Individual-level syringe coverage among Needle and Syringe Program attendees in Australia

Utilising Integrated Bio-behavioural Surveillance (IBBS) to investigate declining hepatitis C antibody prevalence among people who inject drugs in the Australian Needle and Syringe Program Survey

BACKGROUND

Prevalence of hepatitis C virus (HCV) antibody (Ab) on dried blood spot (DBS) samples in the Australian Needle and Syringe Program Survey (ANSPS) decreased nationally from 57% in 2015 to 32% in 2022. We aimed to investigate potential explanations for this decline.

METHODS

Changes in DBS HCV Ab prevalence were investigated by redefining positive cases as those with those with either a positive HCV Ab test result or a self-reported history of ever having HCV treatment (modified prevalence), examining HCV Ab prevalence by birth and age cohorts, and assessing trends in key risk behaviours.

RESULTS

Overall prevalence of DBS HCV Ab declined rapidly and significantly from 57% in 2015 to 32% in 2022 (p<0.001) however modified HCV Ab prevalence remained stable over time (85% and 88% in 2015 and 2022, respectively, p=0.357). The proportion of participants with negative HCV Ab and self-reported HCV infection increased from 20% in 1995 to 40% in 2022 (p<0.001) and the proportion with negative HCV Ab and lifetime HCV treatment increased from 3% in 1999 to 67% in 2022 (p<0.001). We also observed a decreasing trend in DBS HCV Ab prevalence in all birth and age cohorts with a noticeable acceleration in the decline commensurate with the advent of HCV DAA treatment. A long-term decreasing trend was also observed for key risk behaviours (p<0.001) however the short-term trend was not significant for recent receptive syringe sharing.

CONCLUSION

The temporal decline in HCV Ab prevalence appears related to reduced sensitivity of DBS HCV Ab detection with viral clearance following treatment. Since 2016, HCV treatment uptake has increased markedly including among people who inject drugs. In this context, continuing to monitor HCV Ab prevalence by DBS testing is problematic, with a shift to surveillance of active infection the most relevant to guide policy and practice in this setting.

Updates on syringe coverage and service uptake among needle and syringe programs in the United States, 2019-2020

BACKGROUND

As injection drug use has increased in the US, so too has the prevalence of receptive syringe sharing. Since the 1980s, Needle and Syringe Programs (NSPs) have been an important source of clean injection equipment and disposal of used syringes. This study reports national syringe coverage and examines the impact of program attributes on organizational-level service uptake, defined as number of syringes distributed per participant contact per year.

METHODS

In 2019 and 2020, we administered an annual cross-sectional survey to NSPs operating in the US (n = 260). A national estimate of coverage was calculated by dividing the total number of syringes distributed by the 2019 and 2020 population estimate of people who inject drugs (PWID). Frequency distributions and percentages were calculated for categorical variables (e.g., funding, census region, distribution policy/modality), and median and interquartile ranges (IQR) were calculated for continuous variables (e.g., participant contacts, syringes distributed). Bivariate and multivariable mixed effects logistic regression models were used to estimate the odds ratio associated with organizational characteristics on increasing service uptake at the NSP level.

RESULTS

From 2019 to 2020, the total number of participant contacts by NSPs increased from 871,976 to 898,891, and the number of syringes distributed increased from 92,648,529 to 113,071,748. The national coverage estimate increased from 29.5 (95 % CI = 15.0, 58.2) to 35.8 (95 % CI = 18.2, 70.6) syringes per PWID. Fifty-eight percent of NSPs increased service uptake in 2020 as compared to the previous year. NSPs that received government funding and NSPs that changed to a less restrictive syringe distribution policy were more likely to increase service uptake (aOR 1.80, 95 % CI = 1.01, 3.22 and aOR 3.33, 95 % CI = 1.11, 9.94, respectively). Syringe distribution modalities also diversified, with more NSPs reaching participants via backpacking/outreach, fixed site pop-ups, mobile delivery, mail-based delivery, leaving supplies out, and secondary distribution.

CONCLUSION

Both governmental investment in harm reduction programming and needs-based distribution of syringes increased service uptake and thus should be expanded and sustained to reduce harms associated with injection drug use.

Prevalence and associates of non-fatal overdose among people who inject drugs in Saveh, Iran

Background

As a public health issue, non-fatal overdose (NFOD) is highly prevalent among people who inject drugs (PWID). This can lead to an elevated risk of future overdose, causing various harms including possible death. It is essential to improve knowledge concerning this problem and its associated risk factors to inform overdose prevention and assistance programs. The primary aim of the present study was to determine the prevalence of NFOD and associated risk factors among PWID in Saveh, Iran.

