Proceedings--Workshop on Needle Exchange and Bleach Distribution Programs (1994) / Chapter Skim
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U.S. NEEDLE EXCHANGE DATA
U.S. NEEDLE EXCHANGE DATA
Pages 5-64
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, SANDRA LINE, ARTHUR L REINGOLD, and JAMES SORENSEN, Needle Exchange Program Evaluation Project, The University of California In this paper we describe the multidisciplinary methods used in our report on needle exchange programs (NEPs)
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, public health officials, NEP staff members, researchers and experts in drug treatment and injection drug use, and community leaders either favoring or opposing the programs. Three team members also made two trips to CDC headquarters in Atlanta, GA early in the project to seek further input on the research questions and to delineate methods for answering them.
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The approximately 60 attendees included researchers, NEP staff, law enforcement and public health officials, injection drug users (IDUs) , and community members.
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were searched to identify local and national public opinion poll questions addressing NEPs. Per capita city AIDS case rates and selected HIV seroprevalence data were obtained from the CDC and demographic information on the cities visited came from the Bureau of the Census6 and Statistics Canada.7 Information on drug treatment availability in the US cities where site visits were conducted was obtained from the National Drug and Alcoholism Treatment Unit Survey (NDATUS)
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They were selected in consultation with the CDC to reflect the range of existing NEPs with respect to size, legal status, geographical location, IDU HIV seroprevalence, and extent of prior evaluation research. The Project Director initially called the NEP staff to explain the purpose of the project and to obtain permission to visit the NEP.
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Methodological Framework Portland, OR San Francisco, CA Santa Cruz, CA Seattle, WA Tacoma, WA Vancouver, BC In order to achieve internal and external validity for our study we utilized methodological triangulation:23 multiple data collection methods with multiple iterations. This cross-checking helps to ensure a level of confidence in the results that would otherwise be lacking.24 26 Interviews, focus groups, and NEP site observations used the Rapid Assessment Procedure (RAP)
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Table 3 Observations, Interviews, and Focus Groups Conducted Total site observations Interviews with: NEP directors and staff Public health officials IDU researchers Community leaders Focus groups with: NEP clients (~1 focus groups) NEP non-clients (7 focus groups)
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In initial telephone contacts with NEP staff, the Project Director discussed conducting anonymous focus groups with IDUs who were clients of the NEP and with those not using the NEP. NEP staff provided guidance on how best to recruit client focus group members.
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the systematic evaluation of studies of NEP impact on HIV risk behaviors; (3) the assessment and further development of existing mathematical models of NEP impact on HIV transmission; and (4)
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Do NEPs Act as Bridges to Public Health Services? Some NEPs have made significant numbers of referrals to drug abuse treatment and other public health services, but referrals are limited by the paucity of drug treatment slots.
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Who Are the IDUs Who Use NEPs? Although NEP clients vary from location to location, the programs generally reach a group of IDUs with long histories of drug injection who remain at significant risk for HIV infection.
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Do NEPs Affect Rates of HTV Drug and/or Sex Risk Behaviors? The majority of studies of NEP clients demonstrate decreased rates of HIV drug risk behavior, but not decreased rates of HIV sex risk behavior.
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Any controversy in local communities can be me zed by involving all interested communities in the planning of needle exchange services, both prior to opening the NEP and after it is implemented' to address concerns such as program sites and hours of operation. NEPs should be conceptualized as an integral part of public health efforts to stem HIV infection among drug users and should be part of a comprehensive approach to drug use, that should also emphasize expanded access to drug treatment and school- and community-based interventions to prevent the initiation and continuation of drug use.
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* Prescription laws preclude the purchase of a syringe without a prescription, limiting sterile syringe availability and creating a risk of arrest for needle exchange program staff and clients.
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4. NEP Effect on HIV Risk Behavior Do NEPs affect rates of HIV drug and/or sex risk behaviors?
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et al. The public health impact of needle exchange programs in the United States and abroad, Summary.
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Let the needles do the talking! Evaluating the , New Haven needle exchange.
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In the U.S., the controversy surrounding syringe exchange has limited opportunities for conducting researched, and no large-scale controlled studies have been carried out to date. The approach taken by many researchers has been to collect different indicators of the effects of syringe exchange, including HIV risk behavior information, HIV and hepatitis B serology, and community incidence trends, and to determine whether the relationships between exchange programs and these indicators suggest reduction in blood-borne viral transmission7~~6.
