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Characteristics and attendance patterns of a fixed-site NSP and nearby SVM: The benefits of 24-hour access to sterile injecting equipment
Abstract
Aims: This article describes the characteristics and attendance patterns of clients of a co-located fixed-site needle and syringe program (NSP) and syringe vending machine (SVM) to assess the utilisation and benefits of providing access to multiple distribution services. Methods: Data were collected through cross-sectional surveys with a convenience sample of NSP (n = 98) and SVM (n = 91) recruited attendees in Sydney, Australia. Surveys collected demographic data, self-reported injecting patterns, self-reported receptive equipment sharing, knowledge of hepatitis C and utilisation of the fixed-site NSP and SVM services. Findings: The demographic profile and characteristics of these NSP and SVM groups were similar; no differences were evident in knowledge about hepatitis C risk practices or type of drug used, frequency of injecting, sharing of injecting equipment and place of injecting. Both fixed-site NSP- and SVM-recruited attendees primarily accessed equipment from the fixed-site NSP in the last month. The SVM was usually accessed outside the opening hours of the fixed-site NSP, between 8 pm and 4 am, or in circumstances where equipment could not be obtained from the NSP. Conclusions: Findings support the argument that SVMs act as a complementary service alongside fixed-site NSP services and indicate that providing 24-h access to syringes through multiple mechanisms has benefits for provision of sterile equipment to people who inject drugs.
... Timestamped transaction data were previously used by Duplessy and Reynaud [14] in an evaluation of Parisian SDMs, finding that most SDM presentations occurred during daylight hours-findings that contrast with other studies suggesting that SDM use often occurs outside fixed-site NSP operating hours [9,11,16]. A similar system was implemented in Melbourne, Australia, in 2017, using an innovative SDM data capture system. ...
... Some evidence suggests SDMs may also attract greater numbers of people who are younger, female, and/or have limited connection to health care services compared to individuals accessing primary NSPs or pharmacies [4][5][6][7]. There were an estimated 399 SDMs operating across Australia in 2021 [1], which potentially provide expanded harm reduction access to a more diverse range of people who inject drugs than fixed-site services, but findings around these clienttype differences are inconsistent [8][9][10][11][12][13]. ...
... In research evaluating the effects of SDMs, different recruitment methods have been employed to recruit individuals who acquire syringes from SDMs, such as having researchers stationed adjacent to SDMs [9,12], paper flyers advertising research located near SDMs [11] and within distributed SDM packs [9], internal timestamped counting devices [14] and viewing of CCTV footage at SDM sites [15]. All these methods have limitations and biases. ...
Background
Australian needle and syringe distribution occurs via a mix of modalities, including syringe dispensing machines (SDMs). SDMs are electronic vending machines providing (often) 24-h access to needles/syringes and may attract greater numbers of people who are younger, female, and/or have limited connection to health care services compared to individuals accessing fixed-site needle and syringe programs (NSPs). However, validating the demographic characteristics of SDM clients has proven difficult in previous research.
Methods
In this paper, we analyse SDM order and client demographic data from four SDMs located in South-East Melbourne, Australia, and compare this against the managing fixed-site NSP between May 2017 and December 2020. SDM data were collected via a novel 0–9 numeric keypad input tool. Via the tool, SDM clients were requested to input their categorised age, gender and postcode. Given the novelty of the tool, we evaluate the feasibility of the data collection method. We analysed data according to: (1) total SDM orders made, (2) estimated ‘unique SDM presentations’ and (3) describing the demographics of unique SDM clients. Importantly, we noted substantial invalid demographic data, and consequently, severely restricted data for analysis.
Results
There were 180,989 SDM orders made across the four SDMs to an estimated 90,488 unique SDM presentations. There was little variation in unique presentations across days of the week, but 69% occurred out of NSP operating hours. Across the study period, the SDMs distributed 66% of the number of syringes distributed by the fixed-site NSP. Due to invalid demographic data, our restriction method provided only 10,914 (6% of all data) unique presentations for analysis. There were some demographic differences between SDM and NSP client, but these should be treated with caution.
Conclusions
The data collection tool provides a novel means of comparing SDM and fixed-site presentations, demonstrating the substantial expansion of service via the SDMs. However, the validity of the demographic data was highly questionable and requires significant data coding, meaning it is not feasible for community NSPs. While we recommend the inclusion of automatically collected SDM order data, the use of a 0–9 numeric keypad to collect demographic data—while an innovation—requires alteration to support NSP data.
... Several studies have shown that some people who use ADMs differ from those who access face-to-face NSPs or pharmacies for injecting equipment, reporting that primary ADM users were younger, had shorter durations of injecting, injected less frequently, were less likely to report risky injecting practices or to have received opioid agonist treatment (OAT) [5,7,17,18]. However, two recent Australian studies suggested that when ADMs were located adjacent to face-to-face NSPs and near pharmacies, the ADM was primarily used by clients of face-to-face services who used the ADM outside business hours [19,20]. ...
... In regard to HCV prevention and testing, some studies report that people who use ADMs report less syringe sharing [16] and do not differ from those who primarily use face-to-face NSPs in terms of HCV risk practices [8,20,21]. However, uptake of HCV testing and particularly treatment among people who use ADMs remains unclear, including potential gender differences. ...
... Only two occasions of use were by people who appeared to be transgender, so these were excluded from analysis of gender only. Three-quarters of occasions of use were by unaccompanied people (75%), and most people obtained one or two fit-packs (85%; range [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Although only one-quarter of the occasions of use were by females ( Table 1), compared to males, and females were significantly more likely to be accompanied by one or two others (40% vs 20%; p 0.004) and to obtain more (> 3) fitpacks (28% vs 11%; p 0.003; Table 1). ...
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.
