Is point of access to needles and syringes related to needle sharing? Comparing data collected from pharmacies and needle and syringe programs in south-east Sydney

Setting foot in private spaces: extending the hepatitis C cascade of care to automatic needle/syringe dispensing machines, a mixed methods study

Background

Global commitment to achieving hepatitis C virus (HCV) elimination has enhanced efforts in improving access to direct-acting antiviral (DAA) treatments for people who inject drugs (PWID). Scale-up of efforts to engage hard-to-reach groups of PWID in HCV testing and treatment is crucial to success. Automatic needle/syringe dispensing machines (ADMs) have been used internationally to distribute sterile injecting equipment. ADMs are a unique harm reduction service, affording maximum anonymity to service users. This paper explores the feasibility and acceptability of extending the HCV cascade of care to sites where ADMs are located.

Methods

The ADM users into Treatment (ADMiT) study was undertaken in a metropolitan region in Sydney, Australia. This mixed methods study involved analysis of closed-circuit television footage, ethnographic methods (fieldwork observation and in-depth interviews) and structured surveys. Researchers and peers conducted fieldwork and data collection over 10 weeks at one ADM site, including offering access to HCV testing and treatment.

Results

Findings from 10 weeks of fieldwork observations, 70 survey participants and 15 interviews highlighted that there is scope for engaging with this population at the time they use the ADM, and enhanced linkage to HCV testing and treatment may be warranted. Most survey participants reported prior HCV testing, 61% in the last 12 months and 38% had received HCV treatment. However, fieldwork revealed that most people observed using the ADM were not willing to engage with the researchers. Field work data and interviews suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement.

Discussion

Enhanced linkage to HCV testing and treatment for people who use ADMs may be warranted. However, data suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement. The current study raises important public health questions about the need to ensure interventions reflect the needs of affected communities, including their right to remain anonymous.

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.

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.

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.

Needle acquisition patterns, network risk and social capital among rural PWID in Puerto Rico

BACKGROUND

People who inject drugs (PWID) take on significant risks of contracting blood-borne infection, including injecting with a large number of partners and acquiring needles from unsafe sources. When combined, risk of infection can be magnified.

METHODS

Using a sample of PWID in rural Puerto Rico, we model the relationship between a subject's number of injection partners and the likelihood of having used an unsafe source of injection syringes. Data collection with 315 current injectors identified six sources of needles.

RESULTS

Of the six possible sources, only acquisition from a seller (paid or free), or using syringes found on the street, was significantly related to number of partners.

CONCLUSIONS

These results suggest that sources of syringes do serve to multiply risk of infection caused by multi-partner injection concurrency. They also suggest that prior research on distinct forms of social capital among PWID may need to be rethought.

Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: a systematic review and meta-analysis

AIMS

To appraise the evidence critically for effectiveness of pharmacy-based needle/syringe exchange programmes (pharmacy-based NSPs) on risk behaviours (RBs), HIV/HCV prevalence and economic outcomes among people who inject drugs (PWID).

DESIGN

Systematic review and meta-analysis.

SETTING

Primary care setting.

PARTICIPANTS

Of 1568 studies screened, 14 studies with 7035 PWID were included.

MEASURES

PubMed, Embase, Web of Sciences, CENTRAL and Cochrane review databases were searched without language restriction from their inception to 27 January 2016. All published study designs with control groups that reported the effectiveness of pharmacy-based NSP on outcomes of interest were included. Outcomes of interest are risk behaviour (RB), HIV/hepatitis C virus (HCV) prevalence and economic outcomes. The estimates of pooled effects of these outcomes were calculated as pooled odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. Heterogeneity was assessed by I² and χ² tests.

