Comparing new participants of a mobile versus a pharmacy-based needle exchange program

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).

Baseline differences in characteristics and risk behaviors among people who inject drugs by syringe exchange program modality: an analysis of the Miami IDEA syringe exchange

Background

In March of 2016, Florida passed the Infection Disease Elimination Act (IDEA), legalizing the formation of the first syringe exchange program in Florida, which opened in December of 2016 at a fixed site in Overtown, Miami. Since that time, the exchange expanded in April of 2017 to include a mobile van unit that provides the same services at different locations throughout Miami-Dade County.

Methods

Trained interviewers conducted face-to-face interviews from all first-time participants at the IDEA Exchange, both at the fixed site and the mobile van unit.

Results

Among 718 first-time enrollees, 74.8% were male, 52.1% were non-Hispanic White, 85.9% completed high school, 59.8% were unemployed, 42.1% were homeless, 54.2% reported an annual income of less than $15,000, and the mean age was 38 years. Participants at the fixed site and mobile van unit reported differences in socioeconomic status, injection drug-related behaviors, and pre-existing hepatitis C virus (HCV) infection status.

Conclusions

Taken together, these results suggest that the mobile unit is capturing a subset of PWID in Miami that the fixed site is not, and vice-versa. As the opioid crisis extends into all demographics, such multimodal efforts to target various populations of PWID should be kept in mind, especially when unveiling future syringe exchanges in Florida and other late-adopting states.

Scoping out the literature on mobile needle and syringe programs-review of service delivery and client characteristics, operation, utilization, referrals, and impact

BACKGROUND

Needle and syringe program (NSP) service delivery models encompass fixed sites, mobile services, vending machines, pharmacies, peer NSPs, street outreach, and inter-organizational agreements to add NSP services to other programs. For programs seeking to implement or improve mobile services, access to a synthesis of the evidence related to mobile services is beneficial, but lacking.

METHODS

We used a scoping study method to search MEDLINE, PSYCHInfo, Embase, Scopus, and Sociological for relevant literature. We identified 39 relevant manuscripts published between 1975 and November 2017 after removing duplicates and non-relevant manuscripts from the 1313 identified by the search.

RESULTS

Charting of the data showed that these publications reported findings related to the service delivery model characteristics, client characteristics, service utilization, specialized interventions offered on mobile NSPs, linking clients to other services, and impact on injection risk behaviors. Mobile NSPs are implemented in high-, medium-, and low-income countries; provide equipment distribution and many other harm reduction services; face limitations to service complement, confidentiality, and duration of interactions imposed by physical space; adapt to changes in locations and types of drug use; attract people who engage in high-risk/intensity injection behavior and who are often not reached by other service models; and may lead to reduced injection-related risks.

DISCUSSION

It is not clear from the literature reviewed, what are, or if there are, a "core and essential" complement of services that mobile NSPs should offer. Decisions about service complement for mobile NSPs need to be made in relation to the context and also other available services. Reports of client visits to mobile NSP provide a picture of the volume and frequency of utilization but are difficult to compare given varied measures and reference periods.

CONCLUSION

Mobile NSPs have an important role to play in improving HIV and HCV prevention efforts across the world. However, more work is needed to create clearer assessment metrics and to improve access to NSP services across the world.

Pharmacists' role in harm reduction: a survey assessment of Kentucky community pharmacists' willingness to participate in syringe/needle exchange

BACKGROUND

Pharmacists' role in harm reduction is expanding in many states, yet there are limited data on pharmacists' willingness to participate in harm reduction activities. This study assessed community pharmacists' willingness to participate in one harm reduction initiative: syringe/needle exchange.

METHODS

In 2015, all Kentucky pharmacists with active licenses were emailed a survey that examined attitudes towards participation in syringe/needle exchange. Response frequencies were calculated for community pharmacist respondents. Ordinal logistic regression estimated the impact of community pharmacist characteristics and attitudes on willingness to provide clean needles/syringes to people who inject drugs and to dispose of used syringes/needles, where both dependent variables were defined as Likert-type questions on a scale of 1 (not at all willing) to 6 (very willing).

