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PubMed1998

The role of needle exchange programs in HIV prevention.

Injecting drug users (IDUs) are at high risk for infection by human immunodeficiency virus (HIV) and other blood-borne pathogens. In the United States, IDUs account for nearly one-third of the cases of acquired immunodeficiency syndrome (AIDS), either directly or indirectly (heterosexual and perinatal cases of AIDS where the source of infection was an IDU). IDU also account for a substantial proportion of cases of hepatitis B (HBV) and hepatitis C (HCV) virus infections. The primary mode of transmission of HIV among IDUs is parenteral, through direct needle sharing or multiperson use of syringes. Despite high levels of knowledge about risk, multiperson use of needles and syringes is due primarily to fear of arrest and incarceration for violation of drug paraphernalia laws and ordinances that prohibit manufacture, sale, distribution, or possession of equipment and materials intended to be used with narcotics. It is estimated that in 1997 there were approximately 110 needle exchange programs (NEPs) in North America. In part, because of the ban on the use of Federal funds for the operation of needle exchange, it has been difficult to evaluate the efficacy of these programs. This chapter presents data from the studies that have evaluated the role of NEPs in HIV prevention. Evidence for the efficacy of NEPs comes from three source: (1) studies originally focused on the effectiveness of NEPs in non-HIV blood-borne infections, (2) mathematical modeling of data on needle exchange on HIV seroincidence, and (3) studies that examine the positive and negative impact of NEPs on HIV and AIDS. Case-control studies have provided powerful data on the positive effect of NEPs on reduction of two blood-borne viral infections (HBV and HCV) For example, a case-control study in Tacoma, Washington, showed that a six-fold increase in HBV and a seven-fold increase in HCV infections in IDUs were associated with nonuse of the NEP. The first federally funded study of needle exchange was an evaluation of the New Haven NEP, which is legally operated by the New Haven Health Department. Rather than relying on self-report of reduced risky injection drug use, this study utilized mathematical and statistical modeling, using data from a syringe tracking and testing system. Incidence of HIV infection among needle exchange participants was estimated to have decreased by 33% as a result of the NEP. A series of Government-commissioned reports have reviewed the data on positive and negative outcomes of NEPs. The major reports are from the National Commission on AIDS; the U.S. General Accounting Office; the Centers for Disease Control/University of California; and the National Academy of Sciences. The latter two reports are used in this chapter. The aggregated results support the positive benefit of NEPs and do not support negative outcomes from NEPs. When legal restrictions on both purchase and possession of syringes are removed, IDUs will change their syringe-sharing behaviors in ways that can reduce HIV transmission. NEPs do not result in increased drug use among participants or the recruitment of first-time drug users.

Case-Control Studies↗
PubMed1998

Satellite exchange in the Baltimore Needle Exchange Program.

OBJECTIVE: Our first objective was to develop an index of satellite exchange and then determine whether satellite exchangers (SEs) differed demographically or behaviorally from other injecting drug users (IDUs). Our second objective was to determine the degree that SEs contributed to needle exchange program (NEP) effectiveness. METHODS: We collected data from approximately 5000 Baltimore Needle Exchange Program (BNEP) participants on the number of syringes acquired and returned over the two-year period February 1995 to February 1997. We then conducted one-way ANOVAs and logistic regressions to determine if SEs were different from other IDUs. RESULTS: We classified 9.35% of the IDUs and SEs and showed that SEs reported levels of drug use and risk behavior similar to other BNEP participants. Although SEs represented less than 10% of all BNEP clients, they accounted for more than 64% of all needles distributed by the BNEP. We showed that SEs accessed more wide-ranging drug use networks than non-SE IDUs and thus can act as potential bridges for human immunodeficiency virus (HIV) prevention materials and messages to larger numbers of drug injectors. CONCLUSIONS: SEs can be expressly targeted with specific prevention messages and encouraged to be "ambassadors" for HIV prevention messages. Efforts to curtail the activities of SEs may detract from the effectiveness of NEPs.

