Peer Reviewed Research About Syringe Service Programs

Below is a compilation of peer-reviewed research about the public health impact of Syringe Service Programs (SSPs) since 2007. SSPs have an extensive evidence base that goes back nearly three decades. Meta-analyses reviewing this body of research are included on this list.

 

Year

Cost Effectiveness

(2019) Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, WenUsing Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia
(2019) Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, WenUsing Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia
Year:
2019
Citation:

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Study Methods:

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Gap in evidence addressed:

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Key Findings:

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

(2014) Nguyen, Weir, Des Jarlais, Pinkerton, HoltgraveSyringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment.
(2014) Nguyen, Weir, Des Jarlais, Pinkerton, HoltgraveSyringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment.
Year:
2014
Citation:
AIDS Behavior 18(11):2144-55. doi: 10.1007/s10461-014-0789-9.
Study Methods:

The strategy for answering this question is to start from an equation for the number of new HIV infections due to injection drug use over a 1-year period, and to relate parameters in this equation to syringe supply. Such equation would allow us to estimate how a hypothetical increase in syringe supply would affect the number of new infections. The initial equation is based on the premise that the number of new infections in a year equals the number of uninfected (thus at risk) persons times the probability that an uninfected person becomes infected over the course of the year.

Gap in evidence addressed:

The key question is if NSP syringe supply were increased by a certain amount, what would happen to the number of people contracting HIV? If we could answer this question, we could evaluate the cost effectiveness of such hypothetical increase in NSP syringe supply by costing it and estimating savings resulting from infections averted.

Key Findings:

In the base case scenario with no additional syringe exchange funding, an estimated 2,575 HIV infections occur in a year due to drug injection risk. Based on lifetime treatment costs of $391,223 in 2011 USD per infection, the total treatment costs for these infections is $1.01 billion. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion. These analyses indicate that it would be highly cost-saving to invest additional funds to expand syringe exchange services in the US. Over the course of 1 year an additional investment of only $10 million would avert an estimated 194 HIV infections and avoid $75.8 million in lifetime HIV treatment costs (saving $65.8 million net), representing a rate of financial return on investment of 7.58. If the investment increase were $50 million, it would also be highly cost-saving: approximately 816 HIV infections would be averted, equivalent to nearly one-third (32 %) of the annual number of new HIV infections due to drug injection risk; $319.1 million of lifetime HIV treatment costs would be avoided (net savings $269.1 million), representing a 6.38 rate of financial return on investment. Sensitivity analyses showed that when uncertainties about parameter values were accounted for, investment increase remained highly cost-saving.

(2012) Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, WilsonEstimating the cost-effectiveness of needle-syringe programs in Australia.
(2012) Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, WilsonEstimating the cost-effectiveness of needle-syringe programs in Australia.
Year:
2012
Citation:
AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.
Study Methods:

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

Gap in evidence addressed:

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

Key Findings:

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

(2008) Belani, Hrishikesh, MuennigCost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City
(2008) Belani, Hrishikesh, MuennigCost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City
Year:
2008
Citation:
Journal of HIV/AIDS & Social Services, 7(3) 229-240 https://doi.org/10.1080/15381500802307492
Study Methods:

Using data specific to the Lower East Side Harm Reduction Center in New York City, we assessed the cost-effectiveness of NSE over a range of conservative estimates of efficacy, obtained from both longitudinal and small-area studies. A decision-analysis model was created to compare the outcomes and costs associated with NSE. Model inputs included the cost of living with HIV and the seroprevalence of HIV among injection drug users in New York City. This analysis was conducted from both the government and societal perspectives.

Gap in evidence addressed:

Shared needle and syringe use among injection drug users continues to be a major mode of transmission of HIV. Needle and syringe exchange (NSE) may be a viable strategy to reduce the transmission of the virus; yet the difficulty in measuring the actual efficacy of NSE has limited attempts to evaluate the cost-effectiveness of the intervention.

Key Findings:

Tested over a range of conservative parameter estimates, NSE appears to save money and lives. The NSE program we evaluated cost $502 per client and produced a gain of 0.01 quality adjusted life years per client. It also reduced HIV treatment costs by $325,000 per case of HIV averted, and averted 4-7 HIV infections per 1000 clients, producing a net cost savings.