RESULTS

Of 4699 practicing Kentucky pharmacists, 1282 pharmacists responded (response rate = 27.3%); the majority (n = 827) were community pharmacists. Community pharmacists were divided on willingness to provide clean needles/syringes, with 39.1% not willing (score 1 or 2 of 6) and 30% very willing (score 5 or 6 of 6). Few were willing to dispose of used needles/syringes, with only 18.7% willing. Community pharmacists who agreed that pharmacists could have significant public health impact by providing access to clean needles expressed 3.56 times more willingness to provide clean needles (95% CI 3.06-4.15), and 2.04 times more willingness to dispose of used needles (95% CI 1.77-2.35). Chain/supermarket pharmacists (n = 485, 58.6% of community pharmacies) were 39% less likely to express willingness to dispose of used needles (95% CI 0.43-0.87) when compared with independent community pharmacists (n = 342, 41.4% of community pharmacies). Independent pharmacists reported different barriers (workflow) than their chain/supermarket pharmacist colleagues (concerns of clientele).

CONCLUSIONS

Kentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.

Nonprescription naloxone and syringe sales in the midst of opioid overdose and hepatitis C virus epidemics: Massachusetts, 2015

OBJECTIVES

To determine the prevalence of nonprescription naloxone and sterile syringe sales, factors associated with nonprescription sales, geospatial access to nonprescription naloxone and syringe-selling pharmacies, and targets for potential interventions.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Massachusetts has experienced steep increases in reported opioid overdoses and hepatitis C virus cases in the past decade. Pharmacists have the potential to play a substantial role in increasing access to nonprescription naloxone and sterile syringes, which can reverse opioid overdoses and decrease hepatitis C virus transmission, respectively. We completed brief telephone surveys with 809 of 1042 retail pharmacies across Massachusetts (response rate = 77.6%) during 2015 to assess experience with nonprescription sales of naloxone and sterile syringes.

OUTCOME MEASURES

Our primary outcomes were the stocking and selling of naloxone in the pharmacy (yes or no) for nonprescription sales and nonprescription syringe sales (yes or no). We conducted multivariable regression analyses and created maps using a geographic information system to identify factors associated with nonprescription sales of naloxone and sterile syringes, and to improve our understanding of geospatial access to pharmacy-based naloxone and syringe sales.

RESULTS

More than 97% of pharmacies reported selling sterile syringes without requiring a prescription, and 45% of pharmacies reported stocking and selling naloxone. Factors associated with nonprescription sales included hours of operation, experience with and interest in harm reduction activities, and presence in an opioid overdose hotspot. Geographic access to nonprescription sale of sterile syringes is widespread, whereas geospatial access to naloxone is limited. Training to understand the benefits, applications, and distribution needs of naloxone is of interest to surveyed pharmacists.

CONCLUSION

Access to sterile syringes through nonprescription sales is strong across Massachusetts, and although more than 350 pharmacies (45%) reported stocking and selling naloxone to prevent opioid overdose deaths, there is much room for improvement in access and training among pharmacy staff members.

A cross-national analysis of the effects of methadone maintenance and needle and syringe program implementation on incidence rates of HIV in Europe from 1995 to 2011

Although many studies have found an association between harm reduction interventions and reductions in incidence rates of Human Immunodeficiency Virus (HIV) infection, scant research explores the effects of harm reduction cross-nationally. This study used a year- and country-level fixed effects model to estimate the potential effects of needle-and-syringe programs (NSPs) and methadone maintenance therapy (MMT) on incidence rates of HIV in the general population and among people who inject drugs (PWID), in a sample of 28 European nations. After adjusting for Gross Domestic Product (GDP) and total expenditures on healthcare, we identified significant associations between years of MMT and NSP implementation and lower incidence rates of HIV among PWID and the general population. In addition to years of implementation of NSP and MMT, the greater proportion of GDP spent on healthcare was associated with a decrease in logged incidence rates of HIV. The findings of this study suggest that MMT and NSP may reduce incidence rates of HIV among PWID cross-nationally. The current study opens a new avenue of exploration, which allows for a focus on countrywide policies and economic drivers of the epidemic. Moreover, it highlights the immense importance of the adoption of harm reduction programs as empirically-based health policy as well as the direct benefits that are accrued from public spending on healthcare on incidence rates of HIV within the general population and among subpopulations of PWID.