Adult↗
PubMed1998

Drug abuse treatment success among needle exchange participants.

OBJECTIVE: Although lowering incidence rates of human immunodeficiency virus (HIV) transmission is the primary goal of needle exchange programs (NEPs), other desirable outcomes are possible. Referring exchange participants to more comprehensive drug abuse treatment programs has the potential to reduce or eliminate the use of drugs. This possibility was evaluated by comparing the treatment responses of new admissions with an outpatient opioid agonist treatment program in Baltimore, Maryland. METHODS: New admissions (1994 - 1997) to an opioid agonist treatment program were first grouped by referral source (needle exchange, n = 82 vs. standard referrals, n = 243) and then compared on admission demographic and clinical variables and response to treatment during the first three months. Outcome measures included retention rates, self-reported drug use and injecting frequencies, self-reported illegal activities for profit, and results from weekly urinalysis testing for opioids and cocaine. RESULTS: Patients from the NEP were significantly older and more likely to be male, African American, and unemployed than standard referral patients. Needle exchange patients also had a greater baseline severity of drug use than patients in the standard referral group. Despite these baseline differences, both groups achieved comparably good short-term treatment outcomes (including reduced drug use and criminal activity for profit); treatment retention was also good, although slightly better in the standard referral group (88% vs. 76%). CONCLUSION: These data demonstrate the feasibility and merits of creating strong linkages between NEPs and more comprehensive drug abuse treatment clinics.

Adult↗
PubMed2004

Displacement of Canada's largest public illicit drug market in response to a police crackdown.

BACKGROUND: Law enforcement is often used in an effort to reduce the social, community and health-related harms of illicit drug use by injection drug users (IDUs). There are, however, few data on the benefits of such enforcement or on the potential harms. A large-scale police "crackdown" to control illicit drug use in Vancouver's Downtown Eastside provided us with an opportunity to evaluate the effect. METHODS: As part of our ongoing prospective cohort study of IDUs in Vancouver, we examined data collected from 244 IDUs in the 3 months before the police crackdown and from 142 IDUs in the 3 months after the start of the crackdown, on Apr. 7, 2003. All study subjects were active drug users. We also examined external data on needle exchanges and syringe disposal. RESULTS: The 2 groups of IDUs were statistically similar: they were mainly young (mean age 39 years) and male (63%), and they had injected illicit drugs for 13 years on average. Ethnic background and the proportion homeless were also similar. There were no statistically significant reported differences (all p > 0.1) in the street price of heroin, cocaine or "crack" in the 2 periods. In the 3-month periods before and after the crackdown, respectively, the rates of daily heroin injection were 27.9% and 26.8%, daily cocaine injection 28.7% and 27.5%, and daily crack use 59.4% and 60.6% (all p > 0.1). The proportions of study subjects receiving methadone treatment, 41.0% and 44.4% (p = 0.516), did not differ. However, the proportions reporting a change in where drugs were used, 22.5% and 33.8% (p < 0.05), and the proportions reporting a change in the neighbourhood of use because of police presence, 18.1% and 26.8% (p < 0.05), increased significantly. Needle-exchange data confirmed that the community levels of drug use were unchanged. Disposal statistics demonstrated that the monthly average number of used syringes found on the streets outside the traditional area of drug use increased from 784 in the 3 months before Apr. 1 to 1253 in the subsequent 3 months (p = 0.002) and the monthly average number of used syringes found in public boxes for the safe disposal of syringes decreased from 865 to 502 (p = 0.018). INTERPRETATION: The effort to control illicit drug use did not alter the price of drugs or the frequency of use, nor did it encourage enrollment in methadone treatment programs. Several measures indicated displacement of injection drug use from the area of the crackdown into adjacent areas of the city, which has implications for both recruitment of new initiates into injection drug use and HIV prevention efforts.

Adult↗