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CORK Bibliography: Syringe/Needle Exchange

57 citations. January 2009 to present

Prepared: September 2012

Aalto M; Visapaa JP; Halme JT; Fabritius C; Salaspuro M. Effectiveness of buprenorphine maintenance treatment as compared to a syringe exchange program among buprenorphine misusing opioid-dependent patients. Nordic Journal of Psychiatry 65(4): 238-243, 2011. (21 refs.)

Aims: To investigate the effectiveness of buprenorphine maintenance treatment (BMT) among opioid dependents who are mainly misusing buprenorphine intravenously. Methods: The study was a prospective naturalistic follow-up with a non-randomized control group. In Finland, 30 opioid dependents reporting previous misuse of buprenorphine and participating in the outpatient BMT and 30 matched controls participating in a syringe exchange program (SEP) were followed. Based on the evidence for the superiority of maintenance treatment, randomization was not done. The effectiveness was evaluated by retention rate, European Addiction Severity Index (EuropASI) interviews, Beck Depression Inventory (BDI), visual analogue scale for quality of life (VAS) during the 2-year follow-up and mortality rates during the 3-year follow-up. Because of drop-outs in the SEP group, only the BMT group was interviewed at 24 months. Results: At 3 months, the retention rate of the BMT group was 100% and of the SEP group 47%. At 12 months, the corresponding percentages were 83% and 37%. The total EuropASI composite score improved significantly only in the BMT group. In the BMT group, the BDI total score and VAS scales for quality of life improved significantly more than they did in the SEP group. During 3-year follow-up, four patients in the SEP died and none in the BMT. Conclusions: BMT appears to be an effective treatment for opioid dependents using mainly buprenorphine intravenously. On the other hand, bare SEP appears to result in high drop-out, not significant improvements and deaths.

Arnaud S; Jeannin A; Dubois-Arber F. Estimating national-level syringe availability to injecting drug users and injection coverage: Switzerland, 1996-2006. International Journal of Drug Policy 22(3): 226-232, 2011. (38 refs.)

Background: Measuring syringe availability and coverage is essential in the assessment of HIV/AIDS risk reduction policies. Estimates of syringe availability and coverage were produced for the years 1996 and 2006, based on all relevant available national-level aggregated data from published sources. Methods: We defined availability as the total monthly number of syringes provided by harm reduction system divided by the estimated number of injecting drug users (IDU), and defined coverage as the proportion of injections performed with a new syringe, at national level (total supply over total demand). Estimates of supply of syringes were derived from the national monitoring system, including needle and syringe programmes (NSP), pharmacies, and medically prescribed heroin programmes. Estimates of syringe demand were based on the number of injections performed by IDU derived from surveys of low threshold facilities for drug users (LTF) with NSP combined with the number of IDU. This number was estimated by two methods combining estimates of heroin users (multiple estimation method) and (a) the number of IDU in methadone treatment (MT) (non-injectors) or (b) the proportion of injectors amongst LTF attendees. Central estimates and ranges were obtained for availability and coverage. Results: The estimated number of IDU decreased markedly according to both methods. The MT-based method (from 14,818 to 4809) showed a much greater decrease and smaller size of the IDU population compared to the LTF-based method (from 24,510 to 12,320). Availability and coverage estimates are higher with the MT-based method. For 1996, central estimates of syringe availability were 30.5 and 18.4 per IDU per month: for 2006, they were 76.5 and 29.9. There were 4 central estimates of coverage. For 1996 they ranged from 24.3% to 43.3%, and for 2006, from 50.5% to 134.3%. Conclusion: Although 2006 estimates overlap 1996 estimates, the results suggest a shift to improved syringe availability and coverage over time.

Bachireddy C; Bazazi AR; Kavasery R; Govindasamy S; Kamarulzaman A; Altice FL. Attitudes toward opioid substitution therapy and pre-incarceration HIV transmission behaviors among HIV-infected prisoners in Malaysia: Implications for secondary prevention. Drug and Alcohol Dependence 116(1-3): 151-157, 2011. (56 refs.)

Background: Pre-incarceration HIV transmission behaviors and current attitudes toward opioid substitution therapy (OST) among HIV-infected male prisoners in Malaysia have important implications for secondary HIV prevention efforts. Methods: In June 2007, 102 HIV-infected male prisoners within 6 months of community-release were anonymously surveyed in Kota Bharu, Malaysia. Results: Nearly all subjects (95%) met criteria for opioid dependence. Overall, 66% of participants reported sharing needles, and 37% reported unprotected sex in the 30 days prior to incarceration. During this period, 77% reported injection drug use, with 71% injecting daily and 65% injecting more than one substance. Injection of buprenorphine (28%), benzodiazepines (28%) and methamphetamines (49%) was reported. Nearly all (97%) of those reporting unprotected sex did so with someone not known to be HIV-infected. While 51% believed that opioid substitution therapy COST) would be helpful, only 33% believed they needed it to prevent relapse after prison release. Most participants (70%) expressed interest in learning more about OST. Those reporting the highest injection risks were more likely to believe OST would be helpful (p < 0.05), to believe that it was needed to prevent relapse post-release (p < 0.05), and to express interest in learning more about OST (p < 0.01). Conclusions: Secondary HIV prevention among prisoners in Malaysia is crucial to reduce community HIV transmission after release. Effectively reducing HIV risk associated with opioid injection will require OST expansion, including social marketing to improve its acceptability and careful monitoring. Access to sterile injection equipment, particularly for non-opioid injectors, and behavioral interventions that reduce sexual risk will also be required.

Barrio G; Bravo MJ; Brugal MT; Diez M; Regidor E; Belza MJ. Harm reduction interventions for drug injectors or heroin users in Spain: Expanding coverage as the storm abates. Addiction 107(6): 1111-1122, 2012. (62 refs.)

Aims: To show the utility of analysing time trends of need and coverage of needle-exchange programmes (NEPs) and opioid substitution treatment (OST) to assess harm reduction policies targeting drug injectors or heroin users. Design Multiple methods applied to secondary data. Setting: Spain. Participants Thousands of drug injectors or heroin users included in administrative registers, surveys and published studies during 19872010. Measurements Coverage for the general population was calculated as the ratio between interventions provided (obtained directly from the sources) and interventions needed (estimated by multiple methods), and as the difference between the two. Timeliness was estimated by time elapsed between year of highest need and year in which coverage reached a reference level. Findings In 2010 NEPs provided 138 syringes per drug injector [95% confidence interval (CI) 100223], covering 25.7% (95% CI 18.343.3) of their need. OST coverage was 60.3% (95% CI 44.394.2). Syringe and OST provision increased between 1991 and 2001 and then declined. Syringe and OST coverage also increased substantially during this period and then stabilized, due mainly to decreases in drug injection or heroin use. Medium-level coverage for both syringes and OST was not achieved until 2000, 8 years after the peak in need (1992). Conclusions: In Spain, the expansion of harm reduction interventions was greatly delayed, although the concomitant decrease in heroin and injecting drug use led to reasonable coverage after 2000. A longitudinal measurement of need and coverage provides insight into the timeliness and potential population impact of interventions, enabling better assessment of their adequacy.

Bobashev GV; Zule WA. Modeling the effect of high dead-space syringes on the human immunodeficiency virus (HIV) epidemic among injecting drug users. Addiction 105(8): 1439-1447, 2010. (50 refs.)

Aims To illustrate the impact of different proportions of injecting drug users (IDUs) sharing high dead-space syringes (HDSS) or low dead-space syringes (LDSS) on the probability of human immunodeficiency virus (HIV) transmission; and thus the impact on injection-related HIV prevalence and incidence. Design A stochastic mathematical model was used to evaluate the impact of HDSS use in high- and low-risk IDU populations. Model parameters were obtained from peer-reviewed publications. Analytical solutions of a simplified deterministic model were obtained to explain the effect of HDSS on HIV endemic states. Findings: Simulation analysis shows that the HIV epidemic could be sustained even when a small percentage of sharing (10%) involved HDSS. The effect is much stronger in high-risk compared with low-risk populations. Steady state HIV prevalence increases with the proportion of HDSS, and for high- and low-risk populations reaches around 80% and 20%, respectively. For low-risk populations, the use of LDSS could result in the virtual elimination of HIV. These results are dependent upon an evidence-supported assumption of a significant difference in HIV transmission risk associated with HDSS versus LDSS. Conclusions: Our models suggest that injection-related HIV epidemics may not occur when most (e.g. 95% or more) IDUs use LDSS. While these results are based on indirect risk measures and a number of simplifying assumptions, the effect of blood retained in high dead-space syringes on HIV prevalence seems to be very strong, even using relatively conservative assumptions. The findings have potential implications for needle exchange programs and the types of syringes produced and distributed world-wide.

Brandeau ML; Zaric GS. Optimal investment in HIV prevention programs: More is not always better. Health Care Management Science 12(1): 27-37, 2009. (52 refs.)