Methods

In the present cross-sectional study, 272 PWID living in Saveh, Iran were interviewed face-to-face using a structured survey. Data concerning socio-demographics, substance use, risky behaviors, and services utilization data were collected. The outcome variable (i.e., NFOD) was assessed by answering “Yes” to the question: “In the past three months, have you ever overdosed (at least once) by accident?”

Results

The prevalence of NFOD among PWID in the past three months was 54%. The characteristics and behaviors that were associated with an increased risk of experiencing NFOD in the past three months were being of older age (AOR = 5.2, p < 0.05), drug use initiation under the age of 22 years (AOR = 7.8, p < 0.05), being an alcohol user (AOR = 3.0, p < 0.05), and being a simultaneous multiple drug user (AOR = 5.8, p < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing a non-fatal overdose in the past three months. Findings also indicated that those who (i) attended a needle and syringe program (AOR: 0.3, p < 0.05), (ii) were visited by a general practitioner (AOR: 0.03, p < 0.05), and (iii) received a psychosocial intervention (AOR: 0.1, p < 0.05) were 0.3, 0.03 and 0.1 times less likely to report non-fatal overdosing than other participants, respectively.

Conclusions

The results indicate that intervention and prevention initiatives seeking to reduce NFOD among PWID should not only be focused on the primary drug used but also the use of alcohol and polysubstance use. Specific and tailored psychological interventions combined with pharmacotherapy may be highly beneficial for PWID who experience more severe types of substance use, including alcohol use disorders and/or polysubstance abuse.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Consider the Source: Associations between Syringe Sources and Risky Injection Behaviors in California's Central Valley

BACKGROUND

Sterile syringe access is critical to prevent serious viral and bacterial infections among people who inject drugs (PWID) but many areas across the United States lack sufficient access. Although California law allows nonprescription pharmacy syringe sales and syringe services programs (SSPs), access gaps remain in the largely rural Central Valley.

OBJECTIVE

The purpose of this study was to examine syringe access and related injection behaviors among PWID in Fresno, California.

METHODS

We used respondent driven sampling to recruit 494 individuals for a survey about syringe access and injection behaviors between April and September 2016. Participants were ≥18 years old and injected at least twice in the past 30 days. Descriptive statistics examined syringe access and logistic regression determined if discrete syringe source categories were significantly associated with syringe sharing and/or reuse.

RESULTS

A majority (67%) obtained syringes from an authorized source; SSPs were most common (59%), while few reported pharmacy purchase (14%). Unauthorized sources were even more common (79%), primarily friends (64%) or someone on the street (37%). Compared to PWID who used only authorized sources, those using only unauthorized sources had a higher odds of syringe sharing (AOR = 3.40, 95% CI: 1.66, 6.95) and syringe reuse (AOR = 6.22; 95% CI: 2.24, 17.29), as did those who reported mixed sources (AOR = 3.78; 95% CI: 1.90, 7.54 and AOR = 4.64; 95% CI: 2.08, 10.35).

CONCLUSIONS

Our findings demonstrate a need to expand syringe access in nonurban California to prevent the syringe sharing and reuse that contributes to serious viral and bacterial infections among PWID.

Non -fatal overdose among people who inject drugs in Tehran, Iran

BACKGROUND

With increasing frequencies of non-fatal overdose in people who inject drugs (PWID), it is essential to improve our knowledge about associated risk factors for overdose to inform overdose prevention and assistance programs. The aim of present study was to determine the prevalence of non-fatal overdose and the associated risk factors among PWID in Tehran, Iran.

METHODS

Snowball sampling was used to collect data from 465 participants in Tehran using a cross-sectional survey. Consenting participants who reported drug injecting in the past month and were able to speak and comprehend Farsi enough to respond to survey questions were interviewed. The endpoint of interest was non-fatal overdose in the previous 6 months, or answering "Yes" to the question: "In the last six months, have you ever overdosed by accident? (at least once)". We used STATA v. 14 for this analysis. Statistical significance was defined as p < 0.05 for all analyses.