... It should be noted that this NSP is operated by a peer-based drug consumer organization. As discussed elsewhere, this service is user friendly and nonjudgmental, thus experiences with service staff may be more positive than would be found elsewhere (Cama, Brener, & Bryant, 2014), supported by the low mean score on the scale assessing perceptions of discriminatory treatment by staff at the NSP. Furthermore, in this study and in previous research, self-reported sharing of injecting equipment among attendees of this service has been found to be low (Cama et al., 2014), and the inner-Sydney area is well-serviced for PWID to access sterile injecting equipment even where staffed NSPs are closed (e.g., automatic dispensing machines), highlighting the utility of providing multiple modalities for distribution of sterile injecting equipment in geographic areas frequented by PWID. ...
... As discussed elsewhere, this service is user friendly and nonjudgmental, thus experiences with service staff may be more positive than would be found elsewhere (Cama, Brener, & Bryant, 2014), supported by the low mean score on the scale assessing perceptions of discriminatory treatment by staff at the NSP. Furthermore, in this study and in previous research, self-reported sharing of injecting equipment among attendees of this service has been found to be low (Cama et al., 2014), and the inner-Sydney area is well-serviced for PWID to access sterile injecting equipment even where staffed NSPs are closed (e.g., automatic dispensing machines), highlighting the utility of providing multiple modalities for distribution of sterile injecting equipment in geographic areas frequented by PWID. ...
Background:
Perceived experiences of stigma have been found to be associated with poorer psychosocial outcomes and engagement in risk practices among people who inject drugs. Yet the extent to which people internalize or accept the stigma surrounding their injecting drug use, and whether this is associated with risky injecting practices, is not well known.
Objectives:
The aim of this study was to assess the extent of internalized stigma among a sample of people who inject drugs in Australia and identify socio-demographic, injecting risk, and mental health correlates.
Methods:
People who inject drugs were recruited from a needle and syringe program located in Sydney, Australia to complete a brief survey. The survey included measures of internalized stigma, severity of drug dependence, self-esteem, depression, and shared use of injecting equipment.
Results:
The sample comprised 102 people who inject drugs. Internalized stigma was higher among participants who reported being depressed in the past month, and was also associated with greater severity of drug dependence and diminished self-esteem. There was no relationship between internalized stigma and shared use of needles or other injecting equipment in the past month.
Conclusions/importance:
Findings underscore the need for further investigation of internalized stigma among people who inject drugs. In particular, future research should assess the impact of implicit (i.e., subconscious) internalized stigma on mental health.
... Implementing public health vending machines (PHVMs), sometimes referred to as harm reduction vending machines or syringe vending machines, is an evidence-based strategy for mitigating substance useassociated morbidity and mortality via the dispensation of a variety of essential supplies to people who use drugs, such as: sterile syringes and other injection equipment, HIV test kits, condoms, sharps containers, information about available health and social services, first aid kits, hygiene kits, pregnancy tests, and overdose prevention resources [21][22][23][24][25]. PHVMs are not new to the field of public health; they were first implemented in 1987 in Copenhagen, Denmark, and have subsequently been implemented in more than 14 countries [25]. ...
Introduction Implementing public health vending machines (PHVMs) is an evidence-based strategy for mitigating substance use-associated morbidity and mortality via the dispensation of essential supplies to people who use drugs, including overdose prevention resources. PHVMs have been implemented throughout the world; however, their implementation in the United States (US) is a recent phenomenon. In 2017, Trac-B Exchange (a syringe services program in Clark County, Nevada) installed three PHVMs. In 2019, naloxone dispensation was launched at PHVMs in Clark County. The purpose of this research is to examine the extent to which naloxone dispensation at PHVMs was associated with changes in opioid-involved overdose fatalities.Methods Monthly counts of opioid-involved overdose fatalities among Clark County residents that occurred from January 2015 to December 2020 were used to build an autoregressive integrated moving averages (ARIMA) model to measure the impact of naloxone dispensation at PHVMs. We forecasted the number of expected opioid-involved overdose fatalities had naloxone dispensation at PHVMs not occurred and compared to observed monthly counts. Interrupted time series analyses (ITSA) were used to evaluate the step (i.e. the immediate impact of naloxone dispensation at PHVMs on opioid-involved overdose fatalities) and slope change (i.e. changes in trend and directionality of monthly counts of opioid-involved overdose fatalities following naloxone dispensation at PHVMs).Results During the 12-months immediately following naloxone dispensation at PHVMs, our model forecasted 270 opioid-involved overdose fatalities, but death certificate data indicated only 229 occurred, suggesting an aversion of 41 deaths. ITSA identified a significant negative step change in opioid-involved overdose fatalities at the time naloxone dispensation at PHVMs was launched (B = −8.52, p = .0022) and a significant increasing slope change (B = 1.01, p
... SDM clients may have sought out alternate sources of needles/syringes that were not the NSP, such as pharmacies or mobile delivery services. Given the documented difficulties in recruiting and surveying representative samples of clients who principally utilise SDMs [18,19], it is uncertain how SDM clients may have responded to SDM access difficulties, or if any increase in injecting risk was experienced. While we did not note a statistically significant decline in NSP presentations associated with the lockdowns, this was part of an overall downward trend in presentations for the MCNSP. ...
Background
Australian harm reduction services are provided via a mix of modalities, including fixed-site needle and syringe programmes (NSP) and syringe-dispensing machines (SDMs). SDMs are cost-effective and provide 24-h anonymous access to needles/syringes, often to underserved geographic areas, and can attract clientele who may choose not to use NSPs. The introduction of COVID-19 control measures saw disruptions and adaptations to the provision of harm reduction services. It is possible that SDMs filled the gap in otherwise disrupted harm reduction services in Melbourne. In this paper, we use data from four SDMs and an NSP to explore changes to harm reduction usage during periods of COVID-19 lockdowns in Melbourne, Australia, in 2020.