This paper develops a mathematical/economic framework to address the following question: Given a particular population, a specific HIV prevention program, and a fixed amount of funds that could be invested in the program, how much money should be invested? We consider the impact of investment in a prevention program on the HIV sufficient contact rate (defined via production functions that describe the change in the sufficient contact rate as a function of expenditure on a prevention program), and the impact of changes in the sufficient contact rate on the spread of HIV (via an epidemic model). In general, the cost per HIV infection averted is not constant as the level of investment changes, so the fact that some investment in a program is cost effective does not mean that more investment in the program is cost effective. Our framework provides a formal means for determining how the cost per infection averted changes with the level of expenditure. We can use this information as follows: When the program has decreasing marginal cost per infection averted (which occurs, for example, with a growing epidemic and a prevention program with increasing returns to scale), it is optimal either to spend nothing on the program or to spend the entire budget. When the program has increasing marginal cost per infection averted (which occurs, for example, with a shrinking epidemic and a prevention program with decreasing returns to scale), it may be optimal to spend some but not all of the budget. The amount that should be spent depends on both the rate of disease spread and the production function for the prevention program. We illustrate our ideas with two examples: that of a needle exchange program, and that of a methadone maintenance program.

Carrieri MP; Desenclos JC. Expanded access to SEPs and other harm reduction measures in France. (commentary). Addiction 104(9): 1447-1448, 2009. (19 refs.)

This is a commentary on the article in this issue "Doing harm reduction better: syringe exchange in the United States" (p 1441-1446) by Des Jarlais, et al.

Coffin PO; Coffin LS; Murphy S; Jenkins LM; Golden MR. Prevalence and characteristics of femoral injection among Seattle-area injection drug users. Journal of Urban Health 89(2): 365-372, 2012. (20 refs.)

Injection drug use (IDU) into central veins, most common among long-term IDUs with no other options, can lead to severe infectious, vascular, and traumatic medical consequences. To follow-up on anecdotal reports of femoral vein injection and related medical problems in Seattle, we analyzed data from the annual survey of a community-based syringe exchange program. A total of 276 (81%) of 343 program attendees completed the survey in August 2010. Among 248 IDUs, 66% were male, 78% white, and 86% primarily injected opiates. One hundred respondents (40%) had injected into the femoral vein, 55% of whom were actively doing so, and 58% of whom reported medical complications that they attributed to the practice. Most (66%) used the femoral vein due to difficulty accessing other veins, although 61% reported other veins they could access and 67% reporting using other sites since initiating femoral injection. While injecting into muscle was more frequent among older IDUs with longer injection careers, the prevalence of femoral injection was highest among respondents in their late twenties with 2.5-6 years of injecting drugs. Multivariate analysis demonstrated an increased risk of initiating femoral injection each calendar year after 2007. Injecting into the femoral vein was also associated with white versus other race (odds ratio [OR] 2.7, 95% CI 1.3-5.4) and injection of primarily opiates versus other drugs (OR 6.3, 95% CI 1.2-32.9) and not associated with age, length of IDU career, or a history of injecting into muscle. These findings suggest a secular trend of increasing femoral injection among Seattle-area IDUs with a high rate of related medical problems. Interventions, such as education regarding the hazards of central venous injection and guidance on safe injection into peripheral veins, are needed to minimize the health consequences of femoral injection.

Cooper HLF; Bossak B; Tempalski B; Jarlais DCD; Friedman SR. Geographic approaches to quantifying the risk environment: Drug-related law enforcement and access to syringe exchange programmes. (editorial). International Journal of Drug Policy 20(3, Special Issue): 217-226, 2009. (71 refs.)

The concept of the "risk environment" - defined as the "space ... [where] factors exogenous to the individual interact to increase the chances of HIV transmission" - draws together the disciplines of public health and geography. Researchers have increasingly turned to geographic methods to quantify dimensions of the risk environment that are both structural and spatial (e.g., local poverty rates). The scientific power of the intersection between public health and geography, however, has yet to be fully mined. In particular, research on the risk environment has rarely applied geographic methods to create neighbourhood-based measures of syringe exchange programmes (SEPs) or of drug-related law enforcement activities, despite the fact that these interventions are widely conceptualized as structural and spatial in nature and are two of the most well-established dimensions of the risk environment. To strengthen research on the risk environment, this paper presents a way of using geographic methods to create neighbourhood-based measures of (1) access to SEP sites and (2) exposure to drug-related arrests, and then applies these methods to one setting (New York City [NYC]). NYC-based results identified substantial cross-neighbourhood variation in SEP site access and in exposure to drug-related arrest rates (even within the subset of neighbourhoods nominally experiencing the same drug-related police strategy). These geographic measures - grounded as they are in conceptualizations of SEPs and drug-related law enforcement strategies - can help develop new arenas of inquiry regarding the impact of these two dimensions of the risk environment on injectors' health, including exploring whether and how neighbourhood-level access to SEP sites and exposure to drug-related arrests shape a range of outcomes among local injectors.

Costenbader EC; Zule WA; Coomes CC. Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales. International Journal of Drug Policy 21(5): 425-428, 2010. (26 refs.)

Background: Injecting drug users (IDUs) are at increased risk of acquiring and transmitting HIV and other bloodborne pathogens through the multi-person use of syringes. Although research has shown that increased access to syringes through syringe exchange programs (SEPs) is an effective strategy to reduce risky injection practices many areas of the United States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies over-the-counter sales of syringes has also been shown to reduce syringe sharing. The success of pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia laws, which in turn may contribute to fear among IDUs about being caught purchasing and carrying syringes. Methods: Between 2003 and 2006, 851 out-of-treatment IDUs were recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were collected using audio-computer assisted interview (ACASI) technology. Multiple logistic regression analyses were performed to assess factors associated with purchasing syringes from pharmacies. Results: In our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes. Conclusions: Given the absence of syringe exchange programs and the relatively high prevalence of HCV and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source of syringes among African-American IDUs in this study sample is problematic. The study findings support the need for effective multilevel interventions to increase access to clean needles in this population, as well as for policy interventions, such as legalization of SEPs and elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats posed by receptive syringe sharing.

Craine N; Hickman M; Parry JV; Smith J; McDonald T; Lyons M. Characteristics of injecting drug users accessing different types of needle and syringe programme or using secondary distribution26. Journal of Public Health 32(3): 328-335, 2010. (26 refs.)

In the UK, needle and syringe programmes (NSP) are delivered via community pharmacies or substance misuse services (SMSNSP). Understanding the profile of drug injectors primarily using different sources of injecting equipment can help service design. Blood spot samples and behavioural data were collected from drug injectors and tested for antibodies to hepatitis C and hepatitis B. Data were analysed in relation to NSP use by multivariate logistic regression. Of 700 eligible individuals interviewed, 657 provided information on their main source of equipment; 26% reported pharmacy NSP, 56% SMSNSP and 18% secondary distribution. In the adjusted analysis, individuals whose main source was SMSNSP were more likely to report markers of increased risk (homelessness, groin injection, having injected > 16 days/month) and had a higher hepatitis B antibody prevalence than individuals primarily using pharmacy NSP. Individuals whose main source was secondary distribution had a different profile (e.g. they were younger, more likely to be recent onset injectors than main source SMSNSP users and less likely to report being in drug treatment). Differences exist in the populations primarily accessing different NSP and commissioning of services must reflect these differences. Injecting drug users relying on secondary exchange should be targeted to improve health service contact.

Day C; Topp L. Commentary on Turner et al. (2011): Significant global scale-up of harm reduction interventions and pragmatic research approaches needed to prevent hepatitis C transmission. (editorial). Addiction 106(11): 1989-1990, 2011. (15 refs.)

Des Jarlais DC; Arasteh K; Friedman SR. HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years. Substance Use & Misuse 46(2-3): 131-139, 2011. (55 refs.)

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.

Des Jarlais DC; Arasteh K; McKnight C; Hagan H; Perlman DC; Torian LV et al. HIV infection during limited versus combined HIV prevention programs for IDUs in New York City: The importance of transmission behaviors. Drug and Alcohol Dependence 109(1-3): 154-160, 2010. (34 refs.)

Objectives: As no single HIV prevention program has eliminated HIV transmission, there is growing interest in the effectiveness of "combined" prevention programming. To compare HIV infection among persons injecting in the initial programs environment (IPE) in New York City (self-initiated risk reduction, methadone, education/outreach, and HIV testing) to HIV infection among persons injecting in a combined programs environment (CPE) (above programs plus large-scale syringe exchange). To identify potential behavioral mechanisms through which combined programs are effective. Methods: Subjects were recruited from the Beth Israel drug detoxification program. A risk behavior questionnaire was administered and HIV testing conducted. Subjects who injected only between 1984 and 1994 (WE) were compared to subjects who injected only between 1995 and 2008 (CPE). Results: 261 IPE subjects and 1153 CPE subjects were recruited. HIV infection was significantly lower among the CPE subjects compared to WE subjects: prevalence 6% versus 21%, estimated incidence 0.3/100 person-years versus 4/100 person-years (both p < 0.001). The percentage of subjects at risk of acquiring HIV through receptive syringe sharing was similar across CPE and IPE subjects (30% versus 33%). The percentage of subjects at risk of transmitting HIV through injection-related behaviors (who were both HIV seropositive and reported passing on used needles/syringes), was much lower among the CPE subjects than among the WE subjects (1% versus 10%, p < 0.001). Conclusions: Combined prevention programs can greatly reduce HIV transmission. Reducing distributive sharing by HIV seropositive injecting drug users (IDUs) may be a critical component in reducing HIV transmission in high seroprevalence settings.

