Characteristics and utilization patterns of needle-exchange attendees in Chicago: 1994-1998

HIV risk and prevention among clients of a delivery-based harm reduction service during an HIV outbreak among people who use drugs in northern rural Minnesota, USA

BACKGROUND

Since 2019, multiple HIV outbreaks occurred among people who inject drugs (PWID) in Minnesota. Syringe service programs (SSPs) are evidence-based programs that reduce the spread of HIV. We conducted an assessment of characteristics and HIV risk and prevention among clients of a delivery-based SSP near an HIV outbreak in rural, northern Minnesota.

METHODS

In the fall of 2021, we conducted a cross-sectional survey of clients of a mobile SSP based in Duluth, Minnesota. Survey topics included demographics, drug use, sexual behavior, HIV testing history, and HIV status. We conducted descriptive analyses and used univariate logistic regression to identify correlates of syringe sharing. The analysis was limited to PWID in the last six months.

RESULTS

A total of 125 people were surveyed; 77 (62%) were PWID in the last six months. Among these participants, 52% were female and 50% were homeless. Thirty-two percent reported sharing syringes and 45% reported sharing injecting equipment. Approximately one-half (49%) of participants had been tested for HIV in the past year, and none reported being HIV-positive. Individuals reported low condom usage (88% never used), and 23% of participants reported engaging in some form of transactional sex in the last six months. Incarceration in the last year was associated with sharing syringes (odds ratio = 1.4, 95% confidence interval 1.1-1.8).

CONCLUSION

HIV risk was high among PWID receiving services at this SSP. These data highlight a rural SSP that is engaged with people at risk for HIV and needs additional support to expand harm reduction services.

Preliminary Efficacy of a Theory-Informed Intervention to Increase COVID-19 Testing Uptake Among People Who Inject Drugs in San Diego County: Findings From a Pilot Randomized Controlled Trial

BACKGROUND

People who inject drugs (PWID) have low rates of COVID-19 testing yet are vulnerable to severe disease. In partnership with a mobile syringe service program (SSP) in San Diego County, CA, we developed the evidence-, community-, and Social Cognitive Theory-informed "LinkUP" intervention (tailored education, motivational interviewing, problem-solving, and planning) to increase COVID-19 testing uptake among PWID.

PURPOSE

To assess preliminary efficacy of LinkUP in increasing PWID COVID-19 testing in a pilot randomized controlled trial (RCT).

METHODS

We referred participants (PWID, ≥18 years old, San Diego County residents who had not recently undergone voluntary COVID-19 testing) to mobile SSP sites that had been randomized (by week) to offer the active LinkUP intervention or didactic attention-control conditions delivered by trained peer counselors. Following either condition, counselors offered on-site rapid COVID-19 antigen testing. Analyses estimated preliminary intervention efficacy and explored potential moderation.

RESULTS

Among 150 participants, median age was 40.5 years, 33.3% identified as Hispanic/Latinx, 64.7% were male, 73.3% were experiencing homelessness, and 44.7% had prior mandatory COVID-19 testing. The LinkUP intervention was significantly associated with higher COVID-19 testing uptake (p < .0001). Homelessness moderated intervention effects; LinkUP increased COVID-19 testing uptake more among participants experiencing homelessness (adjusted risk ratio [aRR]: 1.80; 95% CI: 1.56-2.09; p < .0001) than those not experiencing homelessness (aRR: 1.20; 95% CI: 1.01-1.43; p = .04).

CONCLUSIONS

Findings from this pilot RCT support the preliminary efficacy of the "LinkUP" intervention to increase COVID-19 testing among PWID and underscore the importance of academic-community partnerships and prevention service delivery through SSPs and other community-based organizations serving vulnerable populations.