Methods
Our data span September 2017–December 2020. We analysed daily counts of SDM use and monthly counts of NSP use, according to unique presentations to both. Auto-regressive integrated moving average (ARIMA) time-series models were fitted to the data with the effects of lockdowns estimated via a step function.
Results
Across the study period, we estimated 85,851 SDM presentations and 29,051 NSP presentations. Usage across both the SDMs and the NSP declined during the COVID-19 lockdowns, but only the decline in SDM usage was significant in ARIMA analysis.
Conclusions
The slight, but significant decline in SDM use suggests barriers to access, though this may have been mitigated by SDM users acquiring needles/syringes from other sources. The decline, however, may be a concern if it led to lowered needle/syringe coverage and a subsequent increase in injecting risk. Further work is needed to properly explore potential changes in preference for needle/syringe acquisition site and associated barriers. Importantly, this work adds to the body of literature around the impacts of COVID-19 on harm reduction provision and potential areas of improvement.
... In addition to SSPs, other public health strategies communities may consider implementing to ensure access to sterile injection equipment and minimize COVID-19 risks. For example, implementing public health vending machines, sometimes referred to as syringe vending machines, may hold promise for increasing access to harm reduction resources for populations underserved by the more traditional SSP model [22,23]. Mail-based supply distribution may also be of public health utility, particularly for meeting the needs of PWID residing in isolated areas with limited SSP access [24]. ...
Background
The coronavirus pandemic (COVID-19) exacerbated risks for adverse health consequences among people who inject drugs by reducing access to sterile injection equipment, HIV testing, and syringe services programs (SSPs). Several decades of research demonstrate the public health benefits of SSP implementation; however, existing evidence primarily reflects studies conducted in metropolitan areas and before the COVID-19 pandemic.
Objectives
We aim to explore how the COVID-19 pandemic affected SSP operations in rural Kentucky counties.
Methods
In late 2020, we conducted eighteen in-depth, semi-structured interviews with persons (10 women, 8 men) involved in SSP implementation in rural Kentucky counties. The interview guide broadly explored the barriers and facilitators to SSP implementation in rural communities; participants were also asked to describe how COVID-19 affected SSP operations.
Results
Participants emphasized the need to continue providing SSP-related services throughout the pandemic. COVID-19 mitigation strategies (e.g., masking, social distancing, pre-packing sterile injection equipment) limited relationship building between staff and clients and, more broadly, the pandemic adversely affected overall program expansion, momentum building, and coalition building. However, participants offered multiple examples of innovative solutions to the myriad of obstacles the pandemic presented.
Conclusion
The COVID-19 pandemic impacted SSP operations throughout rural Kentucky. Despite challenges, participants reported that providing SSP services remained paramount. Diverse adaptative strategies were employed to ensure continuation of essential SSP services, demonstrating the commitment and ingenuity of program staff. Given that SSPs are essential for preventing adverse injection drug use-associated health consequences, further resources should be invested in SSP operations to ensure service delivery is not negatively affected by co-occurring crises.
... SVM supply sterile needles and syringes and other injection paraphernalia, condoms, risk reduction and other health information. Available evidence shows that in addition to providing 24/7 access for regular NSP service users, SVM are successful in reaching sub-groups that for a variety of reasons do not normally attend fixed site NSPs, such as younger PWIDs and women ( Cama et al., 2014 ;Islam & Conigrave, 2007a , b ;Jones et al., 2010 ;Moatti et al., 2001 ). Nonstigmatized access to sterile equipment, anonymity and privacy have been reported as important advantages of SVM ( Government of Western Australia, 2014 ;McDonald, 2007 ;Otiashvili et al., 2019 ). ...
Background
Syringe vending machines (SVM) have proven to be an effective vehicle for providing an uninterrupted supply of sterile equipment to PWID, but they have not been implemented or disseminated broadly. The aim of this study was to implement and evaluate outcomes of introducing SVM in Tbilisi, Georgia.
Methods
We installed SVM at five HIV prevention sites in 10 locations in Tbilisi, Georgia and studied implementation over 20 months. We used the RE-AIM framework to assess outcomes across four RE-AIM domains: reach, effectiveness at providing syringe access, adoption and implementation.
Results
Reach. SVM reached 8% of the target population. Effectiveness at Providing Syringe Access. SVM dispensed 14% of all syringes distributed by HIV prevention services. Using SVM was associated with PWID receiving more sterile syringes from HIV prevention outlets. Adoption. All HIV prevention sites (N=5) invited to implement SVM agreed to participate. Sixty one percent of PWID who received SVM access cards used SVM at least once. Women and young PWID were more likely to use SVM compared to other PWID. Implementation. At some sites adherence of the outreach staff to the operational protocol was suboptimal.
Conclusions
SVM are an acceptable, feasible and effective intervention for improving access to sterile injection equipment for PWID. Future research will need to elaborate approaches to build the sense of ownership and improve motivation of the field staff to engage with the new intervention, and to examine strategies for attracting groups of PWID who are not in contact with prevention and treatment services.
... SVMs supply sterile needles and syringes and other injection paraphernalia, condoms, risk reduction and other health information, and contact information for available services, and other minor health supplies. Although evidence on effectiveness is limited, available evidence shows that in addition to providing 24/7 access for regular NSP service users, SVMs are successful in reaching sub-groups that for a variety of reasons do not normally attend fixed site NSPs, such as younger PWIDs and women [26][27][28][29][30]. Non-stigmatized access to sterile equipment, anonymity, and privacy has been reported as important advantages of SVM [31,32]. ...