Des Jarlais DC; Arasteh K; McKnight C; Ringer M; Friedman SR. Syringe exchange, injecting and intranasal drug use. Addiction 105(1): 155-158, 2010. (15 refs.)

Objective: To assess trends in injecting and non-injecting drug use after implementation of large-scale syringe exchange in New York City. The belief that implementation of syringe exchange will lead to increased drug injecting has been a persistent argument against syringe exchange. Methods: Administrative data on route of administration for primary drug of abuse among patients entering the Beth Israel methadone maintenance program from 1995 to 2007. Approximately 2000 patients enter the program each year. Results: During and after the period of large-scale implementation of syringe exchange, the numbers of methadone program entrants reporting injecting drug use decreased while the numbers of entrants reporting intranasal drug use increased (P < 0.001). Conclusion: While assessing the possible effects of syringe exchange on trends in injecting drug use is inherently difficult, these may be the strongest data collected to date showing a lack of increase in drug injecting following implementation of syringe exchange.

Dube E; Masse R; Noel L. Acceptability of interventions in harm reduction: Contributions of the population to ethnic debates in public health. Canadian Journal of Public Health 100(1): 24-28, 2009. (22 refs.)

Objective: To explore convergence and divergence in ethical stances of public health and of members of the population regarding acceptability of harm reduction interventions, in particular needle exchange programs. Methods: Forty-nine semi-structured interviews were conducted with French-speaking residents of Quebec City. Content analysis was done to explore the views of the respondents with regard to injection drug users (IDUs) and interventions addressed to them, as well as Quebec policies on harm reduction. Results: Four main categories of social representations about IDUs have emerged from the discourses of the respondents. IDU were represented as: suffering from a disease (n=17); victim of a situation that they could not control (n=1 4); having chosen to use drugs (n=1 2); or delinquent people (n=6). Those social representations were associated with different ethical stances regarding acceptability of harm reduction interventions. Main divergences between respondents' ethical positions on harm reduction and public health discourses were related to the value of tolerance and its limits. Conclusions: The Quebec City population interviewed in this study had a high level of tolerance regarding needle distribution to drug addicts. Applied ethics could be a useful way to understand citizens' interpretation of public health interventions.

Ford R. An analysis of nurses' views of harm reduction measures and other treatments for the problems associated with illicit drug use. Australian Journal of Advanced Nursing 28(1): 14-24, 2010. (48 refs.)

Objective: To analyse nurses' views of harm reduction measures and other treatments for the problems associated with illicit drug use. Design and setting: The study, a cross-sectional survey, sampled the entire registered nurse population of the ACT. A self-complete survey was posted to home or workplace addresses. The views of all nurses registered in the ACT were sought. Subjects: The study sample (n = 1,605: 50% response rate), was predominantly comprised of nurses working outside specialist drug and alcohol fields (94%), with a small group from specialist fields. Main outcome measures: A 6-point Likert scale comprising 7 items (illicit drug treatments). Comparison with the Australian population was achieved through use of the National Drug Strategy Household Survey database. Results: Nurses mirrored the views of the Australian population, being strongly supportive of two abstinence-based measures (naltrexone for the maintenance of abstinence - 82% and rapid detoxification therapy 77%) and one harm reduction measure (the needle and syringe program - 76%). Nurses' lower support for the methadone maintenance program (66%) was statistically significant. Conclusions: Nurses reported high approval for the needle and syringe program but were mistakenly optimistic about abstinence-based measures for problems associated with illicit drugs. They reported significantly less support for important harm reduction measures - the methadone maintenance program and safe injection rooms. Nurses' low approval rating for these harm reduction measures is at odds with the evidence. This study highlights the need for education on the evidence base for the various illicit drug treatments.

Gervasoni JP; Balthasar H; Huissoud T; Jeannin A; Dubois-Arber F. A high proportion of users of low-threshold facilities with needle exchange programmes in Switzerland are currently on methadone treatment: Implications for new approaches in harm reduction and care. International Journal of Drug Policy 23(1): 33-36, 2012. (25 refs.)

Background: Increasingly, patients receiving methadone treatment are found in low threshold facilities (LTF), which provide needle exchange programmes in Switzerland. This paper identifies the characteristics of LTF attendees receiving methadone treatment (MT) compared with other LTF attendees (non-MT). Methods: A national cross-sectional survey was conducted in 2006 over five consecutive days in all LTF (n = 25). Attendees were given an anonymous questionnaire, collecting information on socio-demographic indicators, drug consumption, injection, methadone treatment, and self-reported HIV and HCV status. Univariate analysis and logistic regression were performed to compare MT to non-MT. The response rate was 66% (n = 1128). Results: MT comprised 57.6% of the sample. In multivariate analysis, factors associated with being on MT were older age (OR: 1.38), being female (OR: 1.60), having one's own accommodation (OR: 1.56), receiving public assistance (OR: 2.29), lifetime injecting (OR: 2.26), HIV-positive status (OR: 2.00), and having consumed cocaine during the past month (OR: 1.37); MT were less likely to have consumed heroin in the past month (OR: 0.76, not significant) and visited LTF less often on a daily basis (OR: 0.59). The number of injections during the past week was not associated with MT. Conclusions: More LTF attendees were in the MT group, bringing to light an underappreciated LTF clientele with specific needs. The MT group consumption profile may reflect therapeutic failure or deficits in treatment quality and it is necessary to acknowledge this and to strengthen the awareness of LTF personnel about potential needs of MT attendees to meet their therapeutic goals.

Gindi RM; Rucker MG; Serio-Chapman CE; Sherman SG. Utilization patterns and correlates of retention among clients of the needle exchange program in Baltimore, Maryland. Drug and Alcohol Dependence 103(3): 93-98, 2009. (35 refs.)

NEP effectiveness at a population level depends on several factors, including the number of injection drug users (IDUs) retained, or consistently accessing services. Patterns of retention in the Baltimore Needle Exchange Program (BNEP) from 1994 to 2006 were calculated using enrollment Surveys and client records. We used Andersen's Behavioral Model of Health Services Use to frame our examination Of factors associated with retention. Client retention was measured in two ways: whether a client returned to the exchange within 12 months of enrollment and how many times a client returned within these 12 months. BNEP clients (N = 12,388) were predominantly male (69%), African-American (73%), and >= age 30 (86%). Nearly two-thirds (64%) of clients returned within 12 months of their first BNEP visit. The median number of return visits per client within 12 months was one (IQR: 0-5). Young age (<30), being married, having an injection drug use history of less than 20 years, and living farther from the BNEP site were characteristics independently associated with both measures of low retention in multivariate analysis. Among younger injectors, geographical proximity was a particularly important predictor of retention. Further insight into the influence of these factors may help in developing programmatic changes that will be effective in increasing retention.

Gowan T; Whetstone S; Andic T. Addiction, agency, and the politics of self-control: Doing harm reduction in a heroin users' group. Social Science & Medicine 74(8): 1251-1260, 2012. (100 refs.)

Our 2007-2009 ethnography describes and analyses the practice of harm reduction in a heroin users' group in the midwestern United States. While dominant addiction interventions conceptualize the addict as powerless either through moral or physical weakness this group contested such "commonsense," treating illicit drug use as one of many ways that modern individuals attempt to "fill the void." Insisting on the destigmatization of addiction and the normalization of illicit drug use, the group helped its members work on incremental steps toward self-management. Although "Connection Points" had very limited resources to improve the lives of its members, our work suggests that the users' group did much to restore self-respect, rational subjectivity, and autonomy to a group historically represented as incapable of reason and self-control. As the users cohered as a community, they developed a critique of the oppressions suffered by "junkies," discussed their rights and entitlements, and even planned the occasional political action. Engaging with literature on the cultural construction of agency and responsibility, we consider, but ultimately complicate, the conceptualization of needle exchange as a "neoliberal" form of population management. Within the context of the United States' War on Drugs, the group's work on destigmatization, health education, and the practice of incremental control showed the potential for reassertions of social citizenship within highly marginal spaces.

Green TC; Bluthenthal RN; Singer M; Beletsky L; Grau LE; Marshall P et al. Prevalence and predictors of transitions to and away from syringe exchange use over time in 3 US cities with varied syringe dispensing policies. Drug and Alcohol Dependence 111(1-2): 74-81, 2010. (46 refs.)

Syringe exchange programs (SEPs) can reduce HIV risk among injecting drug users (IDUs) but their use may depend heavily on contextual factors such as local syringe policies. The frequency and predictors of transitioning over time to and from direct, indirect, and non-use of SEPs are unknown. We sought, over one year, to: (1) quantify and characterize transition probabilities of SEP attendance typologies; (2) identify factors associated with (a) change in typology, and (b) becoming and maintaining Direct SEP use; and (3) quantify and characterize transition probabilities of SEP attendance before and after changes in policy designed to increase access. Using data collected from 583 IDUs participating in a three-city cohort study of SEPs, we conducted a latent transition analysis and multinomial regressions. Three typologies were detected: Direct SEP users, Indirect SEP users and Isolated IDUs. Transitions to Direct SEP use were most prevalent. Factors associated with becoming or maintaining Direct SEP use were female sex, Latino ethnicity, fewer injections per syringe, homelessness, recruitment city, injecting speedballs (cocaine and heroin), and police contact involving drug paraphernalia possession. Similar factors influenced transitions in the syringe policy change analysis. Policy change cities experienced an increase in Indirect SEP users (43-51%) with little increased direct use (29-31%). We found that, over time, IDUs tended to become Direct SEP users. Policies improving syringe availability influenced SEP use by increasing secondary syringe exchange. Interactions with police around drug paraphernalia may encourage SEP use for some IDUs and may provide opportunities for other health interventions.