RESULTS

Of 465 PWIDs who participated in this study, all were male, and about half had less than a high school education. The prevalence of self-reported non-fatal overdose in the past 6 months was 38% (CI95%: 34, 43%). Our findings indicate that characteristics and behaviors that were associated with an increased risk of experiencing an overdose in the past 6 months were drug use initiation under 22 years (AOR =2.2, P < 0.05), using methamphetamine (AOR =2.8, P < 0.05), and using multiple drugs at the same time (AOR =2.1, P < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing an overdose in the past 6 months. The odds of experiencing a non-fatal overdose among PWIDs who regularly attended NSP were 0.6 times less than for those who did not attend regularly (OR = 0.6,95% CI: 0.2-0.9).

CONCLUSION

Methamphetamine and alcohol use were the most significant association for non-fatal overdose among PWIDs. Our results indicate that intervention and prevention initiatives seeking to reduce overdoses among PWIDs should not only be focused on the primary drug used but also the use of alcohol and poly-drug use.

Transforming lives and empowering communities: evidence, harm reduction and a holistic approach to people who use drugs

PURPOSE OF REVIEW

We reviewed the global state of harm reduction for people who use and/or inject drugs.

KEY FINDINGS

Although harm reduction is now the key response to HIV among people who use drugs globally, intervention coverage remains suboptimal, exacerbated by chronic under-funding, declining donor support and limited domestic investment, particularly in low-income and middle-income countries. We describe the current environment and review recent innovations and responses, including peer distribution of naloxone, low dead space syringes, drug consumption rooms and drug-checking services. However, despite efforts by people who use drugs and supporting partners to sustain harm reduction services and to develop and implement novel interventions, programmes are often under-scaled and under-resourced and people who use drugs continue to face significant barriers to accessing services.

SUMMARY

There is an urgent need to bring existing harm reduction programmes to scale and to broaden their scope, as well to complement them with innovative interventions targeting new populations and new substances. Under and disinvestment in harm reduction and the absence of enabling legal environments threatens to undermine the global HIV response and exacerbate the morbidity and mortality associated with the current epidemic of opioid overdose.

Harm reduction programs and policy in Australia: barriers and enablers to effective implementation

Abstract. Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.

Assessing individual-level needle and syringe coverage parameters and the measurement of coverage in Melbourne, Australia: methods and impacts

Background

To assess the structure of individual-level needle and syringe coverage measurement formula, and to estimate the impact of coverage-related behaviours/parameters (instances of syringe acquisition, total syringes acquired, peer-to-peer syringe distribution, injecting frequency) on overall coverage.

Methods

Data are drawn from the Melbourne (Australia) injecting drug user cohort study, 2010-16. Data from 518 participants were analysed. We used correlations to explore the relationships between coverage parameters; pooled multiple-linear regression to estimate the effect of each parameter on coverage over time; and exploratory factor analysis to assess the relevance of each parameter within the coverage formula.

Results

A 1-unit increase in injecting frequency over time reduced coverage by 10.93 percentage points, almost twice as much as other coverage parameters. Factor analysis results indicated potential improvements to coverage formula structure.

Conclusions

Our results suggest that reducing injecting frequency amongst people who inject drugs has the largest improvement in coverage levels, indicating harm reduction services should prioritize it. We also demonstrate that coverage measurement has been inconsistent to date. We sought to refine the method to assist in generating comparable research.

Measures of harm reduction service provision for people who inject drugs

Coverage is an important dimension in measuring the effectiveness of needle and syringe programmes in providing sterile injecting equipment for people who inject drugs. The World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) currently recommend methods for measuring coverage at the population level, that is, across an estimated population of people who inject drugs within a given geographical area. However, population-level measures of coverage rely on highly uncertain population estimates and cannot capture the different levels of syringe acquisition and injecting episodes among individual users. Consequently, such measures only broadly evaluate the extent of programme service delivery, rather than describe how people who inject drugs as individuals and sub-groups interact with needle and syringe programmes. In response to these limitations, several researchers have proposed measuring coverage at the individual level, by the percentage of injecting episodes in relation to the number of sterile needles and syringes acquired. These measures evaluate coverage according to each individual’s needs. Such measures provide enhanced information for planning and monitoring of harm reduction programmes and have now been used in multiple international research studies. We advise that WHO, UNODC and UNAIDS add individual-level coverage measurement methods to their international monitoring guidelines for harm reduction programmes. By doing this, more responsive and effective programmes can be created to better reduce injecting risk behaviours and blood-borne virus transmission among people who inject drugs.

Estimating the number of people who inject drugs and syringe coverage in Australia, 2005-2016

BACKGROUND

Effective targeting of harm reduction programs for people who inject drugs (PWID) requires timely and robust estimates of the size of this population. This study estimated the number of people who inject drugs on a regular basis in Australia, calculated syringe coverage per person and the proportion of their injections covered by a sterile needle and syringe.