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Studies of Risk Behavior in Local IDUs Interviews with injecting drug users in the county have been carried out since 1988. The details of the methods used in this study have been described elsewhere26.
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HIV risk behavior was recorded for each client, and HIV testing was done on sera remaining after routine blood tests were performed. Case-Contro]
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Self-reported safer injection may have been influenced by subject-bias whereby exchange users would be motivated to report cessation of injection risk behavior. All interviews have been carried out by well-trained interviewers who are not affiliated with the exchange program, so subjects are unlikely to expect to gain by giving specific responses.
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From page 28... ...
Condom and bleach distribution, screening for tuberculosis and other infectious disease, health and social service referrals, and facilitation of drug treatment admission have been elements in the majority of syringe exchange programs in the U.S.2 It is also difficult to draw the line between the effects on individual users and community norms. It is conceivable that, by increasing awareness of injection-related HIV risk and establishing new norms of needlehygiene, syringe exchange's influence extends far beyond the individual user.
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Syringe-exchange programmer for injecting drug users.
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and associated risk behaviors in clients of a needle exchange in central London.
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Morris J Factors associated with risk behavior among injecting drug users.
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Exchange Users Non-Exchangers Characteristic (n=426)
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Exchange Users Non-Exchangers P.O.R.*
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:3 a a, as a o ~ Z o 1 I , b 1 : Go it?
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To determine differences between a syringe exchange program and an outreach program, Exchange clients were compared with clients of the Portland NIDA-funded NADR outreach project for IV drug users. Clients of both groups were those who were still shooting up at s~x-month followup.
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Thirteen subjects seroconverted in 63.3 person-years at risk, for an HBV seroconversion rate of 20.5 per 100 person-years at risk (95% confidence intervals 12.0, 35.~. Syringe exchange clients showed a considerable reduction in risk behavior over a range of risk behaviors measured at intake and at six months.
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There was little overlap between the samples, with the Portland NADR project finding that only 11% of its sample had ever used the syringe exchange. Thus, it appears that syringe exchanges and outreach programs might best be seen as complementary strategies that recruit and produce risk reduction among different sub-populations of drug injectors, rather than as competing options that should be chosen among to fiend which is the best approach to HIV prevention.
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In spite of the fact that syringe exchanges aim to increase the availability of (sterile) syringes for drug injectors, this exchange has not led to an increase in the number of discarded syringes with which children or others might stick themselves.
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Magnuson LT, Des Jarlais DC. Impact of needle exchange program on potentially infectious syringes in public places.
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TABLE 1 Portland Syringe Exchange Opened November 1, 1989 after more than two years of effort In its first two years: 1,145 clients made 6,378 visits 753 (demo) enrolled in this research evaluation study Syringe Distribution Summary: Dispensed: 4S,753 Returned: 45,208 Return Rate: 93~o Year 1: 87% (18,784/16,418)
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TABLE 2 Demographics Among 700 Drug Injectors Who Used the Exchange At Least Once 1.
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TABLE 5 EXCHANGE Sex NADR P < Female 20Yo 27% .15 Male 80% 73% Sexual Orientation Heterosexual 86% Unknown Gay 8% Lesbian 0% Bisexual Male 4% Bisexual Female 2% Ethnicity African American 6% 27% .001 Latino/a 8% 1% White 83% 67% Native American 3% 4% Asian/Pacific Islander 0% I% Highest Grade Completed 1- 8 6% 5% .86 9-11 50% 49% High School Graduate 16% 20% Some College 25% 24% College Graduate 3% 2% Major Source Of Income Job 47% 39% .13 Unemployment 0% 1% Disability 13% 8% Welfare 6% 14% Spouse/Partner 4% 5% Family/Friends 6% 7% Illegal Means 16% 23% Other COO 3% Where Respondent Lives Own Place 43% 30% .01 Someone Else's Place 18% 38% Boarding House 12% 7% Shelter 6% 10% On the Street 13% 11% Other 8% 4% 44
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TABLE 7 Mean number of syringes found before and after Exchange opened. Mean/Month Prior to Exchange opening After Exchange opened 5.19 1.9 Number of days on which syringes were and were not found prior to and subsequent to the opening of the Exchange.