FINDINGS

Most studies (nine of 14, 64.3%) were rated as having a serious risk of bias, while 28.6 and 7.1% were rated as having a moderate risk and low risk of bias, respectively. For sharing-syringe behaviour, pharmacy-based NSPs were significantly better than no NSPs for both main (OR = 0.50, 95% CI = 0.34-0.73; I²  = 59.6%) and sensitivity analyses, excluding studies with a serious risk of bias (OR = 0.52, 95% CI = 0.32-0.84; I²  = 41.4%). For safe syringe disposal and HIV/HCV prevalence, the evidence for pharmacy-based NSPs compared with other NSP or no NSP was unclear, as few of the studies reported this and most of them had a serious risk of bias. Compared with the total life-time cost of US$55 640 for treating a person with HIV infection, the HIV prevalence among PWID has to be at least 0.8% (for pharmacy-based NSPs) or 2.1% (for other NSPs) to result in cost-savings.

CONCLUSIONS

Pharmacy-based needle/syringe exchange programmes appear to be effective for reducing risk behaviours among people who inject drugs, although their effect on HIV/HCV prevalence and economic outcomes is unclear.

Intimate injection partnerships are at elevated risk of high-risk injecting: a multi-level longitudinal study of HCV-serodiscordant injection partnerships in San Francisco, CA

Background

It is increasingly recognized that the risk for HIV and hepatitis C (HCV) transmission among people who inject drugs (PWID), such as syringe sharing, occurs in the context of relationships between (at least) two people. Evidence suggests that the risk associated with injection behavior varies with injection partner types.

Methods

We utilized longitudinal dyad-level data from a study of young PWID from San Francisco (2006 to 2013) to investigate the relationship-level factors influencing high-risk injecting within HCV-serodiscordant injection partners (i.e., individuals who injected together ≥5 times in the prior month). Utilizing data from 70 HCV-serodiscordant injection partnerships, we used generalized linear models to examine relationship-level predictors (i.e., partnership composition, partnership closeness, and partnership dynamics) of: (1) receptive syringe sharing (RSS); and (2) receptive cooker use (RCU), as reported by the HCV-negative injection partner.

Results

As reported by the “at-risk” HCV-negative injection partner, receptive syringe sharing (RSS) and receptive cooker use (RCU) were 19% and 33% at enrollment, and 11% and 12% over all visits (total follow-up time 55 person-years) resulting in 13 new HCV-infections (incidence rate: 23.8/100 person-years). Person-level factors, injection partnership composition, and partnership dynamics were not significantly associated with either RSS or RCU. Instead, intimate injection partnerships (those who lived together and were also in a sexual relationship) were independently associated with a 5-times greater risk of both RSS and a 7-times greater risk of RCU when compared to injecting only partnerships.

Conclusion

Our findings suggest a positive, and amplified effect of relationship factors on injecting drug risk behaviors among young PWID injection partnerships. The majority of interventions to reduce injection drug use related harms focus on individual-based education to increase drug use knowledge. Our findings support the need to expand harm reduction strategies to relationship-based messaging and interventions.

What's the Cost of Finding the Right Fit? The Cost of Conducting NSP Business in a Range of Modalities

The aim of this study was to calculate the cost of a range of needle and syringe program (NSP) models to contribute to planning for effective NSP delivery. Existing health service data was used to estimate the cost per needle distributed across four modes of service delivery (Primary NSP, including one model of Primary NSP providing primary health care; Secondary NSP; Vending Machine and Outreach) over three years. Costs were primarily affected by the ratio of the volume of equipment distributed to staff costs. The average cost per unit for Primary, Secondary and Outreach modes was approximately $1.00. The cost for Vending Machine provision (accounting for income from service users) was the cheapest option at $0.30–0.40 per unit. When income from services users are not included in calculations, other considerations may be more important than cost when making decisions about providing access to NSP services to a marginalized client group with diverse needs.