Study protocol for a pilot randomized controlled trial to increase COVID-19 testing and vaccination among people who inject drugs in San Diego County

BACKGROUND

People who inject drugs (PWID) have low rates of COVID-19 testing and vaccination and are vulnerable to severe disease. We partnered with a local, community-based syringe service program (SSP) in San Diego County, CA, to develop the single-session theory- and evidence-informed "LinkUP" intervention to increase COVID-19 testing and vaccination. This paper details the protocol for a pilot randomized controlled trial (RCT) of the LinkUP intervention.

METHODS

With significant community input into study design considerations, including through our Community and Scientific Advisory Board, the LinkUP pilot RCT leverages an ongoing cohort study with adult (≥ 18 years) PWID in San Diego County to recruit participants who have not recently undergone voluntary COVID-19 testing and are unvaccinated. Eligible participants are referred to SSP locations randomized to offer the active intervention (involving tailored education, motivational interviewing, and problem-solving strategies) or a didactic attention-control condition (information sharing only). Both conditions are delivered by trained peer counselors hired by the SSP and were designed to be delivered at mobile (outdoor) SSP sites in ~ 30 min. Intake data assesses COVID-19 testing and vaccination history, health status, and harm reduction needs (to facilitate SSP referrals). At the end of either intervention condition, peer counselors offer onsite rapid COVID-19 antigen testing and COVID-19 vaccination referrals. Out-take and follow-up data (via SSP and state health department record linkages) confirms whether participants received the intervention, COVID-19 testing (and results) onsite or within six months, and vaccination referrals (and uptake) within six months. Planned analyses, which are not powered to assess efficacy, will provide adequate precision for effect size estimates for primary (COVID-19 testing) and secondary (vaccination) intervention outcomes. Findings will be disseminated widely including to local health authorities, collaborating agencies, and community members.

DISCUSSION

Lessons from this community-based pilot study include the importance of gathering community input into study design, cultivating research-community partnerships based on mutual respect and trust, and maintaining frequent communication regarding unexpected events (e.g., police sweeps, neighborhood opposition). Findings may support the adoption of COVID-19 testing and vaccination initiatives implemented through SSPs and other community-based organizations serving vulnerable populations of people impacted by substance use and addiction. Trial registration This trial was registered prospectively at ClinicalTrials.gov (identifier NCT05181657).

Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky

PURPOSE

Kentucky experiences a disproportionate burden of substance use disorder (SUD), particularly in rural areas of the state. Multiple factors increase vulnerability to SUD and limit access to services in rural communities. However, the recent implementation and expansion of syringe service programs (SSPs) in rural Kentucky may provide a leverage point to reach at-risk people who inject drugs (PWID).

METHODS

Data were collected as part of an ongoing NIDA-funded study designed to examine uptake of SSPs among PWID in Appalachian Kentucky. Using Respondent Driven Sampling (RDS), the study enrolled a sample of 186 PWID SSP attenders across 3 rural Appalachian Kentucky counties and conducted face-to-face interviews regarding health behaviors, injecting practices, SSP utilization, and treatment services. Using logistic regression analyses, we examined consistent SSP use, as well as importance and confidence to reduce substance use as predictors of current treatment participation.

FINDINGS

For the prior 6 months, 44.6% of the sample reported consistent SSP use. Consistent use of SSPs was associated with treatment participation in the unadjusted logistic regression models. Significant predictors of treatment participation in the adjusted model included high confidence to reduce substance use, and not reporting primary methamphetamine injection.

CONCLUSIONS

Rurally located SSPs may play an important role in supporting confidence and motivation to change substance use behaviors among PWID impacted by SUD. SSPs may be critical venues for integration and expansion of prevention, health promotion, and treatment linkage services for this underserved population.