METHODS

We used trends in indicators of injection drug use to extend the 2005 estimate of the population of people who regularly inject drugs from 2005 to 2016. Included indicators were lifetime/recent injection of illicit drugs, drug-related arrests, drug-related seizures, accidental deaths due to opioids, opioid-related hospital admissions/separations and new diagnoses of hepatitis C virus infection among those aged 15-24 years. Syringe distribution and frequency of injection data were used to assess syringe coverage per PWID and the proportion of their injections covered by a sterile syringe.

RESULTS

The estimated number of people who regularly inject drugs in Australia increased by 7%, from 72,000 in 2005 to 77,270 in 2016. The annual number of syringes distributed per person increased 34%, from 470 syringes in 2005 to 640 syringes in 2016. Syringe coverage per injection first exceeded 100% in Australia in 2013.

CONCLUSIONS

Despite Australia's high syringe coverage by international standards, the number of syringes distributed is likely to be only narrowly meeting demand. It is critical that needle syringe programs be provided with sufficient resources to continue their role as the key intervention required to prevent HIV and HCV transmission among PWID.

Geo-spatial analysis of individual-level needle and syringe coverage in Melbourne, Australia

Distance to health services is known to be negatively associated with usage and needle and syringe programs (NSPs) for people who inject drugs (PWID) are no different. Australia has a mixture of NSP modalities (primary or secondary fixed-site NSPs), which may present unique barriers to access. In this study, we explore 1) the effect of distance to NSPs on individual-level needle and syringe coverage, and 2) differences in coverage dependent on NSP modality. Using data from 219 PWID in an ongoing cohort study in Melbourne, Australia, we measured the straight-line distance from participants’ residence to their nearest primary or secondary fixed-site NSP. We analysed the relationship between geographical distance and coverage via regression analysis. The median distance to any type of NSP was 1872 metres. Regardless of service type, 52% of participants lived within 2 kms of a fixed-site NSP and 87% lived within 5 kms. We found no association between distance to NSPs and syringe coverage or a significant difference in coverage by nearest service type. Our findings suggest that the number and distribution of NSPs in Melbourne, Australia caters adequately for the population of PWID.

Patterns of Peer Distribution of Injecting Equipment at an Authorized Distribution Site in Sydney, Australia

BACKGROUND

Extended distribution refers to the practice whereby people who inject drugs pass on sterile injecting equipment to their networks and can be a means to access people who inject drugs who do not attend state-sanctioned needle and syringe programs. While it is legal, to possess a sterile syringe for the purpose of injecting drugs in New South Wales, Australia, it is a criminal offence to pass this equipment on for others to use. In 2013 a pilot project was established to trial the authorization of "extended" peer distribution. This research describes patterns of distribution among attendees participating in this trial.

METHODS

A cross-sectional survey was conducted during one week in October 2014 of the trial with 200 clients. The survey focused on the extent, characteristics, and perceived risks and benefits of extended distribution practices within peer groups.

RESULTS

Extended distribution is widespread, not in an organized or intentional manner but as a consequence of day-to-day drug using activities. The profiles of those who do and do not distribute were similar. Willingness to distribute small quantities of equipment to others was higher than willingness to distribute larger quantities, and willingness to distribute was related to perceived benefits of extended distribution. Police scrutiny was a key reason for not wanting to distribute.

CONCLUSION

Extended peer distribution is widespread though mostly not organized. This study supports the evidence that drug users act responsibly to prevent harm and promote the use of sterile equipment among their peers.

Analysis of time of drug use according to needle and syringe program operating hours in Melbourne, Australia: Effects on individual-level needle and syringe coverage

BACKGROUND

Restricted needle and syringe program (NSP) operating hours in Australia have been reported as a barrier to access for people who inject drugs (PWID). We explored the prevalence of drug use occurring outside NSP operating hours with a particular focus on its impacts on individual-level needle and syringe coverage.

METHODS

Using data from 584 participants in a cohort of PWID in Melbourne, Australia, we analyzed time and day of drug use for heroin, methamphetamine and pharmaceutical opioids. We related this drug use to the typical operating times of Melbourne's fixed-site NSPs, categorizing drug use as either "in-hours" or "out-of-hours". We explored associations with out-of-hours drug use using a generalized linear mixed model of pooled longitudinal data.

