Implementation and evaluation of a syringe vending machine trial in Tbilisi, Georgia

Evaluating public health vending machine rollout and utilization in criminal-legal settings

INTRODUCTION

Harm reduction resources for people who are involved in the criminal-legal system should be easily accessible. The Rhode Island Department of Corrections (DOC) used funding from a state opioid stewardship fund created through the Rhode Island Opioid Stewardship Act (legislation passed in 2019) to implement five custom-designed vending machines for community corrections offices and state awaiting trial carceral facilities. The vending machines provide resources for overdose prevention, infection prevention, basic needs, and nicotine replacement therapy (NRT). We aim to describe the development and rollout of the vending machines and present data about items taken most frequently by setting.

METHODS

Research and design experts, with DOC and community stakeholders, developed and tailored the public-facing design of the vending machines. Before implementation, the researchers from the development team conducted meetings with staff at each location to discuss harm reduction and their role in addressing the opioid crisis in this high-risk population. The machines were manufactured in 2022 and installed in early 2023 (dates varied by location). The community support and advocacy organization tracks and maintains inventory (items taken and replaced) by month. No individual-level client data is collected.

RESULTS

There were 3720 items dispensed from May 2022 to February 2024 across five locations. Overall, hygiene kits were the most frequently accessed item (28.3 %, n = 1051), followed by NRT (19.0 %, n = 706) and ponchos (16.6 %, n = 616). The fentanyl tests (n = 230), wound care kits (n = 248), resource guide (n = 253), naloxone (n = 221), and safer sex kits (n = 218) each made up between 5.9 % and 6.8 % of items accessed. The pregnancy test was the least accessed at 4.8 % (n = 177). There were statistically significant differences in the monthly number of items distributed by location for the basic needs items, excluding NRT, with 39 items per month at the three Probation/Parole locations compared to 21 per month for the two DOC facilities.

CONCLUSIONS

The utilization patterns demonstrate the demand for basic supplies and support related to harm reduction. Monitoring and summarizing utilization ensures that the vending machines remain useful to the community and facilitates transparency and communication with stakeholders.

The Cost of Safe Injection: Insights on Nonprescription Syringe Price Variability From Systematic Secret Shopping

BACKGROUND

Although the sale of nonprescription syringes in pharmacies is legal in most states, people who inject drugs (PWID) continue to face obstacles to syringe purchase like stigma, prohibitive costs, restrictive policies, and stocking issues. We examined the consistency of syringe pricing as another possible barrier.

METHODS

We analyzed data on syringe prices and other relevant variables from 153 unique secret shopper visits to 2 retail chain pharmacies in Massachusetts (MA), New Hampshire (NH), Oregon (OR), and Washington (WA) as part of the fidelity component of a large pharmacy-focused intervention study. Pretax prices from purchases made between August 2019 and May 2021 were adjusted for inflation to 2022 dollars, and a linear regression of the price of a 10-pack of syringes was constructed to examine the determinants of syringe pricing.

RESULTS

The average real price of a 10-pack of syringes across all states was $4.53 (SD = 0.99), with wide variability between pharmacies (max = $11.44, min = $1.70) and between states (mean OR = $5.76, WA = $4.74, MA = $4.33, NH = $4.30). Forty-seven percent (n = 72) of the purchases were taxed despite syringes being tax exempt in MA and WA, and not having a sales tax in NH or OR. The results of the regression suggest that certain needle gauges were associated with lower overall prices, while 1 pharmacy chain and 2 syringe brands were associated with higher overall prices.

CONCLUSIONS

The high variability in syringe pricing presents another barrier to pharmacy-based syringe access since high prices may leave PWID no choice but to reuse or share needles, especially in areas with limited alternatives or without a syringe service program. Leadership from healthcare systems, pharmacy chains, and state and local policymakers is essential to reduce stigma and to implement policies that streamline syringe purchases, eliminate the taxation of exempt syringes in accordance with state laws, and reduce the variation in syringe prices.

Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia

INTRODUCTION

Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia.

METHODS AND ANALYSIS

KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness.

ETHICS AND DISSEMINATION

The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings.

TRIAL REGISTRATION NUMBER

NCT05657106.

Costs of syringe vending machines in Tbilisi, Georgia

BACKGROUND

Syringe vending machines (SVM) can improve access to sterile injecting equipment, but they have not been widely implemented or evaluated. We evaluate the cost of SVM installed between July 2019-December 2020 in Tbilisi, Georgia.