The Health Benefits of Secondary Syringe Exchange

From a process evaluation, participants in San Francisco's syringe exchange program (SEP) are described. Three groups, primary, secondary, and nonexchangers, were interviewed for a total of 244 study participants recruited from eight needle exchange sessions. Fifty percent of all primary exchangers exchanged for one or more injecting drug user(s) (IDUs). Three general routes of syringe distribution were identified between primary and secondary exchangers: between close friends and lovers; for people who lived in close proximity to them; and with customers who bought drugs from them. Focusing on why some go to SEPs and why some rely on others to go for them, findings are summarized primarily as the barriers for not attending SEPs, including exposure, legal status, illness, drug lifestyle, and conflicts with service provision. The secondary exchangers had similar risk reduction profiles to the SEP users that overall were better than the nonexchangers. For example, they shared syringes and cookers significantly fewer times than nonexchangers. The results demonstrate that these client-provided exchanges enable the SEP to overcome injection drug users' obstacles to program attendance, thereby reaching even hard to access members of IDU populations. We found the effects of these client-provided services to be positive for the larger IDU population.

Consequences of a restrictive syringe exchange policy on utilisation patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk

INTRODUCTION AND AIMS

Syringe distribution policies continue to be debated in many jurisdictions throughout the USA. The Baltimore Needle and Syringe Exchange Program (NSP) operated under a 1-for-1 syringe exchange policy from its inception in 1994 through 1999, when it implemented a restrictive policy (2000-2004) that dictated less than 1-for-1 exchange for non-program syringes.

DESIGN AND METHODS

Data were derived from the Baltimore NSP, which prospectively collected data on all client visits. We examined the impact of this restrictive policy on program-level output measures (i.e. distributed : returned syringe ratio, client volume) before, during and after the restrictive exchange policy. Through multiple logistic regression, we examined correlates of less than 1-for-1 exchange ratios at the client level before and during the restrictive exchange policy periods.

RESULTS

During the restrictive policy period, the average annual program-level ratio of total syringes distributed : returned dropped from 0.99 to 0.88, with a low point of 0.85 in 2000. There were substantial decreases in the average number of syringes distributed, syringes returned, the total number of clients and new clients enrolling during the restrictive compared to the preceding period. During the restrictive period, 33 508 more syringes were returned to the needle exchange than were distributed. In the presence of other variables, correlates of less than 1-for-1 exchange ratio were being white, female and less than 30 years old.

DISCUSSION AND CONCLUSIONS

With fewer clean syringes in circulation, restrictive policies could increase the risk of exposure to HIV among Injection Drug Users (IDUs) and the broader community. The study provides evidence to the potentially harmful effects of such policies.

Community coverage and HIV prevention: assessing metrics for estimating HIV incidence through syringe exchange

BACKGROUND

Evaluations of syringe-exchange programme effectiveness that attempt to measure "coverage" by determining the percentage of the at-risk population reached by a programme are insufficient since programmes must provide syringes on a continual basis. Determining the relationship between the extent of programme coverage and its impact (i.e., reductions in disease risk or incidence) is complicated by the lack of controlled trials with cohorts of drug users and instead has to be estimated by imputation, mathematical modelling, or ecological data analysis. This report offers an approach to determine community-wide impact and discusses the limitations of that approach.

METHODS

Easily created programme tracking data were maintained by exchanges in New Haven, CT, USA and Chicago, IL, USA. Data compiled by month quantified the number of unique participants visiting syringe-exchange programmes and the number of syringes distributed. "Coverage", defined either as the percentage of individuals reached or percentage of community syringe need met, was estimated by incorporating measures of the size of the injector population or injection frequency. These measures of coverage are placed in the context of changing programme operations to estimate the effect of these changes on coverage. Finally, data on AIDS cases from New Haven and Chicago were used to estimate the community-wide impact of syringe exchange.

RESULTS

Two mobile syringe-exchange programmes operated with very different exchange policies. Programme data revealed that coverage of individuals rarely exceeded 10% and was higher in New Haven than in Chicago. On the other hand, coverage measured as the percentage of syringe need met was higher at the Chicago exchange that employed the less restrictive policy. The impact of syringe exchange in the two cities was measured by comparing subsequent AIDS cases. The relative reduction in injection-related AIDS cases as a function of all new AIDS diagnoses was 21.7% in New Haven and 41.4% in Chicago.