RESULTS

23% of heroin use and 50% of methamphetamine use occurred out-of-hours. In regression analysis, males and those injecting in public locations had significantly reduced odds of out-of-hours drug use. Those currently employed and those using methamphetamine (compared to heroin) had significantly increased odds of out-of-hours drug use. There was no significant association between individual-level needle and syringe coverage and hours of drug use.

CONCLUSIONS

Deficiencies in individual-level needle and syringe coverage may not be due to restricted NSP operating hours. Instead, insufficient coverage may be the result of other factors in the lives of PWID or other NSP access difficulties. These preliminary results suggest improvements to coverage in Australia may not result from increased hours of NSP operation, but instead via improvements to client targeting.

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.

Measuring individual-level needle and syringe coverage among people who inject drugs in Myanmar

BACKGROUND

Myanmar has prioritised people who inject drugs (PWID) as a key population for HIV mitigation efforts, with targets for needle and syringe distribution set at a population level. However, individual-level coverage, defined as the percentage of an individual's injecting episodes covered by a sterile syringe, is a more sensitive measure of intervention coverage. We sought to examine individual-level coverage in a sample of PWID in Myanmar.

METHODS

We recruited 512 PWID through urban drop-in-centres in Yangon, Mandalay and Pyin Oo Lwin. Participants were administered a quantitative questionnaire covering five domains: demographics, drug use, treatment and coverage, and injecting risk behaviour. We calculated past fortnight individual-level syringe coverage, estimating levels of sufficient (≥100% of injecting episodes covered by a sterile syringe) and insufficient (<100%) coverage, and examined associations between key variables and insufficient coverage via logistic regression.

RESULTS

Our sample was predominately male (97%), employed (76%), and living in stable accommodation (96%), with a median age of 27. All participants reported heroin as the drug most frequently injected, and injected a median of 27 times in the past two weeks. Nineteen per cent of participants had insufficient coverage in the two weeks before interview. Insufficient coverage was positively associated with syringe re-use (AOR: 5.19, 95% CIs: 2.57, 10.48) and acquiring sterile syringes from a location other than a formal drop-in-centre (AOR: 2.04, 95% CIs: 1.08, 3.82). Participants recruited in Mandalay (AOR: 0.30, 95% CIs: 0.11, 0.80) and Pyin Oo Lwin (AOR: 0.39, 95% CIs: 0.18, 0.87) had lower odds of insufficient coverage than those recruited in Yangon.

CONCLUSION

Our study shows coverage in selected areas of Myanmar was comparable with studies in other countries. Our results inform the delivery of harm reduction services for PWID, specifically by encouraging the use of formal drop-in-centres, over other sources of syringe distribution, such as pharmacies.

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review

Injecting use of image and performance-enhancing drugs (IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme (CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention.

Longitudinal analysis of change in individual-level needle and syringe coverage amongst a cohort of people who inject drugs in Melbourne, Australia

BACKGROUND

Needle and syringe program (NSP) coverage is often calculated at the individual level. This method relates sterile needle and syringe acquisition to injecting frequency, resulting in a percentage of injecting episodes that utilise a sterile syringe. Most previous research using this method was restricted by their cross-sectional design, calling for longitudinal exploration of coverage.

METHODS

We used the data of 518 participants from an ongoing cohort of people who inject drugs in Melbourne, Australia. We calculated individual-level syringe coverage for the two weeks prior to each interview, then dichotomised the outcome as either "sufficient" (≥100% of injecting episodes covered by at least one reported sterile syringe) or "insufficient" (<100%). Time-variant predictors of change in recent coverage (from sufficient to insufficient coverage) were estimated longitudinally using logistic regression with fixed effects for each participant.

RESULTS

Transitioning to methamphetamine injection (AOR:2.16, p=0.004) and a newly positive HCV RNA test result (AOR:4.93, p=0.001) were both associated with increased odds of change to insufficient coverage, whilst change to utilising NSPs as the primary source of syringe acquisition (AOR: 0.41, p=0.003) and opioid substitution therapy (OST) enrolment (AOR:0.51, p=0.013) were protective against a change to insufficient coverage.

CONCLUSIONS

We statistically tested the transitions between time-variant exposure sub-groups and transitions in individual-level syringe coverage. Our results give important insights into means of improving coverage at the individual level, suggesting that methamphetamine injectors should be targeted, whilst both OST prescription and NSP should be expanded.

How does the use of multiple needles/syringes per injecting episode impact on the measurement of individual level needle and syringe program coverage?

