What Is It About Needle And Syringe Programmes That Make Them Effective For Preventing Hiv Transmission?

International Journal of Drug Policy 14 (2003) 361–363

Response

What is it about needle and syringe programmes that make them effective for preventing HIV transmission? Alex H. Kral a,∗ , Ricky N. Bluthenthal b a

Urban Health Studies, Department of Family and Community Medicine, University of California, San Francisco, 3180 18th Street Suite 302, San Francisco, CA 94110, USA b Drug Policy Research Center, Health Program at RAND, and Drew Center on AIDS Research, Education, and Service, Department of Psychiatry, Charles R. Drew University, USA Received 1 December 2002; received in revised form 15 March 2003; accepted 24 July 2003

In this issue of the International Journal of Drug Policy, MacDonald, Law, Kaldor, Hales, and Dore (2003) present data from an ecological study of the effectiveness of syringe exchange programmes (SEPs) in preventing HIV transmission among injection drug users (IDUs) globally (MacDonald et al., 2003). Their study found that within 99 cities internationally, HIV prevalence among IDUs decreased significantly in cities with SEPs as compared to cities without SEPs. This confirms findings from similar ecological studies conducted in the past decade (Friedman, Perlis, & Des Jarlais, 2001; Hurley, Jolley, & Kaldor, 1997; Lurie & Drucker, 1997). Ecological studies of the impact of SEPs and syringe access are amongst the most powerful research tools available as they allow us to assess community-level effectiveness of interventions. However, there are also several limitations to the use of ecological studies. Most noteworthy is that they often rely on data collected for purposes other than studying the specific research question being posed (Kleinbaum, Kupper, & Morgenstern, 1982). This often prohibits the use of key confounding and effect modifying variables, making it difficult to assess whether the observed relationship between exposure and outcome is spurious. For example, MacDonald et al. (2003) study does not control for community or SEP operational factors. While numerous studies have examined SEP effectiveness in preventing HIV transmission, few have studied how community context and SEP operational factors have an impact on effectiveness. Several community contextual factors are likely to affect SEP effectiveness (Table 1). It may be that SEPs are more effective in certain types of communi-

∗

Corresponding author. E-mail address: [email protected] (A.H. Kral).

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2003.07.002

ties than others, or that SEPs with certain operational characteristics are more effective in certain communities. It is important for researchers to study what types of SEPs are most conducive to stemming HIV transmission in different community contexts. Thus, it is crucial that studies of SEPs collect community contextual factors and report and control for them in analyses. Recent reviews of SEP studies suggest that inattention to SEP operational characteristics have biased interpretations of programme effectiveness (Bastos & Strathdee, 2000; Heimer, 1998). Indeed, the current literature on SEPs does not identify operational characteristics associated with optimal HIV risk reduction among clients (Bastos & Strathdee, 2000; Des Jarlais, 2000). There are numerous operational characteristics of SEPs that may affect their ability to prevent HIV transmission (Table 2). According to the 1998 Beth Israel/North American Syringe Exchange Network Annual Programme Survey, U.S. SEPs differ on nearly every aspect of their operations except supplies (over 90% of SEPs provide condoms, alcohol pads, bleach) (Center for Disease Control, 2001). For instance, location of SEP sites includes health vans, health clinics, shooting galleries, cars, sidewalk tables, and staff on foot. Most SEPs operate fixed site exchange with between 6 and 18% of programmes providing mobile syringe exchange or some other site types not listed by the authors. In terms of syringe distribution protocols, 27% of SEPs are strict one-for-one programmes while 73% provide either one-for-one plus extra syringes or conduct distribution based on need (Centers for Disease Control, 2001). Also, 16% of SEPs limit the number of syringes exchanged per visit. On-site HIV testing was reported by 70% of programmes, but HBV, HCV testing and counselling was provided by only 21 and 24% of SEPs, respectively. Further, only 19% of SEPs provided on-site medical care, 18% provided HBV vaccination, 15% pro-

362

A.H. Kral, R.N. Bluthenthal / International Journal of Drug Policy 14 (2003) 361–363