Guardino V; Des Jarlais DC; Arasteh K; Johnston R; Solberg A; Lansky A et al. Syringe exchange programs --- United States, 2008. MMWR. Morbidity and Mortality Weekly Review 59(45): 1488-1491, 2010. (9 refs.)

As of March 2009, a total of 184 Syringe Exchange Programs (SEPs) were known to be operating in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2009). Of these, 123 (67%) SEP directors participated in a mail/telephone survey conducted by NASEN and Beth Israel Medical Center (New York, New York) that covered program operations for the calendar year 2008. To characterize SEPs in the United States, this report summarizes the findings from that survey and compares them with previous SEP survey results from the period 1994--2007 (2--3). In 2008, the 123 SEPs reported exchanging 29.1 million syringes and had budgets totaling $21.3 million, of which 79% came from state and local governments. Most of the SEPs reported offering preventive health and clinical services in addition to basic syringe exchange: 87% offered HIV counseling and testing, 65% offered hepatitis C counseling and testing, 55% offered sexually transmitted disease screening, and 31% offered tuberculosis screening; 89% provided referrals to substance abuse treatment.

Public Doman

Hayashi K; Wood E; Wiebe L; Qi JZ; Kerr T. An external evaluation of a peer-run outreach-based syringe exchange in Vancouver, Canada. International Journal of Drug Policy 21(5): 418-421, 2010. (26 refs.)

Objective: Vancouver, Canada has been the site of an epidemic of human immunodeficiency virus (HIV) amongst injection drug users (IDU). In response, the Vancouver Area Network of Drug Users (VANDU) initiated a peer-run outreach-based syringe exchange programme (SEP) called the Alley Patrol. We conducted an external evaluation of this programme, using data obtained from the Vancouver Injection Drug Users Study (VIDUS). Methods: Using generalised estimating equations (GEE) we examined the prevalence and correlates of use of the SEP amongst VIDUS participants followed from 1 December 2000 to 30 November 2003. Results: Of 854 IDU, 233 (27.3%) participants reported use of the SEP during the study period. In multivariate GEE analyses, service use was positively associated with living in unstable housing (adjusted odds ratio [AOR] =1.83,95% confidence interval [CI]: 1.39-2.40), daily heroin injection (AOR=1.31, 95% CI: 1.01-1.70), daily cocaine injection (AOR =1.34,95% CI: 1.03-1.73), injecting in public (AOR=3.07,95% CI: 2.32-4.06), and negatively associated with needle reuse (AOR=0.65,95% CI: 0.46-0.92). CondIusion: The VANDU Alley Patrol SEP succeeded in reaching a group of IDU at heightened risk for adverse health outcomes. Importantly, access to this service was associated with lower levels of needle reuse. This form of peer-based SEP may extend the reach of HIV prevention programmes by contacting IDU traditionally underserved by conventional syringe exchange programmes.

Heller DI; Paone D; Siegler A; Karpati A. The syringe gap: An assessment of sterile syringe need and acquisition among syringe exchange program participants in New York City. Harm Reduction Journal 6: article 1, 2009. (47 refs.)

Background: Programmatic data from New York City syringe exchange programs suggest that many clients visit the programs infrequently and take few syringes per transaction, while separate survey data from individuals using these programs indicate that frequent injecting - at least daily is common. Together, these data suggest a possible "syringe gap" between the number of injections performed by users and the number of syringes they are receiving from programs for those injections. Methods: We surveyed a convenience sample of 478 injecting drug users in New York City at syringe exchange programs to determine whether program syringe coverage was adequate to support safer injecting practices in this group. Results: Respondents reported injecting a median of 60 times per month, visiting the syringe exchange program a median of 4 times per month, and obtaining a median of 10 syringes per transaction; more than one in four reported reusing syringes. Fifty-four percent of participants reported receiving fewer syringes than their number of injections per month. Receiving an inadequate number of syringes was more frequently reported by younger and homeless injectors, and by those who reported public injecting in the past month. Conclusion: To improve syringe coverage and reduce syringe sharing, programs should target younger and homeless drug users, adopt non-restrictive syringe uptake policies, and establish better relationships with law enforcement and homeless services. The potential for safe injecting facilities should be explored, to address the prevalence of public injecting and resolve the 'syringe gap' for injecting drug users.

Iversen J; Topp L; Wand H; Maher L. Individual-level syringe coverage among needle and syringe program attendees in Australia. Drug and Alcohol Dependence 122(3): 195-200, 2012. (38 refs.)

Background: Harm associated with injecting drug use is a significant public health issue and a major cause of morbidity and mortality, with global estimates of 3 million injectors infected with HIV and 8 million living with chronic hepatitis C virus (HCV) infection. Estimates of program coverage are widely used in the context of HIV prevention and are critical in determining the effectiveness of interventions such as Needle and Syringe Programs (NSPs). Methods: Data from a national cross-sectional study of NSP attendees in Australia were used to estimate individual-level syringe coverage as a proportion of monthly injections covered by a new syringe. Univariate and multivariate logistic regressions modelled associations between demographics, injecting risk, anti-HIV and HCV prevalence and syringe coverage. The median number of syringes retained per NSP attendee per annum was also estimated. Results: Twenty percent of participants had insufficient new syringes for all injections. Syringe reuse (including reuse of one's own syringe) was independently associated with syringe coverage of <100%. Conversely, procurement of syringes from an NSP was independently associated with syringe coverage >= 100%, with a greater protective effect occurring when NSP utilisation was combined with current engagement in opiate substitution therapy. The median number of syringes retained per participant per annum was 720, equivalent to 2 per day. Conclusions: While Australian NSP attendees report high syringe coverage by international standards, prevention efforts could be scaled up. Syringe reuse was associated with syringe coverage of <100%, suggesting the utility of reuse as a proxy for individual-level syringe coverage.

Jarlais DC; McKnight C; Goldblatt C; Purchase D. Doing harm reduction better: Syringe exchange in the United States. Addiction 104(9): 1441-1446, 2009. (13 refs.)

Objective: To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs. Methods: Annual surveys of US SEPs known to North American Syringe Exchange Network (NASEN). Surveys mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. Results: The numbers of programs known to NASEN have increased from 68 in 1994-95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment, human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counseling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of SEPs in 2007. Conclusions: While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing SEPs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of SEPs in the United States.

Jenkins LM; Banta-Green CJ; Maynard C; Kingston S; Hanrahan M; Merrill JO et al. Risk factors for nonfatal overdose at Seattle-Area syringe exchanges. Journal of Urban Health 88(1): 118-128, 2011. (39 refs.)

Opioid-involved overdose deaths are on the rise, both nationwide and in the state of Washington. In a survey of 443 participants at syringe exchanges in Seattle, Washington, 16% had overdosed in the last year. Several factors were significantly associated in bivariate analysis: lack of permanent housing; incarceration of five or more days in the past year; gender of sex partners; sharing of syringes and other injection paraphernalia; use of speedballs (cocaine and heroin together), goofballs (methamphetamine and heroin together), buprenorphine; injection use of crack cocaine and sedatives; and use of opioids with sedatives. Adjusting for other variables in multivariate logistic regression analyses, only recent incarceration and sharing of injection materials were still significantly associated with overdose. Correctional facilities, syringe exchange programs, and other agencies serving opioid injectors should include overdose prevention components in release planning and services.

Jones L; Pickering L; Sumnall H; McVeigh J; Bellis MA. Optimal provision of needle and syringe programmes for injecting drug users: A systematic review. (review). International Journal of Drug Policy 21(5): 335-342, 2010. (38 refs.)

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.

Kidorf M; King VL; Pierce J; Kolodner K; Brooner RK. Benefits of concurrent syringe exchange and substance abuse treatment participation. Journal of Substance Abuse Treatment 40(3): 265-271, 2011. (45 refs.)

Participation in syringe exchange programs (SEPs) is associated with many individual and public health benefits but may have little impact on reducing drug use without concurrent treatment engagement. This study evaluated rates of drug use, other risk behaviors, and illegal activities in newly registered SEP participants (N = 240) enrolled versus not enrolled in substance abuse treatment over a 4-month observation window and examined the effect of days in treatment on these outcomes. After controlling for baseline differences, SEP registrants enrolled in treatment (n = 113) reported less days of opioid and cocaine use, injection drug use, illegal activities, and incarceration than those not enrolled in treatment (n = 127). For those enrolled in treatment, days of treatment was strongly correlated with each of these outcomes. These findings provide good evidence for a dose response effect of treatment in syringe exchangers and suggest that substance abuse treatment significantly expands the harm reduction benefits of SEP participation.

Kidorf M; King VL; Neufeld K; Peirce J; Kolodner K; Brooner RK. Improving substance abuse treatment enrollment in community syringe exchangers. Addiction 104(5): 786-795, 2009. (29 refs.)

