Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis

OBJECTIVE

From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision.

DESIGN

Costing study and longitudinal cohort study.

SETTING

Tijuana, Mexico.

PARTICIPANTS

Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study.

PRIMARY OUTCOME MEASURES

Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal.

RESULTS

During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02).

CONCLUSIONS

Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.

[Conditions of dental extractions in areas health centers of Senegal]

Dental extraction is a surgical act frequently carried out in the African dental structures. It requires the rigorous respect of the conditions of asepsis and antisepsis. Equipments and anaesthetic and avulsional products must be also sufficient. Our study undertaken among 46 dental services in areas health centers of Senegal aimed to determine the conditions under which dental extractions are carried out. The principle results of our study showed that 93% of dental practitioners wore sterilized gloves. 49% of the dentist's care activity consisted in dental extractions. 50% of the practitioners re-use anaesthetic needles, 2% re-use anaesthetic carpules. We noticed that the dental structures were facing a deficit of materials and products of extraction. Face to the outbreak of serious illnesses as infections of HIV and Hepatitis B, the practitioner and his team must be sensitized and trained to struggle against the transmissible infections and to carry out the dental extraction only if the conditions of asepsis and antisepsis are joined together. A pleading towards the medical authorities must be done to support the services in equipments and periodic renewals of the materials and products of extractions.

Controlling HIV among injecting drug users: the current status of harm reduction

HIV among injecting drug users is now a critical issue in global HIV control. Harm reduction strategies have been considered effective, safe and affordable for at least 15 years. In this article, based on a plenary presentation at the conference, Alex Wodak argues that the scientific debate about harm reduction is now over and that the paramount need is to overcome the conventional reliance on drug law enforcement, the major barrier to implementing harm reduction strategies in time and at sufficient scale.

Needle syringe acquisition and HIV prevention among injecting drug users: a treatise on the "good" and "not so good" public health practices in South Asia

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and "friends" continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.

Threat or opportunity? Secondary exchange in a setting with widespread availability of needles

Where authorized access to needles and syringes from exchanges and pharmacies is limited, secondary exchange (SE) can provide an important source of sterile injecting equipment. Interventions can be developed to use SE to facilitate needle and syringe exchange programs to reach a wider population of drug injectors. Yet in a context such as Western Australia, where needles and syringes are available to drug injectors from many authorized sources, the added benefit of SE is unknown. This review of data and literature conducted in October 2003 shows potential benefits but also concerns about undermining vulnerable public and political support for authorized needle provision schemes that has been nurtured and supported over a number of years.

Assessing needle exchange operations in a poor Brazilian community

This article assesses the operations of Porto Alegre, State of Rio Grande do Sul, (southern Brazil) needle exchange program (NEP), a setting where HIV infection rates have been on the rise among injection drug users (IDUs) in recent years, contrasting with substantial declines observed in this population, in major Brazilian cities (located in the southeast and southernmost part of Brazilian northeast). We explored local syringe dynamics, with the exclusive delivery in the local NEP of tagged syringes, and the subsequent monitoring of returned tagged/untagged used syringes from January to September 2002. We further assessed local NEP operations using focus groups and field observation, trying to expose the underlying reasons for the substantial delay in the return of tagged syringes and the continuous and relevant return of untagged syringes throughout the study period. We found that local IDUs reuse, divert, and create caches of syringes at their discretion. All efforts should be made to increase the availability of clean syringes and to fully integrate syringe exchange with comprehensive health education and health screening to effectively curb HIV spread.

Safer injections following a new national medicine policy in the public sector, Burkina Faso 1995-2000

Background

The common failure of health systems to ensure adequate and sufficient supplies of injection devices may have a negative impact on injection safety. We conducted an assessment in April 2001 to determine to which extent an increase in safe injection practices between 1995 and 2000 was related to the increased access to injection devices because of a new essential medicine policy in Burkina Faso.

Methods

We reviewed outcomes of the new medicine policy implemented in1995. In April 2001, a retrospective programme review assessed the situation between 1995 and 2000. We visited 52 health care facilities where injections had been observed during a 2000 injection safety assessment and their adjacent operational public pharmaceutical depots. Data collection included structured observations of available injection devices and an estimation of the proportion of prescriptions including at least one injection. We interviewed wholesaler managers at national and regional levels on supply of injection devices to public health facilities.