Table 1 Community contextual factors likely to affect effectiveness of SEPs Background HIV prevalence and incidence among IDUs (Kaplan and Heimer, 1994) Sexual mixing patterns between IDUs and other groups with high HIV prevalence (e.g. men who have sex with men) (Friedman et al., 2001) Drug (e.g. heroin, cocaine) (Bourgois, 1999) and form of drug being injected (e.g. black tar vs. white powder heroin) (Ciccarone & Bourgois, in press) Syringe prescription and possession laws (Bluthenthal, Kral, Erringer, & Edlin, 1998; Burris, Finucane, Gallagher, & Grace, 1996) Pharmacy sale of syringes (Taussig, Junge, Burris, Jones, & Sterk, 2002) Law enforcement practices (Bluthenthal, Kral, Lorvick, & Watters, 1997) Urban/suburban/rural location (Anderson et al., 2002) Syringe coverage of programme (Bastos & Strathdee, 2000) Table 2 Operational characteristics of SEPs likely to affect effectiveness of SEPs Syringe distribution policy (e.g. one-for-one, one-for-one plus some extra, need-based distribution) (Kral et al., 2002) Syringe limits (e.g. no more than 30 syringes can be exchange at one time) Geographical coverage Fixed vs. mobile and delivery service (Kral et al., 2002) Inside vs. outside fixed sites Number of hours open Days of the week and time of day of operation Ancillary services offered (e.g. medical care, methadone treatment, HIV testing and counselling) “Harm reduction” philosophy of staff (Bluthenthal, Anderson, Flynn, et al., 2002) Cultural appropriateness of staff Type and variety of syringes/needles offered Non-syringe drug paraphernalia offered

vided TB screening, and 13% provided sexually transmitted disease screening. On-site services varied by programme size with very large programmes reporting a median of seven services as compared to two to three services being offered by large, medium, and small programmes. Despite this variety, very little research has been conducted on the impact of differences in operational characteristics on client HIV risk behaviours. Researchers should study which operational characteristics are optimal for which types of communities. Ecological approaches have been used to address a number of other issues related to SEPs, including their impact on drug use among youth (Marx, Brahmbhatt, Beilenson, et al., 2001), criminal activity (Marx, Crape, Brookmeyer, et al., 2000), and biohazardous waste disposal (i.e. used syringes) (Doherty, Garfein, & Vlahov, 1997). While few existing data sources provide relevant information on community context or SEP operational factors, researchers can improve on existing ecological studies by combining secondary analysis of data (e.g. HIV prevalence) with primary data collection. For example, Friedman and colleagues are currently conducting an ecological study combining data from Holmberg’s study of HIV prevalence and incidence in 96 U.S. metropolitan areas (Holmberg, 1996) with primary collection of various community contextual and SEP operational informations (Tempalski et al., 2003). Likewise, we are currently in the last phases of data collection of SEP operational characteristics and individual-level HIV risk and prevalence among clients of all SEPs in California. Now that there is little question of the effectiveness of such programmes, hopefully new research efforts will help guide public health workers in their decisions about where and what type of SEPs to implement in their communities.

Acknowledgements Writing of this editorial was supported by the Centers for Disease Control (Grant # R06/CCR918667) and NIDA (Grant # R01 DA14210).

References Anderson, R., Kral, A. H., Flynn, N., Clancy, L., Scott, A., & Bluthenthal, R. N. (2002). Rural vs. urban: Differences among consumers’ risk behaviours and programs’ operational characteristics at California Syringe Exchange Programs. Fourth National Harm Reduction Conference, Seattle, WA, USA. Bastos, F. I., & Strathdee, S. A. (2000). Evaluating effectiveness of syringe exchange programs: Current issues and future prospects. Social Science and Medicine, 51, 1771–1782. Bluthenthal, R. N., Anderson, R., Flynn, N., Clancy, L., Anderson, K., Kahn, J.G., et al. (2002). The role of harm reduction in syringe exchange programs: Can it be measured and does it matter. Fourth National Harm Reduction Conference, Seattle, WA, USA. Bluthenthal, R. N., Kral, A. H., Erringer, E. A., & Edlin, B. R. (1998). Use of an illegal syringe exchange and injection-related risk behaviors among street-recruited injection drug users in Oakland, California, 1992–1995. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 18, 505–511. Bluthenthal, R. N., Kral, A. H., Lorvick, J., & Watters, J. K. (1997). Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco. Medical Anthropology, 18, 61– 83. Bourgois, P. (1999). Needle exchange, HIV infection and politics of science: Confronting Canada’s cocaine injection epidemic with participant observation. Medical Anthropology, 18, 1–26. Burris, S., Finucane, D., Gallagher, H., & Grace, J. (1996). The legal strategies used in operating syringe exchange programs in