Background
The growing HIV epidemic in Eastern Europe and Central Asia has been driven by high rates of injection drug use. The Republic of Georgia has among the highest injection drug use rates globally, with a prevalence of 2.24%. The reach of evidence-based HIV prevention interventions like needle and syringe programs (NSP) among people who inject drugs (PWID) has remained below rates that could significantly impact the epidemic. Syringe vending machines (SVM) are an effective and cost-effective supplement to standard NSP; if acceptable to PWID, SVM could reach hard-to-reach PWID and cover geographic areas where fixed or mobile NSPs do not operate. The aim of this study was to assess the perceived acceptability of SVM among out-of-service (harm reduction or substance use treatment) PWID in Tbilisi, Georgia.
Methodology
Participants were recruited using respondent-driven sampling (RDS) to participate in cross-sectional, face-to-face interviews. We conducted individual interviews using a structured questionnaire that covered participants’ socio-demographics, drug use practices, and perceived acceptability of SVM. Uni-variate analyses were employed for data analysis.
Results
The final sample (n = 149) was almost exclusively male with a mean age of 42.2 years and mean years of injection drug use of 14.4 years. Heroin, buprenorphine, and stimulants were the main drugs injected. Eighty-five percent of the sample had never received any harm reduction services, and 30% had never been tested for HIV. Fifteen percent of the sample reported sharing injection equipment with others during last month. All but one participant agreed that PWID would benefit from SVM and 145 (97%) said they would personally use SVM. Ninety percent of those sampled stated that they would use HIV self-tests if available from vending machines. The most highly endorsed features of SVM were provision of free injection equipment, no need to deal with pharmacies, uninterrupted 24/7 access, and availability of HIV self-testing kits.
Discussion
Perceived acceptability of syringe vending machines was extremely high among PWID not currently receiving any harm reduction or treatment services, with strong support indicated for uninterrupted free access to sterile injection equipment, privacy, and anonymity. Introducing SVM in Georgia holds the potential to deliver significant public health benefits by attracting hard-to-reach PWID, reducing unsafe injection behavior, and contributing to HIV testing uptake and linkage to care.
... There is a need to employ strategies to ensure that rural PWID access as much sterile equipment as needed to prevent blood-borne viral infections particularly for Aboriginal people who are reportedly more likely to share injecting equipment and are at a greater risk of blood-borne virus infection, such as hepatitis C virus (HCV). 12 Although the dimensions of access 13 to sterile injecting equipment have been investigated from the point of metropolitan PWID, [14][15][16] much less attention has been given in the literature to rural PWID. 17 Therefore, motivated by the need for a greater understanding of the needs and expectations of rural PWID in relation to the ease and acceptability of access to injecting equipment in one particular rural area of New South Wales (NSW), Australia, a survey with service users was undertaken. ...
Objective:
To better understand issues related to access to injecting equipment for people who inject drugs (PWID) in a rural area of New South Wales (NSW), Australia.
Design:
Cross-sectional face-to-face survey using convenience and snowball sampling.
Setting:
Six regional and rural population centres in Northern NSW, within the Hunter New England Local Health District.
Participants:
The sample included 190 PWID who had accessed a needle and syringe program outlet within 4 weeks of the survey.
Main outcome measures:
Data include demographic information, preferred location for accessing injecting equipment, reasons for that preference, whether they obtained enough equipment, travelling distance to an NSP and self-reported hepatitis C virus status.
Results:
Sixty percent self-identified as Aboriginal people. The median age of respondents was 32 years and 60% were men. A significantly larger proportion (P < 0.05) of the Aboriginal respondents were women (27% versus 11.6%) and younger (37.6 versus 12.7%) compared to non-Aboriginal respondents. Most preferred to access injecting equipment at a community health facility (62.6%), as opposed to other secondary outlets, where they gained enough equipment (67.4%). Just over 80% said they were tested for HCV in the past year, with about 37% told they had tested positive.
Conclusions:
There are complex dimensions affecting how rural PWID access secondary NSP outlets. Although access is similarly limited as other rural health services because of the nature of injecting drug use and sensitivities existing in rural communities, there is potential for application of unique access models, such as, promoting secondary distribution networks.
Objective:
Automatic syringe dispensing machines (ADM) have become an important adjunct to Australia's needle and syringe programs (NSP). However, concerns that they reduce face-to-face contact with health staff and other health interventions remain. We examined changes in the number of needle/syringes dispensed at an ADM and occasions of service at a co-located face-to-face NSP and targeted primary healthcare clinic during the first wave of COVID-19 restrictions.
Methods:
We reviewed data from an inner-city harm reduction program during the study period of April 2020 to March 2021 compared to the previous year. Multivariable linear regression models were used to estimate the association between occasions of service and equipment distribution.
Results:
ADM-dispensed equipment increased significantly by 41.1%, while face-to-face NSP occasions decreased by 16.2%. Occasions provided by the targeted primary healthcare clinic increased by 59.7% per month.
Conclusion:
We have shown that 24-hour ADM access did not adversely affect the number of people using targeted primary healthcare when provided within close proximity. Implication for public health: These findings reinforce the demand for 24-hour needle/syringe access and can be used to support the expanded access to ADMs, especially where people who inject drugs (PWID) have access to appropriate healthcare.
Background:
Extended distribution refers to the practice whereby people who inject drugs pass on sterile injecting equipment to their networks and can be a means to access people who inject drugs who do not attend state-sanctioned needle and syringe programs. While it is legal, to possess a sterile syringe for the purpose of injecting drugs in New South Wales, Australia, it is a criminal offence to pass this equipment on for others to use. In 2013 a pilot project was established to trial the authorization of "extended" peer distribution. This research describes patterns of distribution among attendees participating in this trial.
Methods:
A cross-sectional survey was conducted during one week in October 2014 of the trial with 200 clients. The survey focused on the extent, characteristics, and perceived risks and benefits of extended distribution practices within peer groups.