Results

Fifty of 52 (96%) health care facilities were equipped with a pharmaceutical depot selling syringes and needles, 37 (74%) of which had been established between 1995 and 2000. Of 50 pharmaceutical depots, 96% had single-use 5 ml syringes available. At all facilities, patients were buying syringes and needles out of the depot for their injections prescribed at the dispensary. While injection devices were available in greater quantities, the proportion of prescriptions including at least one injection remained stable between 1995 (26.5 %) and 2000 (23.8 %).

Conclusion

The implementation of pharmaceutical depots next to public health care facilities increased geographical access to essential medicines and basic supplies, among which syringes and needles, contributing substantially to safer injection practices in the absence of increased use of therapeutic injections.

Audio-computerized self-interviewing versus face-to-face interviewing for research data collection at drug abuse treatment programs

AIMS

To assess audio computer-assisted self-interviewing (A-CASI) as a mode of data collection with injecting drug users (IDUs) entering two drug treatment programs in New York City. A-CASI has been found to increase reporting of sensitive items among a variety of population subgroups.

DESIGN

A field test of A-CASI data collection conducted within an ongoing cross-sectional study of drug use and HIV risk behaviors among IDUs entering drug treatment. Participants were assigned without bias to either a computer-assisted interviewer-administered personal interview (CAPI) or to a mixed CAPI/A-CASI interview. In the latter, 'sensitive' portions (dealing with stigmatized behavior) of the questionnaire were self-administered through A-CASI, while the remaining portions were interviewer-administered.

SETTING

The Detoxification Program and the Methadone Maintenance Treatment Program (MMTP) at Beth Israel Medical Center in New York City.

PARTICIPANTS

Seven hundred and eighty-three IDUs entering drug treatment.

MEASUREMENTS

Odds ratios and adjusted odds ratios (controlling for demographic differences) for comparison of A-CASI versus CAPI responses on 111 sensitive questions.

FINDINGS

Twenty-three statistically significant differences (each at P < 0.05), all in the direction of more reporting of the behaviors by the A-CASI group. Forty-one per cent of A-CASI participants said they would prefer any subsequent interviews to be fully A-CASI and 46% said they would prefer the mixed CAPI/A-CASI mode.

CONCLUSIONS

A-CASI was associated with greater reporting of potentially stigmatized drug, sex and HIV risk behaviors on a moderate number of questions. Moreover, a large majority of participants who used A-CASI would like to be assigned to this method of data collection in future interviews.

Needlestick-prevention devices. Disposable syringes and injection needles

Needlestick-prevention devices (NPDs) are an essential tool for protecting healthcare workers from injuries that could result in exposure to bloodborne pathogens. More than a dozen NPD varieties are available. They generally take the same form as conventional (nonsafety) sharps but incorporate some type of safety design--for example, a shield or a needle-retracting mechanism. In this Evaluation, we focus on protective devices that are used in place of conventional syringes and injection needles--namely, disposable protective syringes and needle guards. We tested 14 products from 8 suppliers. We give Preferred ratings to three products, all of which are needle-retracting syringes. When used correctly, these devices provide the best protection available. However, their primary safety advantage--preremoval activation--can be negated if the user chooses to activate the safety mechanism after removing the needle from the patient. For many facilities, one of the seven models we rate Acceptable might be a better choice. We caution that our ratings should not be the sole basis of a purchase decision. Staff members need to conduct a hands-on assessment of the available products to identify those that best meet their needs. We also stress that any NPD--even one we rate Not Recommended--is preferable to using no protective device at all.

Needle exchange: how the meanings ascribed to needles impact exchange practices and policies

The consistency among needle exchange practices, HIV prevention, harm reduction goals, and potential program effectiveness are analyzed. Using a modified ethnographic approach, qualitative interviews were conducted with staff (n = 59) of needle exchange programs (NEPs; n = 15). Interviews addressed operational policies; funding and challenges. An iterative, inductive analytic process was used. Differences in exchange practices are traced to differences in how workers define needles as objects of "risk" and/or "prevention." The weight accorded to each definition has implications for service delivery. Among NEPs that ascribe a "risk" meaning, workers enforce a strict one-for-one exchange, encourage clients to take fewer needles, and penalize clients. Programs that focus on the "prevention" meaning of needles work towards improving access, problem solving about proper disposal and do not penalize clients. Operational policies that restrict access to sterile equipment or discourage attendance need to be reconsidered if HIV prevention goals are to be realized.