Factors associated with presence of pharmacies and pharmacies that sell syringes over-the-counter in Los Angeles County

Community pharmacies serve as key locations for public health services including interventions to enhance the availability of syringes sold over-the-counter (OTC), an important strategy to prevent injection-mediated HIV transmission. Little is known about the community characteristics associated with the availability of pharmacies and pharmacies that sell syringes OTC. We conducted multivariable regression analyses to determine whether the sociodemographic characteristics of census tract residents were associated with pharmacy presence in Los Angeles (LA) County during 2008. Using a geographic information system, we conducted hot-spot analyses to identify clusters of pharmacies, OTC syringe-selling pharmacies, sociodemographic variables, and their relationships. For LA County census tracts (N = 2,054), population size (adjusted odds ratio [AOR], 1.22; 95 % confidence interval [CI], 1.16, 1.28), median age of residents (AOR, 1.03; 95 % CI, 1.01, 1.05), and the percent of households receiving public assistance (AOR, 0.97; 95 % CI, 0.94, 0.99) were independently associated with the presence of all pharmacies. Only 12 % of census tracts had at least one OTC syringe-selling pharmacy and sociodemographic variables were not independently associated with the presence of OTC syringe-selling pharmacies. Clusters of pharmacies (p < 0.01) were located proximally to clusters of older populations and were distant from clusters of poorer populations. Our combined statistical and spatial analyses provided an innovative approach to assess the sociodemographic and geographic factors associated with the presence of community pharmacies and pharmacies that participate in OTC syringe sales.

Commentary on Vorobjov et al., "Comparison of injection drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia"

Recent data suggest that globally, between 5% and 10% of all new HIV cases are the result of unsafe injecting practices, and experts agree that reducing these practices is key to tackling the spread of HIV. And yet, despite the overwhelming evidence that providing sterile syringes to injection drug users (IDU) through syringe exchange programs (SEPs) or other means is an effective way of reducing HIV transmission among high-risk subpopulations, IDU in most settings still do not have access to sterile injecting equipment or if they do, access remains too restricted to effectively reduce the risk of HIV transmission. Vorobjov and colleagues have presented in this journal an interesting and timely study from Estonia comparing individuals who obtain syringes from SEPs and those who obtain syringes from pharmacies. As the authors point out, Estonia faces an unacceptably high HIV incidence rate of 50 new HIV cases per 100,000, this rate driven primarily by injection drug use. As such, the authors argue that Estonia's SEP network does not have the capacity to serve a growing IDU population at risk of transmitting HIV and pharmacy dispensation of clean syringes may be one potential approach to decreasing syringe sharing among high-risk injectors. It may be overly optimistic to consider the impact of higher threshold interventions such as pharmacy-based SEPs, given that IDU populations that engage in HIV risk behaviours such as syringe sharing are often hidden or hard to reach. Despite the need for a cautious approach, however, the findings presented by Vorobjov et al. may chart one potential course towards a more comprehensive societal response to reducing the health harms associated with injection drug use.

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.

Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-to-reach and high-risk groups of injecting drug users (IDUs): a review

Reaching hard-to-reach and high-risk injecting drug users (IDUs) is one of the most important challenges for contemporary needle syringe programs (NSPs). The aim of this review is to examine, based upon the available international experience, the effectiveness of syringe vending machines and mobile van/bus based NSPs in making services more accessible to these hard-to-reach and high-risk groups of IDUs. A literature search revealed 40 papers/reports, of which 18 were on dispensing machines (including vending and exchange machines) and 22 on mobile vans. The findings demonstrate that syringe dispensing machines and mobile vans are promising modalities of NSPs, which can make services more accessible to the target group and in particular to the harder-to-reach and higher-risk groups of IDUs. Their anonymous and confidential approaches make services attractive, accessible and acceptable to these groups. These two outlets were found to be complementary to each other and to other modes of NSPs. Services through dispensing machines and mobile vans in strategically important sites are crucial elements in continuing efforts in reducing the spread of HIV and other blood borne viruses among IDUs.

Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users

AIM

To determine whether syringe exchange programs' (SEPs) dispensation policy is associated with syringe coverage among SEP clients.