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through December 1992 (Centers for Disease Control, 1993~. Syringe exchange programs have become a primary method of preventing HIV infection among injecting drug users in almost all developed countries (Des Jarlais & Friedman, 1992)
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We are currently conducting an evaluation study of the recently legalized syringe exchange programs in New York City. This evaluation study will address two fundamental questions: the potential effectiveness of syringe exchange in a high HIV seroprevalence environment, and the New York exchanges as a prototype for an integrated system of syringe exchanges.
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From page 49... ...
Behavioral Change and Seroconversion The fundamental goal of syringe exchange programs is to reduce AIDS risk behavior and actual transmission of HIV. Changes in AIDS risk behaviors and HIV transmission among participants are examined through a series of cross-sectional studies with recapture of subjects who participated in previous cross-sectional studies.
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Assuming an average period of between 6 and 9 months between the first and last saliva sample among the matched saliva samples, there will be an estimated 250 to 375 person years at risk for determining the rate of HIV seroconversion among regular participants in the syringe exchanges. RESULTS Organizational-System Issues Space limitations do not permit a full analysis of the complex issues involved in establishing a network of syringe exchanges within the politically complicated environment of New York City.
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Until 1992, the federal government had not funded any research on syringe exchange programs. AmFAR is funding the current syringe exchanges in New York, with privately obtained money and money from the State Department of Health.
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This method of decision-making provides for maximum egalitarian participation among the totally volunteer staff It also meant that no single person "representing" these two exchanges had authority to make commitments for the exchange. With legal authorization to operate syringe exchanges and funding from AmFAR and the State, these exchanges were required to affiliate legally with a 501 (C)
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From page 53... ...
Much of the development of positive working relationships occurred during monthly meetings hosted by AmFAR and attended by representatives of the syringe exchanges, the State Health Department and the evaluators. These meetings consisted primarily of problem identification followed by protracted, but usually successful, group problem solving.
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From page 54... ...
The "tagging question" is an example of an issue where the perceived needs of the different organizations within the system were in sharp conflict. This issue reflects a more general conflict between having tightly regulated exchanges and the HIV prevention goal of providing sterile injection equipment to as many injecting drug users as possible.
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From page 55... ...
. Self-Reported Change in Risk-Taking Behavior Participants reported that in the 30 days prior to using the syringe exchange, they injected with previously used works an average of 11.6% of the time compared to 3.9% of the time in the last 30 days while using the needle exchange (p<.001)
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The effectiveness of syringe exchanges in reducing HIV transmission among injecting drug users is thus solely a question of the ability of the service providers to provide exchange services and the subsequent behavior of the persons utilizing the services. The ability to provide services is largely determined by the specific operational procedures of the syringe exchange program, which in turn are substantially determined by the other organizations within the syringe exchange system and the availability of volunteers, and indirectly determined by a wide variety of supporters and opponents of syringe exchange.
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From page 57... ...
However, despite the evidence of drug related risk reduction among participants of syringe exchanges in NYC, sexual risk reduction still lags behind (Abdul-Quader et al., 1990; Deren et al., 1993; Des Jarlais, 1992~. Our data indicate that participants are having unprotected sex more than half of the time, whether with primary or casual partners.
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. The Role of the Needle Exchange Project in Prevention HIV Infection among Drug Users in Amsterdam.
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. Authorization to Conduct Hypodermic Syringe arid Needle Exchange Programs (10 NYCRR Section 80.135, p.
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TABLE 1 - Demographic Descriptors of Needle Exchange Participants n= 1752 iMean Age | 35.7(SD=8.0) Gender Male 1192 (70%)
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No 414 (24 boy Currently in Drug Treatment | Yes 644 (46%)
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1167 (88) use alcohol pads yes 418 (33)
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TABLE 4 Risk Behaviors Practiced by Sexually Active Needle Exchange Participants in the Last 30 Days n= 1055 Sexual Behaviors 1 1 ~ (A 1 Same Sex Primary Partner 44 (4) Primary Partner of the Opposite Sex Yes No 753 (71)
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From page 64... ...
Given the data, Moss asked, should a push be made for large-scale federal and state funding of needle exchanges? His own response to the question was a qualified yes, for two reasons: first, the United States does not have a unified strategy for reducing HIV infection among injecting drug users, despite the fact that injection drug use Is a major HIV risk factor in this country.
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