Spain: government orders distribution of clean needles in prisons

In a previous issue of the Review we published an article about the positive results of the evaluation of the first needle exchange programs in Spanish prisons. Recently it was reported that Spain's Ministry of the Interior has ordered that sterile needles be distributed in prisons.

New York City pharmacists' attitudes toward sale of needles/syringes to injection drug users before implementation of law expanding syringe access

In May 2000, New York State passed legislation permitting the sale, purchase, and possession of up to 10 needles and syringes (hereafter "syringes") without a prescription, intended to reduce blood-borne pathogen transmission among injection drug users (IDUs). To obtain baseline data on pharmacists' attitudes and practices related to human immunodeficiency virus (HIV) prevention and IDUs, a telephone survey was administered to 130 pharmacists systematically selected in New York City. Less than half of pharmacists were aware of the new law; 49.6% were willing to or supported providing nonprescription sales of syringes to IDUs. Pharmacists in support tended to be less likely to consider customer appearance "very important." Managing and supervising pharmacists were more likely than staff pharmacists to support syringe sales to IDUs. Managing and supervising pharmacists who stocked packs of 10 syringes and personal sharps disposal containers, pharmacists who supported syringe exchange in the pharmacy, and pharmacists who were willing to sell syringes to diabetics without a prescription were more likely to support syringe sales to IDUs. Syringe disposal was a prominent concern among all pharmacists. Those not in support of syringe sales to IDUs tended to be more likely to believe the practice would increase drug use. These data suggest the need for initiatives to address concerns about syringe disposal and tailored continuing education classes for pharmacists on HIV and viral hepatitis prevention among IDUs.

New York State pharmacists' attitudes toward needle and syringe sales to injection drug users before implementation of syringe deregulation

In May 2000, New York State passed legislation permitting the sale, purchase, and possession of up to 10 needles and syringes without a prescription. The law is intended to reduce the transmission of human immunodeficiency virus (HIV) and hepatitis among injection drug users (IDUs), their sexual partners, and their children. To obtain baseline information about the attitudes and likely practices of New York State pharmacists, we distributed a self-administered questionnaire to attendees of the state pharmacy association meeting in June 2000. Of 48 usable responses, 19% were from New York City and the rest from New York State. Of the 48, 42% were unaware of the new law before the day of the survey, and 60% were somewhat or very willing to sell needles and syringes to an IDU. Of those who were not willing to sell to an IDU, 82% cited familiarity of the customer as a very important consideration in their decision making. Those who were not willing to sell to an IDU were more concerned about the detrimental impact of syringe sales on the community, were less likely to be aware of the new law, and were more likely to be concerned about legal liability for syringe sales. Over 80% of all pharmacists believed that syringe sales to IDUs are an important preventive health measure. The majority also favored learning more about the law. Compared to other state surveys of pharmacists, these preliminary data show a similar level of interest in becoming involved with syringe availability programs.

The role of policy in community pharmacies' response to injection-drug use: results of a nationwide Canadian survey