CONCLUSIONS

A modest investment in the collection of programme data can yield reliable and interpretable information on the extent of programme reach and retention. Limitations to the approach result from the ecological nature of the data and from the need to use data from outside the programme that may be less reliable. For the cases presented here, coverage rates will vary as a function of the programme policies; however, even modest coverage rates - well below those recommended by UNAIDS - can have significant impacts on HIV epidemics. Restrictive policies appeared to increase the coverage if measured only by the proportion of monthly participants and not by the proportion of syringe need met by a programme. More generally, programmes can collect programmatic data and some rapid assessment data (estimates of IDU population and injection frequency) to estimate of the impact of their programmes.

An evaluation of needle exchange programmes in China

OBJECTIVES

To provide an overview of needle exchange programme (NEP) models used in China and factors associated with their use by injecting drug users (IDU).

DESIGN

A cross-sectional survey.

METHOD

Fifteen NEP in Sichuan and Guangxi provinces were selected for study. The managers were asked to complete a short questionnaire and participate in an interview about the services offered, including needle turnover rates, number of clients, and use of peer educators. The local senior police officers were interviewed for their points of views about NEP. Finally, drug users using the NEP and those residents in compulsory detoxification centres were surveyed about using NEP services.

RESULT

The NEP offered services during normal working hours and used peer educators to do additional exchanging that involved secondary exchangers in the community. Needle turnover ranged from 70.1% to over 100%. Most attendees (82.3%) knew about the service through friends, but only 7.3% of local IDU were using the services. Peer educators could get almost all the needles they needed, but secondary exchangers could only get approximately two-thirds of their required needles. NEP attendees were more frequent injectors and had a higher education than non-attendees. Needle turnover was higher when peer educators had a higher wage and when local police were supportive of the programme.

CONCLUSION

NEP are improving in terms of needle turnover and attendance. Greater cooperation from police, higher wages for peer educators, and wider awareness of the programmes among IDU are needed to increase coverage.

Psychiatric comorbidity is associated with drug use and HIV risk in syringe exchange participants

The present study evaluated the effects of psychiatric comorbidity on substance use disorder prevalence, HIV risk behavior, and other problem severity in male and female out-of-treatment injection drug users newly registered at a syringe exchange program. Participants (N = 338) were administered the Structured Clinical Interview for the DSM-IV, the Addiction Severity Index, and the Risk Assessment Battery, and classified into one of four diagnostic groups: (1) no antisocial personality disorder (APD) or Axis I psychiatric disorder (N = 162), (2) APD only (N = 74), (3) Axis I psychiatric disorder only (N = 55), or (4) APD plus Axis I psychiatric disorder (N = 47). Psychiatric comorbidity was associated with higher rates of substance use disorder and more HIV risk and other problem severity. In general, participants with both APD and an Axis I disorder exhibited the most problem severity. APD was uniquely associated with higher prevalence for each substance use disorder assessed in this study and with elevated HIV risk. These results support and extend studies conducted with opioid-dependent individuals recruited from treatment and community settings, and reinforce the need to develop interventions to encourage syringe exchange program participants to enroll in treatment.

Drug use and HIV risk practices of secondary and primary needle exchange users

This study examines HIV risk practices associated with secondary needle exchange, obtaining needles from a needle exchange program (NEP) through others who attend in person. We analyzed data from NEP logs, a survey and HIV testing from 901 drug injectors who (a) always visited NEPs themselves to get needles (primary-only NEP users), (b) obtained at least some NEP needles by having others exchange for them (mixed/secondary NEP users), and (c) obtained no needles from an NEP. About 22% of 40,000 NEP visits involved secondary exchanges, and these accounted for over half of all needles exchanged. In multiple logistic regression analyses, primary-only needle exchange was significantly associated with lower levels of receptive needle sharing, backloading, sharing other injection equipment and lending used needles, and positively associated with obtaining drug treatment. Mixed/secondary needle exchange was associated with less receptive needle sharing and a greater likelihood of drug treatment. Secondary exchange facilitated HIV risk reduction but the salutary effects of NEPs were attenuated in mixed/secondary exchangers.