DESIGN

Cross-sectional samples of SEPs and their clients.

SETTING

SEPs in California, USA.

PARTICIPANTS

Twenty-four SEPs and their injection drug using (IDU) clients (n = 1576).

MEASUREMENTS

Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self-reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange.

FINDINGS

Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Using propensity scoring methods, we compared syringe coverage by dispensation policies while controlling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits.

CONCLUSION

Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. SEPs should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage.

Increasing syringe access and HIV prevention in California: findings from a survey of local health jurisdiction key personnel

This article presents results from the first survey of California local health jurisdictions (LHJs) subsequent to passage of legislation that allows for over-the-counter pharmacy sales of syringes. In 2004 Governor Arnold Schwarzenegger signed Senate Bill 1159 (SB1159) into law to "prevent the spread of HIV, hepatitis and other blood-borne disease among drug users, their sexual partners and their children." This legislation permits counties and cities to authorize a local disease prevention demonstration project (DPDP). Once authorized, a DPDP permits individuals to legally purchase and possess up to ten syringes from registered pharmacies without a doctor's prescription. From June to August 2005, we surveyed health departments in all 61 LHJs to assess implementation status of SB1159. Fifty-seven (93%) LHJs responded. Nine (16%) had approved a DPDP by August 2005, 17 (30%) were in the process of obtaining authorization, and 18 (32%) anticipated that SB1159 would never be authorized in their LHJ. Among LHJs that do not plan to approve a DPDP (n = 18), the reasons included: strong community opposition (41%), competing priorities (35%), law enforcement opposition (29%), and little or no interest among pharmacies (29%). In LHJs that have authorized a DPDP, 31.4% of pharmacies registered to legally sell nonprescription syringes. Preliminary results indicate that local coalitions, comprised of public health, waste management and pharmacy officials, have been instrumental in facilitating DPDP authorization. Further research is needed to identify facilitators and barriers to adopting SB1159, to identify areas for improving technical assistance to implementers, and to assess the public health impact of the legislation.

Assessing the feasibility of harm reduction services for MSM: the late night breakfast buffet study

BACKGROUND

Despite the leveling off in new HIV infections among men who have sex with men (MSM) in San Francisco, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). Among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users. Of particular concern for prevention programs are frequent users and HIV positive men who use MA. These MSM pose a particular challenge to HIV prevention efforts due to the need to reach them during very late night hours.

METHODS

The purpose of the Late Night Breakfast Buffet (LNBB) was to determine the feasibility and uptake of harm reduction services by a late night population of MSM. The "buffet" of services included: needle exchange, harm reduction information, oral HIV testing, and urine based sexually transmitted infection (STI) testing accompanied by counseling and consent procedures. The study had two components: harm reduction outreach and a behavioral survey. For 4 months during 2004, we provided van-based harm reduction services in three neighborhoods in San Francisco from 1-5 a.m. for anyone out late at night. We also administered a behavioral risk and service utilization survey among MSM.

RESULTS

We exchanged 2000 needles in 233 needle exchange visits, distributed 4500 condoms/lubricants and provided 21 HIV tests and 12 STI tests. Fifty-five MSM enrolled in the study component. The study population of MSM was characterized by low levels of income and education whose ages ranged from 18-55. Seventy-eight percent used MA in the last 3 months; almost 25% used MA every day in the same time frame. Of the 65% who ever injected, 97% injected MA and 13% injected it several times a day. MA and alcohol were strong influences in the majority of unprotected sexual encounters among both HIV negative and HIV positive MSM.

CONCLUSION

We reached a disenfranchised population of MA-using MSM who are at risk for acquiring or transmitting HIV infection through multiple high risk behaviors, and we established the feasibility and acceptability of late night harm reduction for MSM and MSM who inject drugs.

Receptive Syringe Sharing Among Injection Drug Users in Harlem and the Bronx During the New York State Expanded Syringe Access Demonstration Program

BACKGROUND

Effective on January 1, 2001, New York State enacted the Expanded Syringe Access Demonstration Program (ESAP), which allows syringes to be sold in pharmacies without a prescription or dispensed through doctors, hospitals, and clinics to persons 18 years of age or older and permits the possession of those syringes for the purposes of injecting drugs.