Aims: The present study evaluated the effectiveness of an intervention combining motivational enhancement and treatment readiness groups, with and without monetary incentives for attendance and treatment enrollment, on enhancing rates of substance abuse treatment entry among new registrants at the Baltimore Needle Exchange Program (BNEP). Design Opioid-dependent study participants (n = 281) referred by the BNEP were assigned randomly to one of three referral interventions: (i) eight individual motivational enhancement sessions and 16 treatment readiness group sessions (motivated referral condition-MRC); (ii) the MRC intervention with monetary incentives for attending sessions and enrolling in treatment-MRC+I); or (iii) a standard referral condition which directed participants back to the BNEP for referral ( standard referral-SRC). Participants were followed for 4 months. Findings MRC+I participants were more likely to enroll in any type of treatment than MRC or SRC participants (52.1% versus 31.9% versus 35.5%; chi(2) = 9.12, P = 0.01), and more likely to enroll in treatment including methadone than MRC or SRC participants (40.4% versus 20.2% versus 16.1%; chi(2) = 16.65, P < 0.001). MRC+I participants also reported less heroin and injection use than MRC and SRC participants. Conclusions: Syringe exchange sites can be effective platforms to motivate opioid users to enroll in substance abuse treatment and ultimately reduce drug use and number of drug injections.

Kidorf M; King VL; Gandotra N; Kolodner K; Brooner RK. Improving treatment enrollment and re-enrollment rates of syringe exchangers: 12-month outcomes. Drug and Alcohol Dependence 124(1-2): 162-166, 2012. (27 refs.)

Background: Developing bridges between community syringe exchange programs (SEPs) and substance abuse treatment could benefit syringe exchangers and the public health. Kidorf et al. (2009) showed that motivational approaches employed at an SEP site improved rates of treatment enrollment and reduced drug use over a 4-month observation window. The present study extends this report by evaluating rates of treatment enrollment and re-enrollment over a 12-month period. Methods: Opioid dependent individuals (n = 281) newly registered at an SEP were randomly assigned to one of three referral interventions: (1) 8 individual motivational enhancement sessions and 16 treatment readiness group sessions designed to improve treatment interest and readiness (motivated referral condition; MRC-only); (2) MRC-only with monetary incentives for attending sessions and enrolling in treatment (MRC+I); or (3) standard referral (SRC). MRC-only and MRC+I participants discharged from treatment could attend a treatment re-engagement group designed to facilitate return to treatment (MRC+I participants received incentives for attending sessions and re-enrolling in treatment). Results: The 4-month outcomes generally extended over 12 months. MRC+I participants were more likely to enroll in methadone maintenance than MRC-only or SRC participants, and to re-enroll in treatment following discharge. MRC+I participants also reported more days of treatment and less heroin and injection use. Conclusions: The good harm reduction outcomes for many SEP participants can be enhanced through strategies designed to facilitate treatment enrollment and re-enrollment.

Kidorf M; King VL; Peirce J; Burke C; Kolodner K; Brooner RK. Psychiatric distress, risk behavior, and treatment enrollment among syringe exchange participants. Addictive Behaviors 35(5): 499-503, 2010. (39 refs.)

The present study evaluated psychiatric distress as a predictor of treatment enrollment in out-of-treatment injection opioid users newly registered at the Baltimore Needle Exchange Program (BNEP). Study participants (n = 281) completed the Addiction Severity Index (ASI), the Risk Assessment Battery (RAB), and the Symptom Checklist-90 (SCL-90-R), and were randomly assigned to one of three different conditions for 4 months that evaluated referral strategies designed to promote treatment interest and enrollment. The Global Severity Index (GSI) of the SCL-90 was used as a measure of psychiatric distress. A logistic regression showed that higher GSI scores predicted more treatment enrollment (Adjusted OR = 2.15, CI = 1.10-4.23, p < 0.05), after controlling for study condition, demographic variables, syringe exchange site, and severity of drug use. The results suggest that the data from the assessment of psychiatric distress in syringe exchange settings can be used to support motivational strategies for encouraging syringe exchangers to seek substance abuse treatment.

Kidorf M; King VL; Peirce J; Kolodner K; Brooner RK. A treatment reengagement intervention for syringe exchangers. Journal of Substance Abuse Treatment 41(4): 415-421, 2011. (34 refs.)

Poor sustained treatment engagement limits the effectiveness of all modalities of substance abuse treatment. This study evaluated the efficacy of a novel treatment reengagement intervention for a subset of syringe-exchange program (SEP) participants (N = 113) that had enrolled in treatment as part of a 4-month clinical trial (M. Kidorf et al., 2009). Three reengagement conditions for participants leaving treatment were compared. Motivational referral condition (MRC) participants (n = 31) could attend group sessions that focused on renewing treatment interest. MRC plus incentive (M RC + I) participants (n = 49) could receive modest monetary incentives for attending these sessions and reenrolling in treatment. Standard referral condition participants (n = 33) could not attend groups or receive incentives. Across a 1-year observation window, almost all study participants (86%) were discharged from treatment. M RC + I participants attended more group sessions than MRC participants and were considerably more likely to reenroll in treatment than participants in the other study conditions. Reengagement strategies can further enhance the public health benefits of SEPs by increasing rates of treatment participation over time.

Macalino GE; Sachdev DD; Rich JD; Becker C; Tan LJ; Beletsky L et al. A national physician survey on prescribing syringes as an HIV prevention measure. Substance Abuse Treatment, Prevention and Policy 4: e-article 13, 2009. (26 refs.)

Background: Access to sterile syringes is a proven means of reducing the transmission of human immunodeficiency virus (HIV), viral hepatitis, and bacterial infections among injection drug users. In many U. S. states and territories, drug paraphernalia and syringe prescription laws are barriers to syringe access for injection drug users (IDUs): pharmacists may be reluctant to sell syringes to suspected IDUs, and police may confiscate syringes or arrest IDUs who cannot demonstrate a "legitimate" medical need for the syringes they possess. These barriers can be addressed by physician prescription of syringes. This study evaluates physicians' willingness to prescribe syringes, using the theory of planned behavior to identify key behavioral influences. Methods: We mailed a survey to a representative sample of physicians from the American Medical Association physician database. Non-responding physicians were then called, faxed, or re-sent the survey, up to four times. Results: Twenty percent responded to the survey. Although less than 1 percent of respondents had ever prescribed syringes to a known injection drug user, more than 60% of respondents reported that they would be willing to do so. Physicians' willingness to prescribe syringes was best predicted by the belief that it was a feasible and effective intervention, but individual and peer attitudes were also significant. Conclusion: This was the first nationwide survey of the physician willingness to prescribe syringes to IDUs. While the majority of respondents were willing to consider syringe prescription in their clinical practices, multiple challenges need to be addressed in order to improve physician knowledge and attitudes toward IDUs.

Mackridge AJ; Scott J. Experiences, attitudes and training needs of pharmacy support staff providing services to drug users in Great Britain: A qualitative study. Journal of Substance Use 14(6): 375-384, 2009. (20 refs.)

Community pharmacies play an important role in providing services to drug users, having provided needle exchange and substitution therapy services for a number of years. Previous studies of these services and the problems faced in implementing them have focused on the attitude and experiences of pharmacists. However, with the increasing use of pharmacy support staff in a range of expanded roles, it is also appropriate to consider this group. This article aims to qualitatively explore the experiences, attitudes, and training needs of pharmacy support staff involved in providing services to drug users. Copies of the questionnaire were issued to a 10% sample of community pharmacies and distributed to up to five support staff working in the pharmacy. The questionnaire asked open questions regarding training needs, personal experiences and attitudes. Data were transcribed and thematically analysed according to Grounded Theory in NVivo v7. 454 respondents made qualitative comments. The data demonstrated a strong desire among some support staff to be further involved in support services. However, many expressed negative attitudes towards drug users and some considered pharmacies as inappropriate venues for providing services to this group. Identified training needs focused on four key areas: advising and working with drug users; the nature of drug use; treatment services and their availability; and clinical and legal detail. Knowledge gaps were evident in some of the responses, most notably a misunderstanding of service aims and intended outcomes. All those involved in designing and delivering pharmacy services to drug users should ensure that they take account of and involve support staff when developing training.

Macneil J; Pauly B. Needle exchange as a safe haven in an unsafe world. Drug and Alcohol Review 30(1): 26-32, 2011. (31 refs.)

Introduction and Aims. The purpose of this paper is to describe the meaning of needle exchange programs from the perspectives of users who access such programs. Design and Methods. We conducted observations, 33 semistructured interviews and two focus groups with users at four needle exchange sites. Qualitative description was used to analyse the data. Results. Participants described experiences of trauma, abuse, violence and physical injuries that had damaged their lives and led to the use of drugs to numb the pain. Respect for persons and the development of trust with outreach staff for clients who use injecting drugs supported clients to feel safe in what for many was an unsafe world. Participants described the important role that needle exchange services play in reducing and countering negative stigma, as well as in providing access to clean supplies and to other services. Discussion and Conclusions. The findings attest to the benefits of having trusted, safe needle exchange services that not only reduce risk behaviours that prevent infections, such as HIV and hepatitis C, but also open the door to other services. This finding is particularly important given that the majority of those interviewed were homeless and living in poverty. The need for both fixed sites and the integration of harm reduction services as part of a broader network of primary health-care services was reinforced.

Malta M; Magnanini MMF; Mello MB; Pascom ARP; Linhares Y; Bastos FI. HIV prevalence among female sex workers, drug users and men who have sex with men in Brazil: A systematic review and meta-analysis. BMC Public Health 10: article 317, 2010. (91 refs.)