Results:
Extended distribution is widespread, not in an organized or intentional manner but as a consequence of day-to-day drug using activities. The profiles of those who do and do not distribute were similar. Willingness to distribute small quantities of equipment to others was higher than willingness to distribute larger quantities, and willingness to distribute was related to perceived benefits of extended distribution. Police scrutiny was a key reason for not wanting to distribute.
Conclusion:
Extended peer distribution is widespread though mostly not organized. This study supports the evidence that drug users act responsibly to prevent harm and promote the use of sterile equipment among their peers.
Rates of hepatitis C virus transmission among people who inject drugs in Australia remain high despite decades of prevention education. A key site of transmission is the sharing of injecting equipment within sexual partnerships. Responsibility for avoiding transmission has long been understood individually, as have the measures designed to help individuals fulfil this responsibility, such as the distribution of sterile injecting equipment. This individualising tendency has been criticised for placing an unfair level of responsibility on poorly resourced, marginalised people and ignoring the social nature of injecting drug use and related health care. Likewise, although research has demonstrated that injecting drug use is gendered, gender and sexual partnerships remain marginal to health promotion efforts. In this article, we address these weaknesses, drawing on a qualitative, interview-based project that explored equipment sharing within (hetero)sexual partnerships. In conducting our analysis, we explore a key theme that emerged in discussions about accessing and sharing injecting equipment, that of convenience, using critical marketing theory to understand this theme. In particular, we investigate the issues of convenience that affect the use of sterile injecting equipment, the many factors that shape convenience itself, and the aspects of equipment use that go beyond convenience and into the realm of intimacy and meaning. We conclude that injecting equipment needs to be both meaningful and convenient if sharing within partnerships is to be reduced further.
Background
Syringe-dispensing machines (SDM) provide syringes at any time even to hard-to-reach injecting drug users (IDUs). They represent an important harm reduction strategy in large populated urban areas such as Paris. We analyzed the performance of one of the world's largest SDM schemes based in Paris over 12 years to understand its efficiency and its limitations, to answer public and stakeholder concerns and optimize its outputs.
Methods
Parisian syringe dispensing and exchange machines were monitored as well as their sharp disposals and associated bins over a 12-year period. Moreover, mechanical counting devices were installed on specific syringe-dispensing/exchange machines to record the characteristics of the exchange process.
Results
Distribution and needle exchange have risen steadily by 202% for the distribution and 2,000% for syringe recovery even without a coin counterpart. However, 2 machines out of 34 generate 50% of the total activity of the scheme. It takes 14 s for an IDU to collect a syringe, while the average user takes 3.76 syringes per session 20 min apart. Interestingly, collection time stops early in the evening (19 h) for the entire night.
Conclusions
SDMs had an increasing distribution role during daytime as part of the harm reduction strategy in Paris with efficient recycling capacities of used syringes and a limited number of kits collected by IDU. Using counting devices to monitor Syringe Exchange Programs (SEPs) is a very helpful tool to optimize use and answer public and stakeholder concerns.
From a process evaluation, participants in San Francisco's syringe exchange program (SEP) are described. Three groups, primary, secondary, and nonexchangers, were interviewed for a total of 244 study participants recruited from eight needle exchange sessions. Fifty percent of all primary exchangers exchanged for one or more injecting drug user(s) (IDUs). Three general routes of syringe distribution were identified between primary and secondary exchangers: between close friends and lovers; for people who lived in close proximity to them; and with customers who bought drugs from them. Focusing on why some go to SEPs and why some rely on others to go for them, findings are summarized primarily as the barriers for not attending SEPs, including exposure, legal status, illness, drug lifestyle, and conflicts with service provision. The secondary exchangers had similar risk reduction profiles to the SEP users that overall were better than the nonexchangers. For example, they shared syringes and cookers significantly fewer times than nonexchangers. The results demonstrate that these client-provided exchanges enable the SEP to overcome injection drug users' obstacles to program attendance, thereby reaching even hard to access members of IDU populations. We found the effects of these client-provided services to be positive for the larger IDU population.
People living with hepatitis C are a highly marginalised population who may not readily access health care. Existing models of hepatitis C care may not meet the needs of these patients. This research evaluates the experiences of patients attending an innovative hepatitis C clinic that offers integrated care and service delivery.
Surveys were completed by 120 clients and comprised of questions relating to changes in lifestyle habits since attending the clinic, hepatitis C knowledge, hepatitis C treatment and experiences with health care staff at the clinic.
The majority of respondents indicated that attendance at the clinic has provided them with the information to better manage their hepatitis C and had given them confidence to make lifestyle changes. Participants demonstrated a very high knowledge of hepatitis C and reported experiencing a less discriminatory environment at the clinic compared to other health care settings. Respondents who had been attending the clinic for more than 6 months were significantly more likely to indicate a desire to commence hepatitis C treatment over the next 5 years.
The findings point to the importance of integrated care in the community setting in providing clients with a positive experience of health care, which appears to increase their skills and desire to better manage their hepatitis C.
Objective:
To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).
Design/methods:
A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.
Results:
We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19 000-77 000 cases) during 2000-2010, leading to 20 000-66 000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.
Conclusion:
Australia's early introduction and high coverage of NSPs has significantly reduced the prevalence of HIV and HCV among IDUs. NSPs are a cost-effective public health strategy and will result in substantial net cost savings in the future.
Syringe vending machines (SVMs) have been trialled in Canberra, Australian Capital Territory, Australia, as an intervention aiming to increase the availability of sterile injecting equipment for use by IDUs. This study evaluated the 12-month trial.