BACKGROUND

Recent work by McCormack et al. (2016) showed that the inclusion of syringe stockpiling improves the measurement of individual-level syringe coverage. We explored whether including the use of a new parameter, multiple sterile syringes per injecting episode, further improves coverage measures.

METHODS

Data comes from 838 people who inject drugs, interviewed as part of the 2015 Illicit Drug Reporting System. Along with syringe coverage questions, the survey recorded the number of sterile syringes used on average per injecting episode. We constructed three measures of coverage: one adapted from Bluthenthal et al. (2007), the McCormack et al. measure, and a new coverage measure that included use of multiple syringes. Predictors of multiple syringe use and insufficient coverage (<100% of injecting episodes using a sterile syringe) using the new measure, were tested in logistic regression and the ability of the measures to discriminate key risk behaviours was compared using ROC curve analysis.

RESULTS

134 (16%) participants reported needing multiple syringes per injecting episode. Women showed significantly increased odds of multiple syringe use, as did those reporting injection related injuries/diseases and injecting of opioid substitution drugs or pharmaceutical opioids. Levels of insufficient coverage across the three measures were substantial (20%-28%). ROC curve analysis suggested that our new measure was no better at discriminating injecting risk behaviours than the existing measures.

CONCLUSION

Based on our findings, there appears to be little need for adding a multiple syringe use parameter to existing coverage formulae. Hence, we recommend that multiple syringe use is not included in the measurement of individual-level syringe coverage.

Internalized Stigma Among People Who Inject Drugs

BACKGROUND

Perceived experiences of stigma have been found to be associated with poorer psychosocial outcomes and engagement in risk practices among people who inject drugs. Yet the extent to which people internalize or accept the stigma surrounding their injecting drug use, and whether this is associated with risky injecting practices, is not well known.

OBJECTIVES

The aim of this study was to assess the extent of internalized stigma among a sample of people who inject drugs in Australia and identify socio-demographic, injecting risk, and mental health correlates.

METHODS

People who inject drugs were recruited from a needle and syringe program located in Sydney, Australia to complete a brief survey. The survey included measures of internalized stigma, severity of drug dependence, self-esteem, depression, and shared use of injecting equipment.

RESULTS

The sample comprised 102 people who inject drugs. Internalized stigma was higher among participants who reported being depressed in the past month, and was also associated with greater severity of drug dependence and diminished self-esteem. There was no relationship between internalized stigma and shared use of needles or other injecting equipment in the past month. Conclusions/Importance: Findings underscore the need for further investigation of internalized stigma among people who inject drugs. In particular, future research should assess the impact of implicit (i.e., subconscious) internalized stigma on mental health.

Individual-level needle and syringe coverage in Melbourne, Australia: a longitudinal, descriptive analysis

Background

Coverage is used as one indicator of needle and syringe program (NSP) effectiveness. At the individual level, coverage is typically defined as an estimate of the proportion of a person who injects drugs’ (PWID) injecting episodes that utilise a sterile syringe. In this paper, we explore levels of individual syringe coverage and its changes over time.

Methods

Data were extracted from 1889 interviews involving 502 participants drawn from the Melbourne drug user cohort study (MIX).

We asked questions relating to participants syringe acquisition, distribution and injecting frequency within the two weeks before interview. We created a dichotomous coverage variable that classified participants as sufficiently (≥100 %) covered if all their injecting episodes utilised at least one sterile syringe, and insufficiently (<100 %) covered if not. We categorised participants as “consistently covered” if they were sufficiently covered across interviews; as “consistently uncovered” if they were insufficiently covered across interviews; and “inconsistently covered” if they oscillated between coverage states.

Chi-square statistics tested proportions of insufficient coverage across sub-groups using broad demographic, drug use and service utilisation domains. Logistic regression tested predictors of insufficient coverage and inconsistently covered categorisation.

Results

Across the sample, levels of insufficient coverage were substantial (between 22–36 % at each interview wave). The majority (50 %) were consistently covered across interviews, though many (45 %) were inconsistently covered.

We found strong statistical associations between insufficient coverage and current hepatitis C virus (HCV) infection (RNA+). Current prescription of opioid substitution therapy (OST) and using NSPs as the main source of syringe acquisition were protective against insufficient coverage.

Conclusion

Insufficient coverage across the sample was substantial and mainly driven by those who oscillated between states of coverage, suggesting the presence of temporal factors. We recommend a general expansion of NSP services and OST prescription to encourage increases in syringe coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1668-z) contains supplementary material, which is available to authorized users.