The response rate to this survey reflects the salience of the topic and the professional concern about and interest in issues presented by HIV. The HIV/AIDS epidemic has presented pharmacists with one of the greatest challenges to their professional training, ethics, and practice. It further expedites a current re-examination that is occurring among community pharmacies concerning their roles in community health practices. In response to HIV there have been dramatic and unprecedented changes in pharmacy policy and practices. Clearly, some community pharmacies have led the way and influenced policy and practices. In view of the recent introduction of many of these policies and practices, it is likely that change will continue. Survey respondents were, in general, very comfortable with an expanded role involving counseling, health promotion, and disease prevention, consistent with a broader role for community pharmacies in general that has been recently advocated. Community pharmacies serve all areas of the country, in communities large and small; many are open seven days a week, and some provide extended hours of service. Community pharmacies may provide an important complement to community outreach programs as a source of clean needles and syringes for IDUs in most communities, and as an alternative service in some communities where more elaborate programs are not feasible. Safer needle use, as part of a health-promotion approach, is divergent from conventional practice. While major changes have occurred, it appears that there has been some polarization of attitudes and response. The explanation for this is not simple, and further analysis is required to determine the full impact from several ethical perspectives that include professional, business, and public health viewpoints. We have highlighted the role that policy has in moving toward preventive and harm-reduction approaches. From a policy perspective, we have found that support from the federal government, regulatory bodies, and professional associations may be an important catalyst to pharmacists' participation in programs. Further, it does not appear to be possible to implement such policies without professional development and continuing education, and collaboration with the community. Based on data on knowledge and educational need, we believe that our study population's lowest levels of information were in such areas as the role of methadone in HIV prevention and the availability of needle-exchange programs. As with other health-promotion campaigns, additional skills training may be important. Movement forward with expanded preventive and harm-reduction strategies by pharmacies will require careful planning. It is anticipated that change in this area will be incremental in nature, and that it is necessary to introduce programs and services into community pharmacies gradually. Successful implementation will require extensive community development and collaboration with other health professionals, public health officials, police, groups who represent IDUs, and persons living with HIV/AIDS. Careful monitoring and evaluation of these programs will be necessary to enhance their effectiveness.

Drawing up and administering intramuscular injections: a review of the literature

Drawing up and administering intramuscular injections: a review of the literature Intramuscular (IM) injections have been an integral part of drug administration in nursing practice for almost half a century. However, there are some conflicting practices which warrant investigation to determine their effectiveness in this aspect of patient care. To this end, this paper presents the results of a literature review which was carried out in order to establish current understanding of present day knowledge, procedures and guidelines for the administration of IM injections. Areas addressed within this review include injection sites used, injuries associated with IM injections, issues surrounding needle selection and volume administered through IM injections, injection techniques and nursing skills associated with IM injections. Synthesis of the research reviewed allows the development of research-based guidelines for this skill. These guidelines offer a framework for nurses who wish to provide practice in line with current research into the process of drawing up and administration of intramuscular injections.

Telephone survey of Alaskan pharmacists' nonprescription needle-selling practices

OBJECTIVES

To determine the availability of nonprescription needles and syringes (NS) through pharmacy sales and to assess the impact of pharmacy policies and municipal paraphernalia laws on pharmacists' selling practices.

DESIGN

Telephone survey of all pharmacies in Alaska's four largest cities.

SETTING

Anchorage, Fairbanks, Juneau, and Ketchikan, Alaska.

SUBJECTS

A single pharmacist from each pharmacy represented in the cities' phone books.

MAIN OUTCOME MEASURES

Reports of (1) pharmacies' policies and individual pharmacists' procedures regarding the nonprescription sale of NS, (2) pharmacists' selling practices, and (3) identification of conditions that may affect pharmacists' decisions to sell nonprescription NS.

RESULTS

Response rate of 86% (37/43); 77% of pharmacists reported selling at least one nonprescription NS in the last month. Store policy was related to selling practices; however, there was no difference in selling practices between a city with a paraphernalia law and cities without such laws. Logistic regression revealed pharmacists were more likely to sell NS if they worked in chain pharmacies and estimated that a high number of other local pharmacists sell nonprescription NS.

CONCLUSION

NS are available through nonprescription sales in Alaskan pharmacies. The majority of pharmacies have store policies that permit pharmacists to sell nonprescription NS, either in all cases or at their discretion. Municipal paraphernalia laws do not determine the selling practices of individual pharmacists.

Influence of Whitacre spinal needle orifice direction on the level of sensory blockade

The purposes of the present study were to determine if the direction of the needle orifice during injection of anesthetic into the subarachnoid space, using a 25-gauge Whitacre spinal needle (Becton Dickinson, Franklin Lakes, NJ) to deliver 15 mg of 0.75% hyperbaric bupivacaine, affected the level of sensory blockade achieved, and if there was a difference in time from injection to surgical anesthesia based on needle orifice direction. A convenience sample was selected from patients presenting for elective surgical procedures. All patients received a standard anesthetic solution using a standard technique and duration of injection. Mean maximum height of sensory blockade was compared between treatment groups using a Student t test. Progression of the sensory blockade was compared at each data collection point using a chi-square test. There was no statistically significant difference in the mean maximum height of block between the treatment groups. The mean maximum height of block for the cephalad group was T4 with an SD of 2.5 dermatomes, and T5 with an SD of 4.57 dermatomes for the caudad group. An incidental finding was that all failed blocks were from the caudad group. There was no statistically significant difference in time from injection to surgical anesthesia between the treatment groups. Although the data support no statistically significant difference between the treatment groups for either research question, the cephalad group provides for a more precise height of block.