Changes in the sharing of drug injection equipment among street-recruited injection drug users in Chicago, Illinois, 1994--1996

This study examines changes in the multi-person use of drug injection paraphernalia during the mid-1990s, a time of increasing awareness of HIV transmission modes and availability of prevention programs. Beginning in 1994, 794 street-recruited injection drug users in Chicago were interviewed and followed at 6 and 12 months postbaseline. Random-effects, pattern-mixture logistic regression models were used to determine correlates of five injection-equipment sharing practices, while accounting for repeated measurement and study attrition. At baseline, 45.7% of participants reported receptive syringe sharing in the previous 6 months. Syringe-mediated sharing was reported by 28.7% of participants and the sharing of cookers (65.1%), cotton filters (55.7%), and rinse water (46.9%) was common. During follow-up, the proportion of all sharing behaviors decreased significantly, especially receptive syringe sharing. Participation in a syringe exchange program was associated with reductions in receptive syringe sharing and syringe-mediated sharing, but not the sharing of cookers.

HIV Risk Practices Among Needle Exchange Users and Nonusers in Chicago

OBJECTIVES

To assess associations between needle exchange program (NEP) use and drug injection risk practices.

METHODS

Between 1997-2000, injecting drug users (IDUs) in Chicago were recruited from NEPs and an area with no NEP, interviewed about risk practices, and counseled and tested for HIV. The risk practices of "regular NEP users"--those who obtained at least half of their needles from an NEP (n = 558)--were compared with those of IDUs who did not use an NEP (n = 175).

RESULTS

In multivariate analysis, regular NEP users, compared with NEP nonusers, were less likely to receptively share needles (adjusted odds ratio [AOR], 0.30; 95% CI, 0.19-0.46); lend used needles (AOR, 0.47; 95% CI, 0.31-0.71); share cookers (AOR, 0.39; 95% CI, 0.25-0.61), cottons (AOR, 0.48; 95% CI, 0.32-0.72), or water (AOR, 0.41; 95% CI, 0.27-0.63); or use a needle for >1 injection (0.15; 95% CI, 0.08-0.27). Among those who shared needles, regular NEP users were significantly more likely to do so for a smaller proportion of injections, with fewer partners and persons socially closer, and to have always bleached used needles before injecting.

CONCLUSIONS

Regular NEP use is associated with less frequent and lower risk HIV injection risk practices.

Sterile syringe access conditions and variations in HIV risk among drug injectors in three cities

AIM

Better sterile syringe access should be associated with a lower likelihood of syringe re-use and receptive syringe sharing, although few empirical studies have examined gradients in syringe access using both individual and ecological data. In this study, we compare syringe re-use and receptive syringe sharing among injection drug users (IDUs) with syringe exchange program (SEP) and legal over-the-counter pharmacy access with limits on syringes that can be purchased, exchanged or possessed to IDUs with no pharmacy sales but unlimited syringe access through SEPs. We address three questions: (1) Does residing in an area with no legal syringe possession increase the likelihood of police contact related to possessing drug paraphernalia? (2) Among direct SEP users, is use of more permissive SEPs associated with less likelihood of syringe re-use and receptive syringe sharing? (3) Among non-SEP users, is residing in an area with pharmacy access associated with lower likelihood of syringe re-use and receptive syringe sharing?

DESIGN

Quantitative survey of IDUs recruited from SEPs, subject nomination and outreach methods. Multivariate analyses compared police contact, syringe re-use and receptive syringe sharing among IDUs recruited in three cities.