Uptake of hepatitis C treatment among people who inject drugs attending Needle and Syringe Programs in Australia, 1999-2011

The majority of new and existing cases of hepatitis C virus (HCV) infection occur among people who inject drugs (PWID). Despite safe and efficacious HCV antiviral therapy, uptake remains low in this population. This study examined trends in HCV treatment uptake among a large national sample of PWID attending Australian Needle and Syringe Programs between 1999 and 2011. Annual cross-sectional sero-surveys conducted among PWID since 1995 involve completion of a self-administered questionnaire and provision of a dried blood spot for HCV antibody testing. Multivariate logistic regression identified variables independently associated with HCV treatment uptake among 9478 participants with both self-reported and serologically confirmed prior HCV infection. Between 1999 and 2011, the proportion currently receiving treatment increased from 1.1% to 2.1% (P < 0.001), while the proportion having ever received treatment increased from 3.4% to 8.6% (P < 0.001). Men were significantly more likely than women to have undertaken HCV treatment (P = 0.002). Among men, independent predictors of HCV treatment uptake were homosexual identity and older age; among women, independent predictors included homosexual identity and an incarceration history. Despite increases in HCV treatment among Australian PWID between 1999 and 2011, uptake remains low. Strategies are required to increase the proportion of PWID assessed and treated for HCV infection to address the increasing burden of disease. Specific approaches that target women may also be warranted. Continued surveillance of HCV treatment uptake among PWID will be important to monitor the roll-out of simple, safe and more effective HCV treatments expected to be available in the future.

Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries

BACKGROUND

About a third of the global HIV infections outside sub-Saharan Africa are related to injecting drug use (IDU), and this accounts for a growing proportion of persons living with HIV. This paper is a response to the need to monitor the state of the HIV epidemic as it relates to IDU and the availability of HIV treatment and harm reduction services in 21 high epidemic countries.

METHODS

A data collection form was designed to cover questions on rates of IDU, prevalence and incidence of HIV and information on HIV treatment and harm reduction services available to people who inject drugs (PWID). National and regional data on HIV infection, IDU in the form of reports and journal articles were sought from key informants in conjunction with a systematic search of the literature.

RESULTS

Completed data collection forms were received for 11 countries. Additional country-specific information was sourced via the literature search. The overall proportion of HIV positive PWID in the selected countries ranged from 3% in Kazakhstan to 58% in Vietnam. While IDU is relatively rare in sub-Saharan Africa, it is the main driver of HIV in Mauritius and Kenya, with roughly 47% and 36% of PWID respectively being HIV positive. All countries had antiretroviral treatment (ART) available to PWID, but data on service coverage were mainly missing. By the end of 2010, uptake of needle and syringe programmes (NSP) in Bangladesh, India and Slovakia reached the internationally recommended target of 200 syringes per person, while uptake in Kazakhstan, Vietnam and Tajikistan reached between 100-200 syringes per person. The proportion of PWID receiving opioid substitution therapy (OST) ranged from 0.1% in Kazakhstan to 32.8% in Mauritius, with coverage of less than 3% for most countries.

CONCLUSIONS

In order to be able to monitor the impact of HIV treatment and harm reduction services for PWID on the epidemic, epidemiological data on IDU and harm reduction service provision to PWID needs to be regularly collected using standardised indicators.

Reduction in HCV incidence among injection drug users attending needle and syringe programs in Australia: a linkage study

OBJECTIVES

We examined trends in HCV incident infection among injection drug users (IDUs) attending needle and syringe programs (NSPs) in Australia in 1995 to 2010.

METHODS

We created a passive retrospective cohort of 724 IDUs who tested negative for HCV antibodies by a simple deterministic method linking partial identifiers to find repeat respondents in annual cross-sectional serosurveillance.

RESULTS

We identified 180 HCV seroconversions over the study period, for a pooled incidence density of 17.0 per 100 person-years (95% confidence interval [CI] = 14.68, 19.66). Incidence density declined, from a high of 30.8 per 100 person-years (95% CI = 21.3, 44.6) in 2003 to a low of 4.0 (95% CI = 1.3, 12.3) in 2009.

CONCLUSIONS

A decline in HCV incidence among Australian IDUs attending NSPs coincided with considerable expansion of harm reduction programs and a likely reduction in the number of IDUs, associated with significant changes in drug markets. Our results demonstrate the capacity of repeat cross-sectional serosurveillance to monitor trends in HCV incidence and provide a platform from which to assess the impact of prevention and treatment interventions.