METHODS

The SVM were stocked with several kit types, including injecting equipment for opioid or stimulant users, naloxone, male and female condoms, and pregnancy tests. We gathered financial data from the project to estimate fixed (staff time, start-up costs, equipment, running costs, and consumables) and variable (harm reduction kits) costs. We calculated the full cost of the SVM intervention, cost per user, cost per additional syringe accessed by SVM users, and cost per kit distributed (2020 Euros).

RESULTS

SVM access cards were issued to 1132 users, and 29,238 kits were distributed through SVM, total cost €204,358. Staff costs were 51% of total, consumable costs 28%, equipment 10%, and start up, recurrent costs, and overheads 5% or less each. Opioid and stimulant kits were most accessed (35% and 32% of total). Cost per user was €66/year, and cost per transaction €7, of which €5 fixed costs and €2 variable. If monthly transactions increased from the average of 1622/month to highest monthly usage (4714), fixed costs per transaction would decrease to < €1. It cost €0.55 per additional syringe accessed/user/month.

CONCLUSIONS

This study provides evidence for governments about the cost of SVM, a novel harm reduction intervention. This is particularly relevant where Global Fund is withdrawing and harm reduction services need to be incorporated into national budgets.

A scoping review of implementation considerations for harm reduction vending machines

BACKGROUND

Community-based harm reduction vending machines (HRVM) are not new to the field of public health; numerous countries have implemented them in response to the needs of people who use drugs over the last three decades. However, until recently, few existed in the United States. Given the rapidity with which communities are standing up harm reduction vending machines, there is a pressing need for a consolidated examination of implementation evidence. This scoping review summarizes existing literature using multiple implementation science frameworks.

METHODS

The scoping review was conducted in five stages including (1) Identify the research question; (2) Identify relevant studies; (3) Select the publications based on inclusion/exclusion criteria; (4) Review and extract data; and, (5) Summarize results. PubMed, Embase, and Web of Science were searched and authors screened publications in English from any year. Data were extracted by applying implementation constructs from RE-AIM and the Consolidated Framework for Implementation Research (CFIR). Both frameworks provided a useful lens through which to develop knowledge about the facilitators and barriers to HRVM implementation. The review is reported according to PRISMA guidelines.

RESULTS

After applying the full inclusion and exclusion criteria, including the intervention of interest ("vending machines") and population of interest ("people who use drugs"), a total of 22 studies were included in the scoping review. None of the studies reported on race, making it difficult to retroactively apply a racial equity lens. Among those articles that examined effectiveness, the outcomes were mixed between clear effectiveness and inconclusive results. Evidence emerged, however, to address all CFIR constructs, and positive outcomes were observed from HRVM's after-hour availability and increased program reach.

RECOMMENDATIONS

HRVM implementation best practices include maximizing accessibility up to 24 h, 7 days a week, offering syringe disposal options, ensuring capability of data collection, and allowing for anonymity of use. Organizations that implement HRVM should establish strong feedback loops between them, their program participants, and the broader community upfront. Considerations for future research include rigorous study designs to evaluate effectiveness outcomes (e.g. reduced drug overdose deaths) and examination of HRVM reach among ethnic and racial communities.

Qualitative exploration of public health vending machines in young adults who misuse opioids: A promising strategy to increase naloxone access in a high risk underserved population

Background

Take home naloxone (THN) programs have been shown to effectively reverse opioid overdose events with limited adverse events, yet often miss young adults who use opioids. To identify opportunities for naloxone expansion, we conducted interviews with young adults who had used opioids. We explored young adults' experience with current THN programs, and perspectives on ideal THN programs and emerging naloxone public health vending machine (PHVM) programs shown to increase access to sterile syringes in young adults.

Methods

We interviewed 16 young adults receiving substance treatment services within an integrated safety net healthcare system. Participants were 18-30 years of age with a history of nonmedical prescription opioid use. Interviews obtained the patient perspective of current THN, ideal THN and PHVM programs. Interviews were transcribed and coded by team-based methods. Themes were developed using an inductive-deductive iterative approach and defined through consensus.

Results

Treatment was often the first exposure to naloxone. Participants recommended easy to access programs for ideal naloxone distribution and had overall positive feedback on PHVMs. Three key themes were identified to improve naloxone uptake: knowledge, convenience, and privacy. Participants identified safety, lack of police presence, and low costs as important vending machine features.

Conclusions

Our results identified implementation opportunities to increase naloxone uptake including convenient location and hours, privacy, and using trusted sources of information to improve program awareness. PHVMs present an opportunity to maximize these opportunities and increase access to naloxone in young adults.