OBJECTIVE

To assess changes in receptive syringe sharing since the inception of the ESAP.

METHODS

Sociodemographic characteristics and syringe use data regarding the last injection episode were combined from 3 projects (n = 1181) recruiting injection drug users in ongoing studies in Harlem and the Bronx in New York City from January 2001 through June 2003. These data were analyzed as serial cross sections by calendar quarter.

RESULTS

Receptive sharing decreased significantly over time, from 13.4% in the first quarter to 3.6% in the last quarter. Obtaining the last injection syringe from an ESAP source (mostly pharmacies) increased significantly over time, from 7.5% in the first quarter to 25.0% in the last quarter. In multiple logistic regression analysis, variables that were significantly associated with less receptive sharing were syringe exchange and ESAP syringe source as well as time since ESAP inception. Female gender and white race/ethnicity were significantly associated with greater receptive sharing.

CONCLUSIONS

The increase in the use of pharmacies and other ESAP syringe sources in this sample has been accompanied by a decline in receptive sharing.

Needle exchange programs. Delivery and access issues

OBJECTIVE

Examine the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts.

METHODS

Using a modified ethnographic approach, semi-structured interviews concerning policies and procedures were conducted with staff (n = 59) of NEPs (n = 15) in Ontario. An iterative, inductive analytic process was used.

RESULTS

According to workers and managers, effectiveness of NEP prevention efforts depend on client development and retention and service design. Fixed and satellite sites, home visits and mobile services provide varied levels of temporal and spatial accessibility. Combining modes of delivery can offset the disadvantages of individual modes.

DISCUSSION

NEP evaluations that do not consider service and resource factors run the risk of concluding that NEPs are ineffective when it may be that the program works for a small proportion of IDUs whom the NEP has the resources to serve.

Two- to sixfold decreased odds of HIV risk behavior associated with use of syringe exchange

We report results of a community study of syringe exchange that compared the HIV risk behavior of exchange clients with that of nonclients. A prospective cohort of 259 untreated injecting drug users (IDUs) was followed a mean of 10.7 months after baseline. In assessing whether HIV risk behavior at follow-up was associated with study participants' follow-up use of the exchange, we controlled their baseline risk behavior and exchange use as markers of risk-taking tendency in addition to other potential confounders. We also examined whether there was a differential benefit of exchange use for IDUs with versus those without access to other sources of syringes. Both univariate and multivariate analyses revealed a more than twofold decreased odds of HIV risk behavior associated with use of the exchange. In a second multivariate analysis, which examined the interaction of exchange use with access to other sources of syringes, the odds of HIV risk behavior were decreased more than sixfold for IDUs without other sources. We conclude that use of the exchange had a substantial protective effect against HIV risk behavior and may have been especially critical for IDUs without other sources of syringes.

Satellite needle distribution among injection drug users: policy and practice in two canadian cities

Access to clean needles and syringes through needle exchange programs (NEPs) has reduced both high-risk behaviors and the transmission of blood-borne infections among injection drug users (IDUs). However, policies regarding "needle-for-needle" exchange versus unrestricted needle distribution remain controversial. The objective of this study was to compare sources of needles, trends in needle distribution, and the practice of satellite needle distribution (SND) among IDUs in Vancouver and Montreal. SND was defined as receiving a new syringe from another individual through trading, purchasing, borrowing, or being given the syringe outright, or supplying a syringe to another individual through trading, selling, lending, or giving a syringe outright. This was practiced by 46% of IDUs in Vancouver and 50% of IDUs in Montreal. SND was associated with borrowing used injection equipment (adjusted OR [AOR], 2.62; 95% CI: 1.85-3.71), conducting bulk needle exchanges (AOR, 1.85; 95% CI: 1.34-2.54), being married or in a common-law relationship (AOR, 1.85; 95% CI: 1.34-2.54), and regular visits to the NEP (> weekly) (AOR, 1.54; 95% CI: 1.17-2.13). In Vancouver, SND was also associated with borrowing used needles (AOR, 2.07; 95% CI: 1.22-3.52). In these two cities, despite different distribution policies, almost half of the participants reported SND, and this was associated with high risk sharing. The practice of SND appears to be an important mechanism for needle acquisition, especially for those at highest risk for HIV and hepatitis C transmission.