Beyond equipment distribution in Needle and Syringe Programmes: an exploratory analysis of blood-borne virus risk and other measures of client need

Background

Despite high levels of equipment distribution through Needle and Syringe Programmes (NSPs) in Australia, the levels of reuse of equipment among people who inject drugs remain concerning. This paper used an exploratory analysis to examine the needs of NSP client that could be addressed by NSPs to enhance service impact and blood-borne virus risk practices.

Methods

People who inject drugs were recruited from six NSP sites in Sydney, Australia, to undertake a self-completed survey.

Results

Using the responses of 236 NSP client participants, three factors were identified in an exploratory factor analysis: recent risky injection (Eigenvalue 3.63, 20.2 % of variance); disadvantage and disability (Eigenvalue 2.26, 12.5 % of variance); and drug use milieu (Eigenvalue 1.50, 8.4 % of variance). To understand the distribution of these factors, the standardised factor scores were dichotomised to explore those participants with ‘above average’ vulnerability on each factor. A small group of NSP clients reported a cluster of vulnerability measures. Most participants (55.5 %) reported vulnerability on none or only one factor, indicating that 45.5 % could be considered as having double (35.6 %) or triple (8.9 %) vulnerability.

Conclusions

These results challenge NSPs to understand the heterogeneity among their client group and develop programmes that respond to their clients’ range of needs beyond those immediately associated with blood-borne virus (BBV) risk. This paper contributes to the growing evidence base regarding the need for BBV prevention efforts to examine strategies beyond equipment distribution.

Syringe Stockpiling by Persons Who Inject Drugs: An Evaluation of Current Measures for Needle and Syringe Program Coverage

Needle and syringe program (NSP) coverage is commonly used to assess NSP effectiveness. However, existing measures don't capture whether persons who inject drugs (PWIDs) stockpile syringes, an important and novel aspect of NSP coverage. In this study, we determine the extent of stockpiling in a sample of Australian PWIDs and assess whether including stockpiling enhances NSP coverage measures. As part of the Illicit Drug Reporting System study, PWIDs reported syringes procured and given away, total injections in the last month, and syringes currently stockpiled in 2014. We calculated NSP coverage with and without stockpiling to determine proportional change in adequate NSP coverage. We conducted receiver operating characteristic curve analysis to determine whether inclusion of stockpiled syringes in the measure improved sensitivity in discriminating cases and noncases of risky behaviors. Three-quarters of the sample reported syringe stockpiling, and stockpiling was positively associated with nonindigenous background, stable accommodation, no prison history, longer injecting careers, and more frequent injecting. Compared with previous measures, our measure was significantly better at discriminating cases of risky behaviors. Our results could inform NSP policy to loosen restricted-exchange practice, allowing PWIDs greater flexibility in syringe procurement practices, promoting greater NSP coverage, and reducing PWIDs' engagement in risky behaviors.

"We get by with a little help from our friends": Small-scale informal and large-scale formal peer distribution networks of sterile injecting equipment in Australia

BACKGROUND

In Australia, sterile needles and syringes are distributed to people who inject drugs (PWID) through formal services for the purposes of preventing blood borne viruses (BBV). Peer distribution involves people acquiring needles from formal services and redistributing them to others. This paper investigates the dynamics of the distribution of sterile injecting equipment among networks of people who inject drugs in four sites in New South Wales (NSW), Australia.

METHODS

Qualitative data exploring the practice of peer distribution were collected through in-depth, semi-structured interviews and participatory social network mapping. These interviews explored injecting equipment demand, access to services, relationship pathways through which peer distribution occurred, an estimate of the size of the different peer distribution roles and participants' understanding of the illegality of peer distribution in NSW.

RESULTS

Data were collected from 32 participants, and 31 (98%) reported participating in peer distribution in the months prior to interview. Of those 31 participants, five reported large-scale formal distribution, with an estimated volume of 34,970 needles and syringes annually. Twenty-two participated in reciprocal exchange, where equipment was distributed and received on an informal basis that appeared dependent on context and circumstance and four participants reported recipient peer distribution as their only access to sterile injecting equipment. Most (n=27) were unaware that it was illegal to distribute injecting equipment to their peers.

CONCLUSION

Peer distribution was almost ubiquitous amongst the PWID participating in the study, and although five participants reported taking part in the highly organised, large-scale distribution of injecting equipment for altruistic reasons, peer distribution was more commonly reported to take place in small networks of friends and/or partners for reasons of convenience. The law regarding the illegality of peer distribution needs to change so that NSPs can capitalise on peer distribution to increase the options available to PWID and to acknowledge PWID as essential harm reduction agents in the prevention of BBVs.