A.H. Kral, R.N. Bluthenthal / International Journal of Drug Policy 14 (2003) 361–363 the United States. American Journal of Public Health, 86, 1161– 1166. Center for Disease Control (CDC). (2001). Update: Syringe exchange programs—United States, 1998. Mortality and Morbidity Weekly Report 50, 384–387. Ciccarone, D., & Bourgois, P. (in press). Explaining the geography of HIV among injection drug users in the United States. Substance Use & Misuse. Des Jarlais, D. C. (2000). Structural interventions to reduce HIV transmission among injecting drug users. AIDS, 14(Suppl. 1), S41– S46. Doherty, M., Garfein, R., & Vlahov, D. (1997). Discarded needles do not increase soon after the opening of a needle exchange program. American Journal of Epidemiology, 145, 730–737. Friedman, S. R., Perlis, T., & Des Jarlais, D. C. (2001). Laws prohibiting over-the-counter syringe sales to injection drug users: Relations to population density, HIV prevalence, and HIV incidence. American Journal of Public Health, 91, 791–793. Heimer, R. (1998). Syringe exchange programs: Lowering the transmission of syringe-borne diseases and beyond. Public Health Reports, 113(Suppl. 1), 67–74. Holmberg, S. D. (1996). The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. American Journal of Public Health, 86, 642–654. Hurley, S. F., Jolley, D. J., & Kaldor, J. M. (1997). Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet, 349, 1797–1800. Kaplan, E. H., & Heimer, R. (1994). A circulation theory of needle exchange. AIDS, 8, 567–574.

363

Kleinbaum, D. G., Kupper, L. L., & Morgenstern, H. (1982). Epidemiologic research: Principles and quantitative methods. New York: Van Nostrand Reinhold. Kral, A. H., Anderson, R., Clancy, L., Flynn, N., Kahn, J. G., & Bluthenthal, R. N. (2002). Injection risk behaviors among clients of SEPs with different operational characteristics: The California Syringe Exchange Study. Twelfth North American Syringe Exchange Convention, Albuquerque, NM, USA. Lurie, P., & Drucker, E. (1997). An opportunity lost: HIV infections associated with lack of a national needle-exchange program in the USA. Lancet, 349, 604–608. MacDonald, M., Law, M., Kaldor, J., Hales, J., & Dore, G. (2003). Ecological analyses and the evaluation of needle syringe programmes. International Journal of Drug Policy Drupol, 14, 359–360. Marx, M. A., Brahmbhatt, H., & Beilenson, P. et al. (2001). Impact of needle exchange programs on adolescent perceptions about illicit drug use. AIDS and Behaviour, 5, 379–386. Marx, M. A., Crape, B., Brookmeyer, R. S., Junge, B., Latkin, C., & Vlahov, D. et al. (2000). Trends in crime and the introduction of a needle exchange program. American Journal of Public Health, 90, 1933–1936. Taussig, J., Junge, B., Burris, S., Jones, T. S., & Sterk, C. E. (2002). Individual and structural influences shaping pharmacists’ decisions to sell syringes to injection drug users in Atlanta, Georgia. Journal of the American Pharmaceutical Association, 42(Pt 6 Suppl. 2), S40–45. Tempalski, B., Friedman, S. R., Des Jarlais, D. C., McKnight, C., Keem, M., & Friedman, R. (2003). What predicts which US metropolitan areas have syringe exchanges? International Journal of Drug Policy, 14, 417–424.