervised injecting fa cilities and vending machines -- while encouraging -- is insufficient for drawing conclusions on the effectiveness of these interventions in reducing drug-related HIV risks among IDUs. Recommendations for Sterile Needle and Syringe Access Programs Recommendation 3-1: Given consistent evidence that multi component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risks, such programs should be implemented where feasible.
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From page 161... ...
Recommendation 3-2: Multi-component HIV prevention programs that include sterile needle and syringe access should: · Maximize their accessibility to the largest number of IDUs by using multiple access points and methods of delivery. · Focus on reducing sex-related HIV risk behavior.
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From page 162... ...
. These studies found that bleach was the most feasible disinfectant because of its wide availability and low cost, and because accidental injection would not greatly harm drug users (Froner et al., 1987)
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From page 163... ...
Field Studies Although laboratory studies show that undiluted bleach inactivates HIV after an exposure time of 30 seconds, the evidence supporting the effectiveness of bleach disinfection in the field is weak. The Centers for Disease Control and Prevention endorses a procedure for using bleach to cleanse injecting equipment (see Box 3.2)
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From page 164... ...
Eighty percent of the 85 bleach users recorded a total contact time of less than 30 seconds, and only 30.6 percent filled the syringe at least halfway. The authors noted that the median contact time per flush was approximately 10 seconds, indicating that drug users might achieve the minimum contact time of 30 seconds if they were encouraged to perform at least three flushes.
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(1994) evaluated the efficacy of bleach disinfection of needles and syringes among IDUs in preventing HIV infection.
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From page 166... ...
Conclusions and Recommendation for Disinfection Programs Conclusion 3-12: If used according to the guidelines of the Cen ters for Disease Control and Prevention, the National Institute on Drug Abuse, and the Center for Substance Abuse Treatment, there is strong evidence that undiluted bleach can be an effective HIV prevention strategy for injecting drug users who share needles and syringes. Conclusion 3-13: Strong evidence from field studies shows that, in practice, IDUs do not correctly use bleach, and that they fail to properly disinfect syringes.
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From page 167... ...
. Outreach activities through NADR included basic risk reduction activities such as literature on HIV prevention and services, distribution of condoms and bleach kits, and referrals to services including drug treatment (Coyle et al., 1998)
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(3) Are changes in behaviors associated with lower rates of HIV infection among IDUs?
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In a prospective cohort study, Wiebel (1996) monitored trends in HIV risk behavior and seroconversion among IDUs receiving street-based outreach in Chicago from 1988 to 1992.
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From page 170... ...
Outreach workers were chosen to represent the town's many ethnic groups, and the majority had a history of injecting drug use. These workers were trained in the basic facts of HIV, the importance of preventing transmission among IDUs and their partners, how to deliver prevention messages, when and where to refer IDUs for drug treatment, and safety and security.
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From page 171... ...
(1998) examined the effectiveness of community-based outreach in reducing risk behavior for HIV transmission in two locations in Madras, India.
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From page 172... ...
Additional research is needed to identify the most effective sexual risk reduction strategies for IDUs, and to determine how to successfully integrate these strategies into multi-component programs and outreach and education. Second, few studies have specifically evaluated whether HIV prevention programs that include needle and syringe exchange lead to unintended consequences such as increases in new drug users, expanded networks of high-risk users, more discarded needles in the community, and changes in crime trends.
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From page 173... ...
· The potential unintended consequences of HIV prevention programs that include needle and syringe exchange, such as in creases in new drug users or in discarded needles in the community, and strategies to address such problems, if they are found.
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From page 174... ...
Needle and syringe exchange could then be added in the experimental communi ties as part of a sequential rollout across all trial sites. A community randomized trial makes particular sense for injecting drug users because they may share the same drug-using network and compare their treat ment experiences.
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From page 175... ...
. CONCLUSION For injecting drug users who cannot gain access to treatment or are not ready to consider it, multi-component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risk behavior such as self-reported sharing of needles and syringes, unsafe injecting and disposal practices, and frequency of injection.
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From page 176... ...
While few studies have specifically examined such outcomes, studies to date have not found evidence of negative effects. More research is needed on potential unintended consequences of HIV prevention programs that include needle and syringe access, and strategies to address such problems if they are found.
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From page 177... ...
1997. High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: Results of a cohort study.
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1998. Outreach-based HIV prevention for injecting drug users: A review of published outcome data.
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1989. Sexual behaviour of injecting drug users and associated risks of HIV infection for non-injecting sexual partners.
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1997. Reaching out beyond the hills: HIV prevention among injecting drug users in Manipur, India.
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1993. Evaluation of syringe-exchange for HIV prevention among injecting drug users in rural and urban areas of Wales.
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2001. Multiple access to sterile syringes for injection drug users: Vending machines, needle exchange programs and legal phar macy sales in Marseille, France.
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2005. Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users.
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From page 184... ...
1996. Increasing the use of bleach and condoms among injecting drug users in Denver: Outcomes of a targeted, community level HIV prevention program.
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2005. Needle and syringe sharing practices of injecting drug users participating in an outreach HIV prevention program in Tehran, Iran: A cross-sectional study.
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1994. Syringe and needle exchange as HIV/AIDS prevention for injection drug users.
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