A utilisation-focused evaluation model, with both formative and summative components, was employed. Four SVMs were installed, each dispensing packs containing four 1 mL syringes and associated injecting paraphernalia. The trial participants were the clients of the SVMs and other key informants. The core measurements used were the number of syringes dispensed in Canberra by SVMs and other outlets, SVM clients' demographics and experiences of and attitudes towards SVMs, perceived impacts of SVMs on needle sharing, unsafe disposal of used syringes in the vicinity of SVMs, and community and stakeholder attitudes.
The trial was implemented successfully, with no adverse consequences identified. The SVMs appear to be serving both the usual clients of the other outlets for sterile injecting equipment (community pharmacies and the Needle Syringe Program outlets) and others who are reluctant to use such outlets or find them inconvenient. The out-of-business-hours provision of syringes through the SVMs was particularly welcomed by both SVM clients and other stakeholders. The continuing operation of the initial four SVMs is widely supported, and additional machines are requested by clients and others.
Owing to the success of the trial in terms of feasibility and outcomes for both IDUs and for the broader community, it is desirable that providing sterile injecting equipment through SVMs continues and be expanded as an integral component of harm reduction strategies.
This study evaluated the usefulness of vending machines in providing injection drug users with access to sterile syringes in Marseille, France.
Self-administered questionnaires were offered to 485 injection drug users obtaining syringes from 32 pharmacies, 4 needle exchange programs, and 3 vending machines.
Of the 343 respondents (response rate = 70.7%), 21.3% used the vending machines as their primary source of syringes. Primary users of vending machines were more likely than primary users of other sources to be younger than 30 years, to report no history of drug maintenance treatment, and to report no sharing of needles or injection paraphernalia.
Vending machines may be an appropriate strategy for providing access to syringes for younger injection drug users, who have typically avoided needle exchange programs and pharmacies.
This review examines recent research into modalities for improving access to sterile syringes for injection drug users (IDUs) as a means to reduce human immunodeficiency virus (HIV) transmission. English language studies with empirical data were collected through Uncover reports and MedLine searches from 1998 to 2000. Although syringe-exchange programs are the most established and well-evaluated means of improving access to sterile syringes, research on alternative modalities-such as pharmacy sale, injector-specific packs, mass distribution, and vending machines-and on coverage of special populations suggests the need to pursue multiple avenues of increasing syringe availability simultaneously and, in particular, to explore modalities other than syringe-exchange programs when HIV incidence is under control. The impacts on HIV transmission of cocaine injection and sex with IDUs need to be explored further. Finally, any evidence of declining hepatitis C incidence among young IDUs might serve as a surrogate for a sharp drop in injection-related HIV risk behaviors in that population.
This study used meta-analysis to examine cumulatively needle exchange program (NEP) change/comparison data from 47 studies between 1988 and 2001, based on data collected between 1986 and 1997. The research question posed was: Is NEP attendance associated with reductions in risky needle-related behaviors? Results indicated that needle sharing (r = -.189), variations on the outcome measure of needle sharing (r = -.161), and needle lending/borrowing (r = -.194) consistently declined among NEP attenders, suggesting the NEPs are effective in reducing risky needle-related behaviors of IDUs. The meta-analytic results lend support to the harm-reduction philosophy often used as the rationale for the establishment and maintenance of NEPs.
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.
The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among injecting drug users (IDUs). NSPs incorporating additional harm reduction strategies have been highlighted as an approach that may impact on HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of NSPs are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data
extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different NSP settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger IDUs and IDUs with higher risk profiles. Two studies of interventions aimed at encouraging IDUs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in NSPs was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among IDUs. Currently, it is difficult to draw conclusions on ‘what works best’ within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery NSPs impact on effectiveness.
Objective: To examine the effectiveness of needle and syringe programmes (NSPs) in preventing HIV transmission among injecting drug users (IDUs). Methods: An ecological study design was used to determine change in HIV prevalence among injecting drug users between cities with and without NSPs. Several data sources, such as electronic journal databases, surveillance reports, websites, and index review of relevant journals, were used to identify studies of HIV seroprevalence among IDUs, and presence of NSPs. The rate of change in HIV prevalence was estimated by regression analysis. Results: There were 778 years of data from 99 cities globally included in the analysis. HIV prevalence decreased by 18.6% per annum in cities that introduce NSPs, and increased by 8.1% in cities that had never introduced NSPs (mean difference −24.7% [95% CI: −43.8, 0.5%], P = 0.06). The mean difference was –33% when comparison was weighted to one over the variance of the regression estimator (29% decrease in cities with NSPs and 5% increase in cities without NSPs, P < 0.001). When analysis was restricted to cities with first HIV seroprevalence less than 10%, the average annual change in seroprevalence was 18% lower in cities with NSPs (P = 0.03). Conclusions: Despite the inherent limitations within an ecological study design, the study provides additional evidence that NSPs reduce transmission of HIV infection. The rapid spread of HIV among IDU populations and increasing rates of injecting in many countries calls for scaling up of NSPs as well as other harm reduction strategies. Crown Copyright © 2003 Published by Elsevier B.V. All rights reserved.