Background: The Brazilian response towards AIDS epidemic is well known, but the absence of a systematic review of vulnerable populations ? men who have sex with men (MSM), female sex workers (FSW), and drug users (DU) remains a main gap in the available literature. Our goal was to conduct a systematic review and meta-analysis of studies assessing HIV prevalence among MSM, FSW and DU, calculating a combined pooled prevalence and summarizing factors associated the pooled prevalence for each group. Methods: Nine electronic databases (MEDLINE via PubMed, EMBASE, Cochrane CENTRAL, AIDSLINE, AMED, CINAHL, TOXNET, SciELO, and ISI-Web of Science) were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1999 to 2009. To be included in the review, studies had to measure HIV prevalence and/or incidence as the primary outcome among at least one specific population under analysis. Results: The studies targeting the three populations analyzed mostly young participants aged 30 years or less. Among FSW, eight studies were selected (3,625 participants), consistently identifying higher condom use with sexual clients than with occasional and stable partners. The combined HIV prevalence for FSW was 6.2 (95% CI: 4.4-8.3). Ten studies targeting MSM were identified (6,475 participants). Unprotected anal intercourse was commonly reported on those studies, but with great variability according to the nature of the relationship - stable vs. occasional sex partners - and sexual practice - receptive vs. insertive anal sex. Pooled HIV prevalence for MSM was 13.6 (95% CI: 8.2-20.2). Twenty nine studies targeting DU were identified (13,063 participants). Those studies consistently identified injection drug use and syringe/needle sharing as key predictors of HIV-infection, as well as engagement in sex work and male-to-male sex. The combined HIV prevalence across studies targeting DU was 23.1 (95% CI: 16.7-30.2). Conclusions: FSW, MSM and DU from Brazil have a much risk of acquiring HIV infection compared to the general population, among which HIV prevalence has been relatively low (similar to 0.6%). Those vulnerable populations should be targeted by focused prevention strategies that provide accurate information, counseling and testing, as well as concrete means to foster behavior change (e. g. access to condoms, drug abuse treatment, and clean syringes in the case of active injecting drug users), tailored to gender and culture-specific needs. Programs that provide these services need to be implemented on public health services throughout the country, in order to decrease the vulnerability of those populations to HIV infection.

McDonald D. The evaluation of a trial of syringe vending machines in Canberra, Australia. International Journal of Drug Policy 20(4): 336-339, 2009. (25 refs.)

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Mendelevich VD. Bioethical differences between drug addiction treatment professionals inside and outside the Russian Federation. Harm Reduction Journal 8: article 15, 2011. (31 refs.)

This article provides an overview of a sociological study of the views of 338 drug addiction treatment professionals. A comparison is drawn between the bioethical approaches of Russian and foreign experts from 18 countries. It is concluded that the bioethical priorities of Russian and foreign experts differ significantly. Differences involve attitudes toward confidentiality, informed consent, compulsory treatment, opioid agonist therapy, mandatory testing of students for psychoactive substances, the prevention of mental patients from having children, harm reduction programs (needle and syringe exchange), euthanasia, and abortion. It is proposed that the cardinal dissimilarity between models for providing drug treatment in the Russian Federation versus the majority of the countries of the world stems from differing bioethical attitudes among drug addiction treatment experts.

Mogg D; Levy M. Moving beyond non-engagement on regulated needle-syringe exchange programs in Australian prisons. Harm Reduction Journal 6: article 7, 2009. (23 refs.)

Background: Australia is at a fork in the road with the possibility of a needle-syringe exchange program (NSP) to be introduced at the new prison in the ACT. However, the current situation is characterised by non-engagement from major stakeholders. We explore why informed discussion will not be enough to convince prison officers, policy makers and the wider community of the benefits of prison-based NSPs. Other methods of engagement and communication will be proposed - in that may provide avenues for "breakthrough". Methods: A review of the literature on needle-syringe exchanges and harm reduction strategies within the context of prisons and prisoner health was conducted. Literature on strategies to change attitudes and move beyond intractable situations was also consulted. In addition, one author, DM, conducted a two-hour interview with an ex-prison officer. Results: No studies were found which investigated the potential efficacy of interventions to modify attitudes or behaviours in the specific context of introducing an NSP into a prison. Nonetheless, several theories were identified which may explain the failure of informed discussion alone to create change in this situation and may therefore lead to suggestions for engagement and communication to move towards a resolution. Discussion: Cognitive-behavioural therapy highlights the importance of individual cognitions and how they shape behaviours in any change campaign. Social identity theory emphasizes changes to social processes that may open the prison officer workforce to change. Peace studies also suggests socialization strategies such as observing an established and effective prison-based needle-syringe exchange. Social marketing provides suggestions on how to sell an exchange to ensuring the benefits are framed to outweigh the costs. Conclusion: Psychology, peace studies and social marketing all agree people's views must be carefully collected and analysed if people are going to be convinced to consider and discuss the issue. By understanding the views and their underlying motivations of those who oppose NSPs, it will be far easier to influence these views. Furthermore, involving all stakeholders, especially prison authorities, will help create a sense of ownership of a solution and therefore increase the chances of that solution succeeding.

Narayanan S; Vicknasingam B; Robson NMH. The transition to harm reduction: Understanding the role of non-governmental organisations in Malaysia. International Journal of Drug Policy 22(4): 311-317, 2011. (34 refs.)

Background: The transition of drug policy from prohibition to harm reduction has never been easy. The deeply entrenched belief in prohibition shared by policy makers and religious leaders provided little room for alternatives, and change came only slowly. The non-governmental organisations (NGOs) in Malaysia played a pivotal role in effecting such a change. Understanding how they did so may be instructive for other similarly placed countries. Methods: Data collected via reviews of published secondary sources, media reports and in-depth interviews with pioneers of harm reduction drawn from NGOs, medical practitioners and the police were analysed to construct the paper. Results: The policy change was the outcome of competition between three groups in the drug policy subsystem - the state, the Muslim religious lobby and the NGOs. Developments such as the poor outcomes from the prohibition programmes and the outbreak of HIV/AIDS did not change policy but did lead to a rethink of core beliefs in the state alliance and spawned a state-NGO partnership. The subsequent failure to meet the Millennium Development Goal with respect to HIV/AIDS in 2005 - was seen as a failure of the Health Ministry which then led the final charge for a policy change arguing that a health crisis was imminent. The NGOs played a pivotal role in this process by educating their partners in the state coalition, by drawing academics and medical practitioners into advocacy and by engaging the religious lobby (albeit with varying success). They were also frontline players in implementing harm reduction programmes and successfully deflected criticisms from unconvinced Islamic groups away from the state. Conclusion: Given their central role in the needle-syringe exchange programme, the NGOs are well positioned to convince injecting drug users to opt for voluntary medical treatment. This can potentially reduce both the harm from drug use and the prevalence of it.

Ngo AD; Schmich L; Higgs P; Fischer A. Qualitative evaluation of a peer-based needle syringe programme in Vietnam. International Journal of Drug Policy 20(2): 179-182, 2009. (9 refs.)

Background: Harm reduction has been identified as an important HIV prevention strategy for injecting drug users (IDUs) in Vietnam. However, to date only small geographically limited formal needle syringe programmes (NSPs) have been implemented; and little attention has been given to assessing the effectiveness of the piloted models. Using data from a qualitative evaluation of an NSP in northern Vietnam, this paper assesses the effectiveness of the intervention, examines barriers to the NSP, and documents lessons which can be applied to replicate and scale up interventions across Vietnam. Methods: Data were gathered using key informant interviews, focus group discussions, in-depth interviews, observation and intercept interviews with IDUs and other project stakeholders. IDUs were introduced to the evaluation by peer educators (PEs). Results: The project contributed to a shift toward safe injecting practices and safe disposal of used needles and syringes (N&S) among IDUs. Collection of used N&S positively influenced community attitudes toward PEs and IDUs. Reduced community discrimination, achieved as a result of project advocacy activities, encouraged IDU to access free needle syringes and other project services provided by PEs. Resistance from the local government officials and community members was turned into support for the programme through intensive advocacy activities. The project highlighted the importance of involving law enforcement in the programme and promoted a public health approach toward working with IDU. However, periodic police campaigns against drug use continued to be an obstacle to successful programme implementation and demonstrated the need for continued efforts to address the issue. Conclusion: Programme success is dependent upon community support. Resistance to NSPs can be overcome through a programme of intensive advocacy with community stakeholders including; local government, mass organizations, local residents, IDUs and their families. Garnering the support of law enforcement officials requires a Sustained effort.

Okwen MP; Ngem BY; Alomba FA; Capo MV; Reid SR; Ewang EC. Uncovering high rates of unsafe injection equipment reuse in rural Cameroon: validation of a survey instrument that probes for specific misconceptions. Harm Reduction Journal 8: article 4, 2011. (75 refs.)