Syringe coverage in an Australian setting: does a high level of syringe coverage moderate syringe sharing behaviour?

We examined individual-level syringe coverage among 417 people who inject drugs who were recruited from pharmacies in New South Wales in 2009. There was a U-shaped distribution of syringe coverage with many people having very high (51%) or very low (23%) coverage. Overall, two-thirds of respondents (63%) reported adequate coverage (≥ 100%). Respondents who had not used a needle and syringe program in the previous month were more likely to report inadequate coverage (AOR 2.25, 95% CI 1.25-4.05) as were those who reported daily or more frequent injecting (AOR 3.69, 95% CI 2.00-6.81). Inadequate syringe coverage was not independently associated with receptive needle sharing. The level of syringe coverage was high among this sample, and met targets set out by UNAIDS and other organisations. We found that inadequate syringe coverage was not independently correlated with receptive needle sharing, possibly because coverage is sufficient to diminish the relationship between syringe availability and sharing behaviours.

Respondent-driven sampling and the recruitment of people with small injecting networks

Respondent-driven sampling (RDS) is a form of chain-referral sampling, similar to snowball sampling, which was developed to reach hidden populations such as people who inject drugs (PWID). RDS is said to reach members of a hidden population that may not be accessible through other sampling methods. However, less attention has been paid as to whether there are segments of the population that are more likely to be missed by RDS. This study examined the ability of RDS to capture people with small injecting networks. A study of PWID, using RDS, was conducted in 2009 in Sydney, Australia. The size of participants' injecting networks was examined by recruitment chain and wave. Participants' injecting network characteristics were compared to those of participants from a separate pharmacy-based study. A logistic regression analysis was conducted to examine the characteristics independently associated with having small injecting networks, using the combined RDS and pharmacy-based samples. In comparison with the pharmacy-recruited participants, RDS participants were almost 80% less likely to have small injecting networks, after adjusting for other variables. RDS participants were also more likely to have their injecting networks form a larger proportion of those in their social networks, and to have acquaintances as part of their injecting networks. Compared to those with larger injecting networks, individuals with small injecting networks were equally likely to engage in receptive sharing of injecting equipment, but less likely to have had contact with prevention services. These findings suggest that those with small injecting networks are an important group to recruit, and that RDS is less likely to capture these individuals.

Fifteen years of HIV surveillance among people who inject drugs: the Australian Needle and Syringe Program Survey 1995-2009

OBJECTIVES

Following bipartisan political support in Australia for the timely introduction of needle and syringe programs (NSPs), HIV prevalence among people who inject drugs (PWID) remains low. This study aimed to determine the correlates of HIV infection among PWID; and to examine these correlates over time.

DESIGN

Annual cross-sectional seroprevalence studies among attendees of sentinel NSP sites.

METHOD

Multiple logistic regressions conducted on aggregated, de-duplicated data from 1995 to 2009 to determine variables independently associated with HIV infection.

RESULTS

Data were available for 22 478 individual NSP attendees, equating to a mean annual response rate of 44% (range 38-60%). Two-thirds of participants were men, with a median age of 30 years, and a median of 10 years since first injection. Eighty-five percent identified as heterosexual, 10% as bisexual and 5% as homosexual. Serology was available for 21 248 participants, of whom 230 (1.1%) tested HIV antibody positive. Variables independently associated with antibody seropositivity were homosexual or bisexual identity; male sex; older age; older age at first injection; and survey participation between 1995 and 1997 rather than later periods.

CONCLUSIONS

Unlike settings in which evidence-based public health approaches to illicit drug policy are yet to be implemented, the epidemiology of HIV among NSP attendees mirrors that of Australia's general population, with the majority of exposures attributed to male-to-male sexual contact. This pattern has remained unchanged over 15 years despite significant variation in drug markets and patterns of drug use. NSPs also play a crucial role in this country's comprehensive HIV surveillance mechanisms.