The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect

INTRODUCTION AND AIMS

Needle and syringe automatic dispensing machines (ADM) aim to increase needle/syringe distribution to people who inject drugs. ADM implementation has been met with community concern about potential perceived increases in crime and drug use and that they will attract non-resident drug users-the 'honey-pot effect'. In April 2013, an ADM commenced operation in inner-city Sydney. We assessed the impact of the ADM on crime and examined its use by non-resident drug users (the honey-pot effect).

DESIGN AND METHODS

Fixed-site needle and syringe program (n = 207) and ADM clients (n = 55) were surveyed to determine whether they lived within 1 km of the ADM. Police-recorded offences between January 2012 and March 2014 across six crime categories for the local and surrounding areas were assessed for trend to measure impact on crime.

RESULTS

The majority (78%) of needle and syringe program clients reported residing within 1 km of the service. Most (95%) ADM users were fixed-site service clients. The 2 year trend for crime categories remained stable or decreased, except for fraud, which increased significantly (P < 0.05).

DISCUSSION AND CONCLUSION

Automatic dispensing machine users were largely clients of the existing fixed-site service and lived locally. There was no apparent concurrent increase in crime or a honey-pot effect. It is important that services continue to be aware of community concerns and respond to them appropriately.[Day CA, White B, Haber PS. The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect. Drug Alcohol Rev 2016;35:637-643].

More than just someone to inject drugs with: Injecting within primary injection partnerships

BACKGROUND

Studies have shown intimate injection partners engage in higher rates of syringe and injecting equipment sharing. We examined the drug use context and development of injection drug use behaviors within intimate injection partnerships.

METHODS

In-depth interviews (n=18) were conducted with both members of nine injecting partnerships in Sydney, Australia. Content analysis identified key domains related to the reasons for injecting with a primary injection partner and development of drug injection patterns.

MAIN FINDINGS

Most partnerships (n=5) were also sexual; three were blood-relatives and one a friend dyad. The main drug injected was heroin (66%) with high rates of recent sharing behaviors (88%) reported within dyads. Injecting within a primary injection partnership provided perceived protection against overdose events, helped reduce stress, increased control over when, where, and how drugs were used, and promoted the development of an injecting pattern where responsibilities could be shared. Unique to injecting within primary injection partnerships was the social connection and companionship resulted in a feeling of fulfillment while also blinding one from recognizing risky behavior.

CONCLUSIONS

Findings illuminated the tension between protection and risks within primary injection partnerships. Primary injection partnerships provide a potential platform to expand risk reduction strategies.

A qualitative study trialling the acceptability of new hepatitis C prevention messages for people who inject drugs: symbiotic messages, pleasure and conditional interpretations

AIM

Prevention of hepatitis C (HCV) remains a public health challenge. A new body of work is emerging seeking to explore and exploit "symbiotic goals" of people who inject drugs (PWID). That is, strategies used by PWID to achieve other goals may be doubly useful in facilitating the same behaviours (use of sterile injecting equipment) required to prevent HCV. This project developed and trialled new HCV prevention messages based on the notion of symbiotic messages.

METHOD

New HCV prevention messages were developed in a series of 12 posters after consultation with staff from needle and syringe programs (NSPs) and a drug user organisation. Two posters were displayed each week for a 6-week period within one NSP. NSP staff and clients were invited to focus groups to discuss their responses to the posters.

RESULTS

A total of four focus groups were conducted; one group of seven staff members and three groups of clients with a total of 21 participants. Responses to each of the posters were mixed. Staff and clients interpreted messages in literal ways rather than as dependent on context, with staff concerned that not all HCV prevention information was included in any one message; while clients felt that some messages were misleading in relation to the expectations of pleasure. Clients appreciated the efforts to use bright imagery and messages that included acknowledgement of pleasure. Clients were not aware of some harm reduction information contained in the messages (such as "shoot to the heart"), and this generated potential for misunderstanding of the intended message. Clients felt that any message provided by the NSP could be trusted and did not require visible endorsement by health departments.

CONCLUSIONS

While the logic of symbiotic messages is appealing, it is challenging to produce eye-catching, brief messages that provide sufficient information to cover the breadth of HCV prevention. Incorporation of symbiotic messages in conversations or activities between staff and clients may provide opportunities for these messages to be related to the clients' needs and priorities and for staff to provide HCV prevention information in accord with their professional ethos.