Background: Unsafe reuse of injection equipment in hospitals is an on-going threat to patient safety in many parts of Africa. The extent of this problem is difficult to measure. Standard WHO injection safety assessment protocols used in the 2003 national injection safety assessment in Cameroon are problematic because health workers often behave differently under the observation of visitors. The main objective of this study is to assess the extent of unsafe injection equipment reuse and potential for blood-borne virus transmission in Cameroon. This can be done by probing for misconceptions about injection safety that explain reuse without sterilization. These misconceptions concern useless precautions against cross-contamination, i.e. "indirect reuse" of injection equipment. To investigate whether a shortage of supply explains unsafe reuse, we compared our survey data against records of purchases. Methods: All health workers at public hospitals in two health districts in the Northwest Province of Cameroon were interviewed about their own injection practices. Injection equipment supply purchase records documented for January to December 2009 were compared with self-reported rates of syringe reuse. The number of HIV, HBV and HCV infections that result from unsafe medical injections in these health districts is estimated from the frequency of unsafe reuse, the number of injections performed, the probability that reused injection equipment had just been used on an infected patient, the size of the susceptible population, and the transmission efficiency of each virus in an injection. Results: Injection equipment reuse occurs commonly in the Northwest Province of Cameroon, practiced by 44% of health workers at public hospitals. Self-reported rates of syringe reuse only partly explained by records on injection equipment supplied to these hospitals, showing a shortage of syringes where syringes are reused. Injection safety interventions could prevent an estimated 14-336 HIV infections, 248-661 HBV infections and 7-114 HCV infections each year in these health districts. Conclusions: Injection safety assessments that probe for indirect reuse may be more effective than observational assessments. The autodisable syringe may be an appropriate solution to injection safety problems in some hospitals in Cameroon. Advocacy for injection safety interventions should be a public health priority.

Orsi MM; Brochu S. The place of syringe exchange programs among harm reduction strategies in Canadian penitentiaries. Canadian Journal of Public Health 100(1): 29-31, 2009. (20 refs.)

The prevalence rates of illicit drug consumption within the prison system are much higher than those in the Canadian population in general. Of the substances used in detention, those of most concern to prison and public health authorities are injection drugs, as the sharing of injection drug equipment may be responsible for the high prevalence of bloodborne diseases in prison facilities. Faced with this situation, the Correctional Service of Canada put in practice a number of harm reduction strategies targeting injection drug users, such as methadone maintenance programs and access to bleach. However, despite their use in the community, needle-exchange programs are not yet allowed in penitentiaries. This article analyzes the limits of harm reduction strategies approved by the prison authorities and discusses the sources of resistance that continue to impede the realization of a pilot project to assess the feasibility of needle-exchange programs in detention in Canada.

Philbin MM; Mantsios A; Lozada R; Case P; Pollini RA; Alvelais J et al. Exploring stakeholder perceptions of acceptability and feasibility of needle exchange programmes, syringe vending machines and safer injection facilities in Tijuana, Mexico. International Journal of Drug Policy 20(4): 329-335, 2009. (49 refs.)

Background: Injection drug use is a growing public health crisis along the U.S.-Mexican border and rising rates of blood-borne infections highlight the pressing need for harm reduction interventions. We explored the acceptability and feasibility of such interventions in Tijuana, a city adjacent to San Diego, California. Methods: Using in-depth qualitative interviews conducted from August 2006-March 2007 with 40 key stakeholders - pharmacists, legal professionals, health officials, religious officials, drug treatment providers, and law enforcement personnel - we explored the acceptability and feasibility of interventions to reduce drug-related harm in Tijuana, Mexico. Interviews were taped with consent, transcribed verbatim, and translated. Content analysis was conducted to identify themes which included barriers, structural limitations, and suggestions for implementation. Results: Topics included acceptance and feasibility of needle exchange programmes (NEPs), syringe vending machines, and safer injection facilities (SIFs), structural barriers and suggestions for implementation. Of these interventions, NEPs were deemed the most acceptable (75%); however, only half believed these could be feasibly implemented, citing barriers involving religion, police, and lack of political will, public awareness, and funding. Conclusions: Increasing HIV infection rates among injection drug users in Tijuana have prompted interest in public health responses. Our results may assist policy strategists in implementing social-structural interventions that will help create enabling environments that facilitate the scale-up and implementation of harm reduction in Tijuana.

Pinkerton SD. Is Vancouver Canada's supervised injection facility cost-saving? Addiction 105(8): 1429-1436, 2010. (44 refs.)

Objective: To determine whether Vancouver's Insite supervised injection facility and syringe exchange programs are cost-saving-that is, are the savings due to averted HIV-related medical care costs sufficient to offset Insite's operating costs? Methods: The analyses examined the impact of Insite's programs for a single year. Mathematical models were used to calculate the number of additional HIV infections that would be expected if Insite were closed. The life-time HIV-related medical costs associated with these additional infections were compared to the annual operating costs of the Insite facility. Results: If Insite were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in life-time HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year. Conclusions: Insite's safe injection facility and syringe exchange program substantially reduce the incidence of HIV infection within Vancouver's IDU community. The associated savings in averted HIV-related medical care costs are more than sufficient to offset Insite's operating costs.

Pollini RA; Rosen PC; Gallardo M; Robles B; Brouwer KC; Macalino GE et al. Not sold here: Limited access to legally available syringes at pharmacies in Tijuana, Mexico. Harm Reduction Journal 8: article 13, 2011. (35 refs.)

Background: Sterile syringe access is a critical component of HIV prevention programs. Although retail pharmacies provide convenient outlets for syringe access, injection drug users (IDUs) may encounter barriers to syringe purchase even where purchase without a prescription is legal. We sought to obtain an objective measure of syringe access in Tijuana, Mexico, where IDUs report being denied or overcharged for syringes at pharmacies. Methods: Trained "mystery shoppers" attempted to buy a 1 cc insulin syringe according to a predetermined script at all retail pharmacies in three Tijuana neighborhoods. The same pharmacies were surveyed by telephone regarding their syringe sales policies. Data on purchase attempts were analyzed using basic statistics to obtain an objective measure of syringe access and compared with data on stated sales policies to ascertain consistency. Results: Only 46 (28.4%) of 162 syringe purchase attempts were successful. Leading reasons for unsuccessful attempts were being told that the pharmacy didn't sell syringes (35.3%), there were no syringes in stock (31.0%), or a prescription was required (20.7%). Of 136 pharmacies also surveyed by telephone, a majority (88.2%) reported selling syringes but only one-third (32.5%) had a successful mystery shopper purchase; the majority of unsuccessful purchases were attributed to being told the pharmacy didn't sell syringes. There was similar discordance regarding prescription policies: 74 pharmacies said in the telephone survey that they did not require a prescription for syringes, yet 10 of these pharmacies asked the mystery shopper for a prescription. Conclusions: IDUs in Tijuana have limited access to syringes through retail pharmacies and policies and practices regarding syringe sales are inconsistent. Reasons for these restrictive and inconsistent practices must be identified and addressed to expand syringe access, reduce syringe sharing and prevent HIV transmission.

Reddon H; Wood E; Tyndall M; Lai C; Hogg R; Montaner J; Kerr T. Use of North America's first medically supervised safer injecting facility among HIV-positive injection drug users. AIDS Education And Prevention 23(5): 412-422, 2011. (49 refs.)

The objective of this study was to examine supervised injecting facility (SIF) use among a cohort of 395 HIV-positive injection drug users (IDUs) in Vancouver, Canada. The correlates of SIF use were identified using generalized estimating equation analyses. In multivariate analyses, frequent SIF use was associated with homelessness (adjusted odds ratio [AOR] = 1.90), daily heroin injection (AOR = 1.56), and daily cocaine injection (AOR = 1.59). The reasons given for not using the SIF included a preference for injecting at home and already having a safe place to inject. The SIF services most commonly used were needle exchange and nursing services. The SIF appears to have attracted a high-risk subpopulation of HIV-positive IDUs; this coverage perhaps could be extended with the addition of HIV-specific services such as disease monitoring and the provision of antiretroviral therapy.

Small D; Glickman A; Rigter G; Walter T. The Washington Needle Depot: Fitting healthcare to injection drug users rather than injection drug users to healthcare -- Moving from a syringe exchange to syringe distribution model. Harm Reduction Journal 7: article 1, 2010. (31 refs.)

Needle exchange programs chase political as well as epidemiological dragons, carrying within them both implicit moral and political goals. In the exchange model of syringe distribution, injection drug users (IDUs) must provide used needles in order to receive new needles. Distribution and retrieval are co-existent in the exchange model. Likewise, limitations on how many needles can be received at a time compel addicts to have multiple points of contact with professionals where the virtues of treatment and detox are impressed upon them. The centre of gravity for syringe distribution programs needs to shift from needle exchange to needle distribution, which provides unlimited access to syringes. This paper provides a case study of the Washington Needle Depot, a program operating under the syringe distribution model, showing that the distribution and retrieval of syringes can be separated with effective results. Further, the experience of IDUs is utilized, through paid employment, to provide a vulnerable population of people with clean syringes to prevent HIV and HCV.

Strike C; Buchman DZ; Callaghan RC; Wender C; Anstice S; Lester B et al. Giving away used injection equipment: Missed prevention message? Harm Reduction Journal 7: article 2, 2010. (39 refs.)