Use of needles and syringes in Miami and Valencia: observations of high and low availability

Two studies engaged in gathering data on injecting drug users (IDUs) employed supplementary resources to enhance their ethnographic components and compare patterns of use of needles/syringes (n/s) in two geographically similar but culturally distinct cities. Despite its policy of making n/s highly available at fair prices, Valencia, Spain, has markedly higher rates of HIV seroprevalence among its IDUs than does Miami, Florida, where possession of n/s is illegal. Ethnographically based models that track IDUs through choices of injection venues help to explain this difference. Inability of IDUs in Valencia to use their own domiciles as venues for injection contrasts sharply with problems of Miami IDUs, who have access to houses but have difficulty finding n/s. This research suggests that intervention in Valencia needs to focus on how people select places where they inject, and intervention in Miami needs to focus on improving availability of n/s.

A thousand points ... needle exchange around the country

Needle exchange in the United States is a part of the AIDS direct action movement. Activists around the country, refusing to wait for health officials to create AIDS interventions for drug users, have taken the task upon themselves. Prevention Point in San Francisco, the National AIDS Brigade in Boston, and ACT UP/New York all run illegal programs in their locales, and member of all three groups have been arrested for their work. Tacoma, Seattle, and New Haven now have authorized programs, but only after Dave Purchase in Tacoma, ACT UP Seattle, and the National AIDS Brigade and ACES in New Haven demonstrated that needle exchange was a viable and necessary public health intervention. Health/PAC here presents some of the stories from this citizen's health action movement.

The use of spring-eye needles in neurosurgery: a survey of neurosurgical theatres in the United Kingdom

Spring-eye needles were commonly used in neurosurgery as a method of closure of craniotomy incisions because of the perceived, but not proven, advantages of easy handling, fast wound closure and reduced infection rate. However, these needles produce more tissue trauma and are more fragile. We surveyed 33 neurosurgical operating theatres in the UK to find out if spring eyed needles are still in use and, if they are not why not. We had a 91% response. The survey involved 117 British neurosurgeons, of whom spring-eye needles were used by 38 (13%). Both round body and cutting needles were used, but the cutting needles have a higher breakage rate. The use of 'eyed' needles is rare in other surgical specialties but they are still in use in neurosurgical theatres; however, their use has declined because of changes in surgical practice, the increased breakage rate of these needles, and reduction of their availability.

The syringe in the machine

This paper is a report on focus-group discussions with Western Australian and South Australian injecting drug users and South Australian drug workers, about the feasibility of and issues surrounding the introduction of needle-and-syringe vending machines in Australia. Injecting drug users and workers supported the idea of introducing vending machines in Australia to complement existing services that provide sterile injecting equipment. The participants emphasised that the machines should be provided in addition to existing services. Possible adverse effects of their introduction included concerns for the safety of minors who are not drug users. The potential benefits to public health includes further reducing that proportion of the sharing of injecting equipment that is related to unavailability of sterile equipment (usually at times when other services do not operate).

The selection of electromyographic needle electrodes

Monopolar and concentric reusable and disposable EMG needle electrodes from several manufacturers were studied at various stages of usage. Needle tips were examined and measured microscopically, and needles were tested for spontaneous noise and resistive and capacitative characteristics at four different test signal frequencies. Resistive and capacitative characteristics were found to be frequency dependent. Needle tip areas differed by as much as 10 times among the various electrodes. The amount of noise correlated most highly with resistive characteristics. Monopolar and concentric needles differed in respect to tip area, noise, and all resistive and capacitative measures. Coaxial disposable and reusable electrodes did not differ significantly and minor differences were noted in electrical characteristics between reusable and disposable monopolar needles, even from the same manufacturer. There was considerable variability among manufacturers for both needle types. In choosing an electrode, consistent tip area is probably the most important consideration to ensure repeatable quantifiable results, but minimizing needle impedance is useful to reduce noise.