Hepatitis C virus (HCV) is silently becoming a major public health problem. Currently, no validated HCV knowledge measures exist. This study aimed to develop and validate a brief measure to assess general knowledge about HCV risk factors, modes of transmissions, and treatment options. A total of 406 individuals participated in this cross-sectional study. All participants completed the proposed 19-item Brief HCV Knowledge Scale. Participants were: HCV mono-infected patients (n = 83), HCV–human immunodeficiency virus (HIV) co-infected patients (n = 24), HIV mono-infected patients (n = 128) community healthcare workers (n = 89), and college students (n = 82). Two-week test–retest data were collected for the college student sample. Psychometric evaluation of the proposed scale demonstrated high levels of validity (content and construct validity) and reliability (internal consistency and retest stability). Factor analysis indicated a one-factor solution, which accounted for 49% of the variance. HCV knowledge was positively correlated with length of time since HCV diagnosis (r = 0.29, p < 0.05). HCV treatment-experienced patients obtained significantly higher HCV knowledge scores (82% correct) than HCV treatment-naïve patients (72% correct) (p < 0.05). HCV knowledge in College students (43% correct) and HIV patients (54% correct) was significantly lower than in HCV patients (77% correct) and community healthcare workers (80% correct) (p < 0.001). Community workers’ HCV knowledge was positively correlated with years of HCV work experience (r = 0.30, p < 0.01). This self-administered Brief HCV Knowledge scale has high levels of validity and reliability across patient, healthcare provider and college student populations. It has valuable applications as a clinical teaching tool with patients and healthcare providers and could be used as an outcome indicator in novel HCV educational intervention studies.
Marginalised populations, including at risk young people, injecting drug users and sex workers, are vulnerable to a range of preventable health related problems, yet they often have difficulty accessing mainstream primary healthcare services. The Kirketon Road Centre in Kings Cross, Sydney, has been providing accessible and acceptable primary healthcare to these populations for the past 25 years. However, limited scientific evidence for the effectiveness of targeted primary healthcare services for this group of patients makes competing for scarce public health resources difficult. This article outlines some of the issues faced by these populations when accessing traditional health services and describes the work of the Kirketon Road Centre.
In a bid to increase the anonymous and non-stigmatized access to sterile injecting equipment for injecting drug users (IDUs) and provide extended hours availability, syringe vending machines were introduced into needle syringe programmes (NSPs) in several countries. This article examines, based on existing international experience, the observed advantages and disadvantages of these machines. Despite the disadvantage associated with their lack of ability to establish contact between health staff and IDUs, syringe vending machines appear to largely enhance access to sterile equipment, in particular to the hidden and high-risk group of IDUs, who for several reasons cannot or do not use existing staffed NSPs. Vending machines that dispense Fitpacks mechanically may also help reduce unsafe disposal of used equipment. As these machines make services more accessible and acceptable to the users and complement other modes of NSPs, they are gradually gaining widespread acceptance in an increasing number of countries.
The United States (U.S.) approved use of federal funds for needle and syringe programs (NSPs) in December 2009. This study compares syringe disposal practices in a U.S. city with NSPs to a U.S. city without NSPs by examining the prevalence of improperly discarded syringes in public places and the self-reported syringe disposal practices of injection drug users (IDUs) in the two cities.
We conducted visual inspection walkthroughs in a random sample of the top-quartile of drug-affected neighborhoods in San Francisco, California (a city with NSPs) and Miami, Florida (a city without NSPs). We also conducted quantitative interviews with adult IDUs in San Francisco (N=602) and Miami (N=448).
In the visual inspections, we found 44 syringes/1000 census blocks in San Francisco, and 371 syringes/1000 census blocks in Miami. Survey results showed that in San Francisco 13% of syringes IDUs reported using in the 30 days preceding the study interviews were disposed of improperly versus 95% of syringes by IDUs in Miami. In multivariable logistic regression analysis, IDUs in Miami had over 34 times the adjusted odds of public syringe disposal relative to IDUs in San Francisco (adjusted odds ratio=34.2, 95% CI=21.92, 53.47).
We found eight-fold more improperly disposed syringes on walkthroughs in the city without NSPs compared to the city with NSPs, which was corroborated by survey data. NSPs may help IDUs dispose of their syringes safely in cities with large numbers of IDUs.
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.
(i) To compare indirect estimation methods to obtain mean injecting drug use (IDU) prevalence for a confined geographic location; and (ii) to use these estimates to calculate IDU and injection coverage of a medically supervised injecting facility.
Multiple indirect prevalence estimation methods.
Kings Cross, Sydney, Australia.
IDUs residing in Kings Cross area postcodes recorded in surveillance data of the Sydney Medically Supervised Injecting Centre (MSIC) between November 2001 and October 2002.
Two closed and one open capture-recapture (CRC) models (Poisson regression, truncated Poisson and Jolly-Seber, respectively) were fitted to the observed data. Multiplier estimates were derived from opioid overdose mortality data and a cross-sectional survey of needle and syringe programme attendees. MSIC client injection frequency and the number of needles and syringes distributed in the study area were used to estimate injection prevalence and injection coverage.
From three convergent estimates, the mean estimated size of the IDU population aged 15-54 years was 1103 (range 877-1288), yielding a population prevalence of 3.6% (2.9-4.3%). Mean IDU coverage was 70.7% (range 59.1-86.7%) and the mean adjusted injection coverage was 8.8% (range 7.3-10.8%). Approximately 11.3% of the total IDU population were estimated to be new entrants to the population per month.
Credible local area IDU prevalence estimates using MSIC surveillance data were obtained. MSIC appears to achieve high coverage of the local IDU population, although only an estimated one in 10 injections occurs at MSIC. Future prevalence estimation efforts should incorporate open models to capture the dynamic nature of IDU populations.
Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs.
We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes.
By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per IDU per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per IDU per year), Middle East and north Africa (0.5 needle-syringes per IDU per year), and sub-Saharan Africa (0.1 needle-syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per IDU per month, there were eight recipients (6-12) of OST per 100 IDUs, and four IDUs (range 2-18) received ART per 100 HIV-positive IDUs.
Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population.
UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council.
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).
Needle-exchange programmes (NEPs) are potentially a key strategy for containing the spread of HIV infection among injecting drug users, but their implementation has been limited by uncertainty about their effectiveness. We used an ecological study design to compare changes over time in HIV seroprevalence in injecting drug users worldwide, for cities with and without NEPs.