Background: Our objective was to examine factors associated with distributive injection equipment sharing and how needle exchange programs (NEPs) can help reduce distributive sharing among injection drug users (IDUs). Methods: 145 English speaking Canadian IDUs ages 16 years and over who had injected in the past 30 days were recruited for a cross-sectional survey. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, social support, drug treatment readiness, program satisfaction, health and social service use and NEP drug use. Bivariate statistics and logistic regression were used to characterize the population and examine correlates of sharing behaviour. Results: More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. Factors associated with giving away used water included: male, injected methadone, injected other stimulants and moved 3+ times in the past 6 months. Factors associated with giving away used filters included: injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included: an ASI mental health score indicative of a mental health problem, and HCV negative status. Conclusions: Our findings show that more IDUs give away cookers than needles or other injection equipment. While the results showed that correlates of sharing differed by piece of equipment, each point to distributive sharing by the most marginalized IDUs. Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission.

Sulmasy DP. Catholic participation in needle- and syringe-exchange programs for injection-drug users: An ethical analysis. Theological Studies 73(2): 422-441, 2012. (62 refs.)

Needle- and syringe-exchange programs aim to decrease infections among those who are dependent on injection drugs. Some have questioned whether church sponsorship of such programs constitutes illicit cooperation in the evil of drug abuse. This article examines the question under classical formulations of cooperation and in light of current empirical evidence and concludes that this is not the case. Questions are also raised about whether, if substance dependence is a disease and not a moral failing, an analysis based on cooperation is actually the appropriate category of analysis.

Todd CS; Nasir A; Stanekzai MR; Fiekert K; Rasuli MZ; Vlahov, D. et al. Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment. Harm Reduction Journal 8: article 22, 2011. (31 refs.)

Background: A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population. Methods: IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use. Results: Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58-22.38 and AOR = 2.33, 95% CI: 1.38-3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22-5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16-2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06-2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08-1.82). Conclusions: HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.

Torre C; Lucas R; Barros H. Syringe exchange in community pharmacies: The Portuguese experience. International Journal of Drug Policy 21(6): 514-517, 2010. (14 refs.)

Background: Since 1993 the participation of Portuguese pharmacies to the national Syringe Exchange Programme (SEP) has remained high. However, no national guidelines or standard procedures are available regarding the provision of this service. We aimed to describe practices and attitudes toward syringe dispensing and other harm reduction strategies in Portuguese pharmacies. Methods: A cross-sectional survey was conducted using an anonymous self-administered questionnaire. All pharmacies in Portugal (n = 2775) were invited to participate. The questionnaire addressed SEP ever involvement and discontinuation; injection equipment policies; problems and needs in service provision. Results: Participation rates were 69.6% among pharmacies involved in SEP and 42.7% in those not involved in the programme. Among current providers, 64.3% followed a strict "one-for-one" policy and 21.6% established limits on the number of syringes distributed. Syringe selling was reported by 76.2%. One-tenth of pharmacies supervised methadone consumption Problems in service provision were experienced by 12.8% of respondents. Need for increased training and improvement of referral pathways were frequently reported. Conclusions: Pharmacy-based harm reduction interventions in Portugal have tended to follow strict policies favouring conservative approaches. Training and feedback adaptation seem indispensable to avoid service discontinuation and boost an activity with an essential humanitarian dimension.

Turner KME; Hutchinson S; Vickerman P; Hope V; Craine N; Palmateer N et al. The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: Pooling of UK evidence. Addiction 106(11): 1978-1988, 2011. (46 refs.)

Aims To investigate whether opiate substitution therapy (OST) and needle and syringe programmes (NSP) can reduce hepatitis C virus (HCV) transmission among injecting drug users (IDUs). Design: Meta-analysis and pooled analysis, with logistic regression allowing adjustment for gender, injecting duration, crack injecting and homelessness. Setting Six UK sites (Birmingham, Bristol, Glasgow, Leeds, London and Wales), community recruitment. Participants: A total of 2986 IDUs surveyed during 2001-09. Measurement Questionnaire responses were used to define intervention categories for OST (on OST or not) and high NSP coverage (>= 100% versus <100% needles per injection). The primary outcome was new HCV infection, measured as antibody seroconversion at follow-up or HCV antibody-negative/RNA-positive result in cross-sectional surveys. Findings: Preliminary meta-analysis showed little evidence of heterogeneity between the studies on the effects of OST (I(2) = 48%, P = 0.09) and NSP (I(2) = 0%, P = 0.75), allowing data pooling. The analysis of both interventions included 919 subjects with 40 new HCV infections. Both receiving OST and high NSP coverage were associated with a reduction in new HCV infection [adjusted odds ratios (AORs) = 0.41, 95% confidence interval (CI): 0.21-0.82 and 0.48, 95% CI: 0.25-0.93, respectively]. Full harm reduction (on OST plus high NSP coverage) reduced the odds of new HCV infection by nearly 80% (AOR = 0.21, 95% CI: 0.08-0.52). Full harm reduction was associated with a reduction in self-reported needle sharing by 48% (AOR 0.52, 95% CI: 0.32-0.83) and mean injecting frequency by 20.8 injections per month (95% CI: -27.3 to -14.4). Conclusions: There is good evidence that uptake of opiate substitution therapy and high coverage of needle and syringe programmes can substantially reduce the risk of hepatitis C virus transmission among injecting drug users. Research is now required on whether the scaling-up of intervention exposure can reduce and limit hepatitis C virus prevalence in this population.

Vorobjov S; Uuskula A; Abel-Ollo K; Talu A; Ruutel K; Des Jarlais DC. Comparison of injecting drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia. Harm Reduction Journal 6: article 3, 2009. (42 refs.)

Background: Both syringe exchange programs (SEPs) and pharmacy sales of syringes are available in Estonia, though the current high incidence and high prevalence of HIV among injection drug users (IDUs) in Tallinn, Estonia requires large-scale implementation of additional harm reduction programs as a matter of great urgency. The aims of this report were to compare risk behavior and HIV infection and to assess the prevention needs among IDUs who primarily use pharmacies as their source of sterile syringes with IDUs who primarily use SEPs in Tallinn. Methods: A cross-sectional study using respondent-driven sampling was used to recruit 350 IDUs for an interviewer-administered survey and HIV testing. IDUs were categorized into two groups based on their self-reported main source for syringes within the last six months. Odds ratios with 95% CI were used to compare characteristics and risk factors between the groups. Results: The main sources of sterile needles for injection drug users were SEP/SEP outreach (59%) and pharmacies (41%). There were no differences in age, age at injection drug use initiation, the main drug used or experiencing overdoses. Those IDUs using pharmacies as a main source of sterile needles had lower odds for being infected with either HIV (AOR 0.54 95% CI 0.33-0.87) or HCV (AOR 0.10 95% CI 0.02-0.50), had close to twice the odds of reporting more than one sexual partner within the previous 12 months (AOR 1.88 95% CI 1.17-3.04) and engaging in casual sexual relationships (AOR 2.09 95% CI 1.24-3.53) in the last six months. Conclusion: The data suggest that the pharmacy users were at a less "advanced" stage of their injection career and had lower HIV prevalence than SEP users. This suggests that pharmacies could be utilized as a site for providing additional HIV prevention messages, services for IDUs and in linking IDUs with existing harm reduction services.

Werb D; Wood E. Commentary on Vorobjov et al., "Comparison of injection drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia". Harm Reduction Journal 6(1): article 33, 2009. (10 refs.)

Recent data suggest that globally, between 5% and 10% of all new HIV cases are the result of unsafe injecting practices, and experts agree that reducing these practices is key to tackling the spread of HIV. And yet, despite the overwhelming evidence that providing sterile syringes to injection drug users (IDU) through syringe exchange programs (SEPs) or other means is an effective way of reducing HIV transmission among high-risk subpopulations, IDU in most settings still do not have access to sterile injecting equipment or if they do, access remains too restricted to effectively reduce the risk of HIV transmission. Vorobjov and colleagues have presented in this journal an interesting and timely study from Estonia comparing individuals who obtain syringes from SEPs and those who obtain syringes from pharmacies. As the authors point out, Estonia faces an unacceptably high HIV incidence rate of 50 new HIV cases per 100,000, this rate driven primarily by injection drug use. As such, the authors argue that Estonia's SEP network does not have the capacity to serve a growing IDU population at risk of transmitting HIV and pharmacy dispensation of clean syringes may be one potential approach to decreasing syringe sharing among high-risk injectors. It may be overly optimistic to consider the impact of higher threshold interventions such as pharmacy-based SEPs, given that IDU populations that engage in HIV risk behaviours such as syringe sharing are often hidden or hard to reach. Despite the need for a cautious approach, however, the findings presented by Vorobjov et al. may chart one potential course towards a more comprehensive societal response to reducing the health harms associated with injection drug use.

Wood E; Kerr T. Could a United Nations organisation lead to a worsening of drug-related harms? Drug and Alcohol Review 29(1): 99-100, 2010. (15 refs.)

The intimate link between illicit injection drug use and the spread of the human immunodeficiency virus (HIV) represents a global public health emergency. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that syringe sharing among illicit injection drug users (IDU) contributes to approximately one-third of new HIV infections outside of sub-Saharan Africa. Addressing this requires collaboration between both illicit drug control and public health systems. The authors point out that there are international agencies which continue to ignore this reality, with the most worrisome being the International Narcotics Control Board. Although various international consensus documents have highlighted the value of sterile syringe distribution programs, such as needle exchange the INCB's reluctance to support this evidence-based approach to HIV prevention has been well described. It is noted that drug control conventions should not support policy decisions which can lead to worsening of the global HIV epidemic.