Risk-taking behaviors among injecting drug users who obtain syringes from pharmacies, fixed sites, and mobile van needle exchanges

Needle-exchange programs (NEPs) have been shown to be effective in reducing harm related to injection drug use and to act as an important link between the injection drug using community and preventive/treatment services. Different needle-exchange distribution methods may reach different subpopulations of injecting drug users (IDUs). We undertook this study to characterize risk behaviors by primary source of clean needles accessed by IDUs in a city with pharmacy access and fixed and mobile exchange programs. We hypothesized there would be a gradient of risk across the three types of distribution. Data were collected from within the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort study. Participants who primarily obtained clean needles from pharmacies, fixed sites, or mobile exchange vans were compared using the Cochran-Armitage trend test to test for trends in increasing risk behaviors across the three types of distribution. Ordinal multivariate regression was used to adjust the associations for potential confounders. Results illustrate clear trends for increasing risk profiles from pharmacy to fixed site to mobile exchange vans. Van users were generally at higher risk than fixed-site and pharmacy users. Independent predictors of van use were fewer years injecting, difficulty finding needles, Aboriginal ethnicity, incarceration in the previous 6 months, and injecting cocaine daily. An important component of needle-exchange programs is outreach to access those who are at highest risk. Use of distribution beyond fixed sites will improve such outreach, thereby increasing program effectiveness and further preventing the transmission of blood-borne infections.

Investigation of a secondary syringe exchange program for homeless young adult injection drug users in San Francisco, California, U.S.A

This study investigated an HIV prevention program for homeless young adult injection drug users (IDUs) that combined a secondary syringe exchange program (SEP) with community-level activities. Homeless young IDUs were recruited from street-based settings in San Francisco, and a structured questionnaire was administered. The secondary SEP operated in a circumscribed geographic area, and for analytic purposes respondents were assigned to the intervention site group if they primarily spent time in this area (n = 67), or the comparison site group if they primarily spent time elsewhere (n = 55). Almost all (96%) intervention site youth had used the secondary SEP in the past 30 days and were significantly more likely to regularly use SEP. In bivariate analysis, comparison site IDUs were more likely to share syringes, reuse syringes, share the cotton used to filter drugs, and use condoms with casual sex partners only inconsistently. In multivariate analysis, comparison site remained positively associated with sharing syringes (adjusted odds ratio [AOR], 3.748; 95% confidence interval [CI], 1.406-9.988), reusing syringes (AOR, 2.769; 95% CI,1.120-6.847), and inconsistent condom use with casual sex partners (AOR, 4.825; 95% CI, 1.392- 16.721). This suggests that the intervention was effective in delivering SEP services to homeless young adult IDUs, and that IDUs who frequented the intervention site had a lower HIV risk than comparison group IDUs.

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

The objectives of this study were to describe characteristics and utilization patterns of participants attending a needle-exchange program (NEP) in Chicago, Illinois. Since 1994, demographics of NEP attendees and program utilization data were collected systematically at 22 sites operated by the Chicago Recovery Alliance (CRA). Descriptive statistics were used to assess time trends, site variations, and characteristics of attendees in day sites versus evening sites. A total of 11,855 injection drug users (IDUs) visited the NEP at least once from 1994 to 1998. Median age was 41 years, and 74% were male. Overall race distribution was African-American 50%, Caucasian 38%, Puerto Rican 10%, other 2%. Over time, there was a proportional decrease in African-American users (55.4% to 39.9%, P < .001), a significant increase in Puerto Rican users (1.4% to 14.1%, P < .001), and a stable proportion of Caucasian users (42%). Each year, 15-20% of all clients were first-time attenders. Overall, participants attending evening versus day sites were younger (median age 39 years vs. 42 years, P < .001) and more ethnically diverse. Over a 4-year period, this NEP reached a diverse population of IDUs and recruited a stable proportion of first-time users. Compared to daytime NEP venues, evening NEP sites attracted younger clients and those who were more diverse ethnically. To maximize coverage of sterile syringes, NEPs should strive for diversification in terms of hours of operation and location.