Published reports of HIV seroprevalence in injecting drug users were identified, and unpublished information on HIV seroprevalence for injecting drug users entering drug treatment in the USA between 1988 and 1993 was obtained from the Centers for Disease Control and Prevention. Details of the implementation of NEPs were obtained from published reports and experts. For each of the 81 cities with HIV seroprevalence data from more than 1 year and NEP implementation details, the rate of change of seroprevalence was estimated by regression analysis. The average difference in this rate for cities with and without NEPs was calculated.
On average, seroprevalence increased by 5.9% per year in the 52 cities without NEPs, and decreased by 5.8% per year in the 29 cities with NEPs. The average annual change in seroprevalence was 11% lower in cities with NEPs (95% CI -17.6 to -3.9, p = 0.004).
A plausible explanation for this difference is that NEPs led to a reduction in HIV incidence among injecting drug users. Despite the possibility of confounding, our results, together with the clear theoretical mechanisms by which NEPs could reduce HIV incidence, strongly support the view that NEPs are effective.
The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. It was found that IDUs who had formerly been exchange users were more likely than never-exchangers to report a substantial (> or= 75%) reduction in injection (ARR = 2.85, 95% confidence limit [CL] 1.47-5.51), to stop injecting altogether (ARR = 3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.
In Marseille, southeastern France, HIV prevention programs for injection drug users (IDUs) simultaneously include access to sterile syringes through needle exchange programs (NEPs), legal pharmacy sales and, since 1996, vending machines that mechanically exchange new syringes for used ones. The purpose of this study was to compare the characteristics of IDUs according to the site where they last obtained new syringes.
During 3 days in September 1997, all IDUs who obtained syringes from 32 pharmacies, four NEPs and three vending machines were offered the opportunity to complete a self-administered questionnaire on demographics, drug use characteristics and program utilization.
Of 485 individuals approached, the number who completed the questionnaire was 141 in pharmacies, 114 in NEPs and 88 at vending machines (response rate = 70.7%). Compared to NEP users, vending machine users were younger and less likely to be enrolled in a methadone program or to report being HIV infected, but more likely to misuse buprenorphine. They also had lower financial resources and were less likely to be heroin injectors than both pharmacy and NEP users.
Our results suggest that vending machines attract a very different group of IDUs than NEPs, and that both programs are useful adjuncts to legal pharmacy sales for covering the needs of IDUs for sterile syringes in a single city. Assessment of the effectiveness and cost-effectiveness of combining such programs for the prevention of HIV and other infectious diseases among IDUs requires further comparative research.
To assess associations between needle exchange program (NEP) use and drug injection risk practices.
Between 1997-2000, injecting drug users (IDUs) in Chicago were recruited from NEPs and an area with no NEP, interviewed about risk practices, and counseled and tested for HIV. The risk practices of "regular NEP users"--those who obtained at least half of their needles from an NEP (n = 558)--were compared with those of IDUs who did not use an NEP (n = 175).
In multivariate analysis, regular NEP users, compared with NEP nonusers, were less likely to receptively share needles (adjusted odds ratio [AOR], 0.30; 95% CI, 0.19-0.46); lend used needles (AOR, 0.47; 95% CI, 0.31-0.71); share cookers (AOR, 0.39; 95% CI, 0.25-0.61), cottons (AOR, 0.48; 95% CI, 0.32-0.72), or water (AOR, 0.41; 95% CI, 0.27-0.63); or use a needle for >1 injection (0.15; 95% CI, 0.08-0.27). Among those who shared needles, regular NEP users were significantly more likely to do so for a smaller proportion of injections, with fewer partners and persons socially closer, and to have always bleached used needles before injecting.
Regular NEP use is associated with less frequent and lower risk HIV injection risk practices.
This study examined the relationship between Needle Exchange Program (NEP) utilization and treatment entry in Baltimore, Maryland. The sample was composed of 440 drug injectors with disadvantaged backgrounds. Face-to-face interviews, focusing on HIV risk behaviors, drug use, and health, were conducted between June 1997 and June 2002. Multivariate logistic analyses revealed that entering treatment was associated with NEP utilization, being female, and being HIV-positive. Cocaine sniffers/snorters were less likely to enter treatment. These findings highlight the importance of NEPs in linking injectors to treatment. These data also suggest that treatment needs to address co-occurring problems, like HIV and mental illness. Study limitations are noted.
The study examines risk behaviours of the users of syringe dispensing machines (SDMs) and evaluates the usefulness of these machines in providing injecting drug users (IDUs) with sterile injecting equipment.
Self-administered questionnaires were used among users of SDMs in an Area Health Service of Sydney.
The majority of the 167 participants reported being happy with the quality of the SDM services. Problems identified with machines were that they were often broken or jammed (32.8% respondents), not in the right place (21.9%) or require money (16.7%). Just over half (50.9%) of the IDUs use SDMs only from 5 p.m. to 9 a.m., the time when almost all other outlets for accessing sterile injecting equipment remain closed. Relatively young IDUs (age < or = 30 years) were more likely to prefer SDMs over staffed needle syringe programmes (NSPs) compared with older users (age > 30) and to identify stigma (a desire to hide their identity or not liking the way people treat them at staffed NSPs or chemists) as a main reason for using these machines. Primary users of SDMs do not differ from primary users of NSP/chemists in terms of sharing of needles. Those users who had shared in the last month were nearly four times as likely to have never used condoms in sexual encounters over that period (95% confidence interval: 1.2 - 14.5).
SDMs appear to complement other outlets of NSPs. Providing free-of-cost equipment from SDMs should be considered carefully, as needing money to buy equipment was a reason given for sharing of needles by 35% of those who shared.
Estimating the cost-effectiveness of needle-syringe programs in Australia
- J A Kwon
- J Anderson
- C C Kerr
- H H Thein
- L Zang
- J Iverson
- D P Wilson