Lessons learned from a peri-urban needle exchange

Injection drug use, HIV/HCV, and related services in nonurban areas of the United States: A systematic review

BACKGROUND

Injection drug use (IDU) in nonurban areas of the United States is a growing public health concern, but there has been no comprehensive assessment of existing research on injection-related HIV and hepatitis C (HCV) in nonurban communities. We conducted a systematic review to assess the current literature and identify knowledge gaps.

METHODS

We systematically searched six databases for relevant articles published between January 1990 and June 2016 and screened, extracted, and analyzed the resulting data. Studies were included if they reported original findings from the nonurban U.S. related to 1) IDU and its role in HIV/HCV transmission, and/or 2) HIV/HCV services for people who inject drugs (PWID).

RESULTS

Of 2330 studies, 34 from 24 unique research projects in 17 states met inclusion criteria. Despite increasing HCV and high vulnerability to injection-related HIV outbreaks in nonurban areas, only three studies since 2010 recruited and tested PWID for HIV/HCV. Twelve reported on sharing injection equipment but used varying definitions of sharing, and only eight examined correlates of injection risk. Nine studies on syringe access suggest limited access through syringe exchange programs and pharmacies. Only two studies addressed HCV testing, none addressed HIV testing, and three examined behavioral or other interventions.

CONCLUSIONS

Despite growing concern regarding nonurban IDU there are few studies of HIV/HCV and related services for PWID, and the existing literature covers a very limited geographical area. Current research provides minimal insights into any unique factors that influence injection risk and HIV/HCV service provision and utilization among nonurban PWID.

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.

Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review

One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.

Development of a risk reduction intervention to reduce bacterial and viral infections for injection drug users

Bacterial infections are widespread problems among drug injectors, requiring novel preventive intervention. As part of a NIDA-funded study, we developed an intervention based on the Information-Motivation-Behavioral Skills model, past research, injection hygiene protocols, and data collected from focus groups with 32 injectors in Denver in 2009. Qualitative responses from focus groups indicated that most participants had experienced skin abscesses and believed that bacterial infections were commonly a result of drug cut, injecting intramuscularly, and reusing needles. Access to injection supplies and experiencing withdrawal were the most frequently reported barriers to utilizing risk reduction. Implications for intervention development are discussed.

Skin and needle hygiene intervention for injection drug users: results from a randomized, controlled Stage I pilot trial

A new skin and needle hygiene intervention, designed to reduce high-risk injection practices associated with bacterial and viral infections, was tested in a pilot, randomized controlled trial. Participants included 48 active heroin injectors recruited through street outreach and randomized to either a 2-session intervention or an assessment-only condition (AO) and followed up for 6 months. The primary outcome was skin- and needle-cleaning behavioral skills measured by videotaped demonstration. Secondary outcomes were high-risk injection practices, intramuscular injection, and bacterial infections. Intervention participants had greater improvements on the skin (d = 1.00) and needle-cleaning demonstrations (d = .52) and larger reductions in high-risk injection practices (d = .32) and intramuscular injection (d = .29), with a lower incidence rate of bacterial infections (hazard ratio = .80), at 6 months compared with AO. The new intervention appears feasible and promising as a brief intervention to reduce bacterial and viral risks associated with drug injection.

Hepatitis C virus infection in USA: an estimate of true prevalence

The recent National Health and Nutrition Examination Survey (NHANES) sampled only the civilian, non-institutionalized population of USA and may have underestimated the prevalence of hepatitis C virus (HCV) in this country. We searched the database MEDLINE, the Bureau of Justice Statistics, Center for Medicare and Medicaid and individual states Department of Corrections for all epidemiological studies regarding the prevalence of HCV in populations not sampled by the NHANES survey namely the incarcerated, homeless, nursing home residents, hospitalized and those on active military duty. Because of their relatively low frequency in the NHANES sample, we also expanded our search to include healthcare workers and long-term dialysis patients. Although included in the NHANES sample, we also performed searches on drug users (injection and non-injection) and veterans to confirm the findings of the NHANES study. Based on the prevalence of studies identified meeting our inclusion criteria, our most conservative estimates state that there at least 142,761 homeless persons, 372,754 incarcerated persons and 6805 persons on active military duty unaccounted for in the NHANES survey. While the NHANES estimates of drug users (both injection and non-injection) appear to be reasonable, the survey seems to have underestimated the number of HCV-positive veterans. Our most conservative estimates suggest that there are at least 5.2 million persons living with HCV in USA today, approximately 1.9 million of whom were unaccounted for in the NHANES survey.