FINDINGS

In multivariate analyses, we found that police contact was associated independently with residing in the area with no legal possession of syringes; among SEP users, those with access to SEPs without limits had lower syringe re-use but not lower syringe sharing; and that among non-SEP users, no significant differences in injection risk were observed among IDUs with and without pharmacy access to syringes.

CONCLUSION

We found that greater legal access to syringes, if accompanied by limits on the number of syringes that can be exchanged, purchased and possessed, may not have the intended impacts on injection-related infectious disease risk among IDUs.

Impact of increased syringe access: preliminary findings on injection drug user syringe source, disposal, and pharmacy sales in Harlem, New York

OBJECTIVE

To evaluate the New York State Expanded Syringe Access Demonstration Program (ESAP) through injection drug user (IDU) surveys, discarded needles and syringes studies, and pharmacy sales and experiences surveys.

DESIGN

Pre-post comparison.

SETTING

In Harlem, New York City, risk surveys among street-recruited IDUs, needle/syringe street counts on 27 systematically sampled city blocks, and Harlem pharmacist reports of sales and experiences.

MAIN OUTCOME MEASURES

Number and types of IDU syringe sources, block mean counts of discarded needles and syringes, level of pharmacy nonprescription syringe sales (NPSS), and pharmacists' experiences.

RESULTS

Comparing 209 pre-ESAP with 396 post-ESAP IDUs, pharmacies as a primary syringe source increased: 3.4% to 5.3% (P < .001, and ever pharmacy use increased: 4.9% to 12.5% (P < .001), respectively. Compared with pre-ESAP IDUs, post-ESAP IDUs tended to be younger and more often black. Harlem pharmacy participation in ESAP increased considerably from March 1, 2001, to March 1, 2002, 49% to 79%, respectively. Among three Harlem pharmacies, there was a modest increase in NPSS; pharmacists reported no problems, and no discarded needles and syringes were observed in pharmacy areas. In the three pharmacies, the proportion of syringe sales that were NPSS was 46% (110 to 240 NPSS/month), 3% (25 to 90 NPSS/month), and 0%. The mean ratios of needles/syringes to background trash have not increased in Harlem since ESAP began.

CONCLUSION

To date, no evidence of harmful effects discarded needles/syringes, pharmacy altercations) resulting from ESAP were observed. While NPSS have increased in Harlem, pharmacy use among IDUs remains low. In Harlem, efforts are underway to increase ESAP awareness and reduce socioenvironmental barriers to ESAP.

High-risk behaviors associated with transition from illicit non-injection to injection drug use among adolescent and young adult drug users: a case-control study

OBJECTIVE

The goal of our study was to elucidate characteristics of persons likely to transition into injection drug use so that an identifiable group with high-risk for blood-borne infection may be targeted for interventions.

METHODS

An age-matched case-control analysis was performed from a cohort study in Baltimore, 1997-1999, of street-recruited non-injection and injection drug users (IDUs), aged 15-30. Cases were IDUs injecting < or = 2 years and controls were age-matched persons who used non-injection heroin, cocaine or crack. At baseline, all were interviewed about prior year-by-year behaviors; analysis using conditional logistic regression was based on information for the year prior to injection onset for the case and the same calendar time for the controls as well as recent behaviors for both groups.

RESULTS

Of 270 participants, most were African American (78%), female (61%), and HIV seroprevalence was 7% at baseline. IDUs were significantly more likely than controls to be non-African American (adjusted odds ratio (AOR)=0.09) and report high school dropout (AOR=2.32), early sex-trading (AOR=2.72), and recent violence victimization (AOR=9.28).

CONCLUSION

Given that new injectors are at high-risk for HIV and hepatitis yet difficult to reach for prevention efforts, our data suggest some categories to use to target non-injectors who are likely to transition into injection use.