Expert Guidance

(2018) Centers for Disease Control & Prevention, compmiled by Carroll, Green, NoonanEvidence-Based Strategies for Preventing Opioid Overdose: What�s Working in the United States An Introduction for Public Heath, Law Enforcement, Local Organizations, and Others Striving to Serve Their Community.
(2018) Centers for Disease Control & Prevention, compmiled by Carroll, Green, NoonanEvidence-Based Strategies for Preventing Opioid Overdose: What�s Working in the United States An Introduction for Public Heath, Law Enforcement, Local Organizations, and Others Striving to Serve Their Community.
Year:
2018
Citation:
https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
Study Methods:
Gap in evidence addressed:
Key Findings:

Syringe services programs are a key component of overdose prevention strategies, because they can facilitate access to and uptake of services and interventions for reducing overdose, enhancing health and wellbeing, and improving public health and public safety. First, some, but not all, people who use drugs experience homelessness, poverty, and other social or financial insecurities that make acquiring clean injection equipment challenging, even in locations where syringes can be purchased without a prescription. The free distribution of clean injection equipment lowers the frequency of syringe sharing and re-use,89�91 with major protective impacts on the rates of infectious diseases like HIV and hepatitis C as well as other injection-related infections or soft tissue injury.92,93 Individuals who participate in syringe services programs are also more likely to seek treatment for a substance use disorder.94 Second, syringe services programs provide people who use drugs a non-judgmental environment in which they are able to build supportive and trusting relationships, talk freely about their needs and concerns, and re-enforce feelings of self-worth, empowerment, and control. Relief from the shame and judgment carried by the stigma associated with drug use gives people the freedom to think objectively about the risks their drug use may pose to themselves and others and to strategize steps they can take to mitigate those risks. For people who are socially marginalized and have internalized stigma about their drug use, these services can substantially benefit their safety and chances of survival. Third, if and when someone who uses drugs chooses to seek medical care, naloxone access, or substance abuse treatment, syringe services programs and their staff are able to help their participants connect with and navigate these services, making syringe services programs a key component of overdose prevention efforts on all fronts.

(2016) Centers for Disease Control & PreventionHIV and Injection Drug Use: Syringe Service Programs for HIV Prevention
(2016) Centers for Disease Control & PreventionHIV and Injection Drug Use: Syringe Service Programs for HIV Prevention
Year:
2016
Citation:
https://www.cdc.gov/vitalsigns/pdf/2016-12-vitalsigns.pdf
Study Methods:
Gap in evidence addressed:
Key Findings:

Syringe services programs (SSPs) can play a role in preventing HIV and other health problems among PWID. They provide access to sterile syringes and should also provide comprehensive services such as help with stopping substance misuse; testing and linkage to treatment for HIV, hepatitis B, and hepatitis C; education on what to do for an overdose; and other prevention services. State and local health departments can work with their lawmakers and law enforcement to make SSPs more available to PWID.

(2016) American Medical AssociationSyringe and Needle Exchange Programs H-95.958
(2016) American Medical AssociationSyringe and Needle Exchange Programs H-95.958
Year:
2016
Citation:
https://policysearch.ama-assn.org/policyfinder/detail/syringe?uri=%2FAMADoc%2FHOD.xml-0-5337.xml
Study Methods:
Gap in evidence addressed:
Key Findings:

Our AMA: (1) encourages all communities to establish needle exchange programs and physicians to refer their patients to such programs; (2) will initiate and support legislation providing funding for needle exchange programs for injecting drug users; and (3) strongly encourages state medical associations to initiate state legislation modifying drug paraphernalia laws so that injection drug users can purchase and possess needles and syringes without a prescription and needle exchange program employees are protected from prosecution for disseminating syringes.

(2013) American Public Health AssociationDefining and Implementing a Public Health Response to Drug Use and Misuse
(2013) American Public Health AssociationDefining and Implementing a Public Health Response to Drug Use and Misuse
Year:
2013
Citation:
https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/08/08/04/defining-and-implementing-a-public-health-response-to-drug-use-and-misuse
Study Methods:
Gap in evidence addressed:
Key Findings:

Drug use and misuse continue to create public health challenges in the United States, leading to overdose deaths, HIV and hepatitis C infections, and other chronic health conditions. Public health approaches offer effective, evidence-based responses, but some of the most effective interventions are not currently allowed in the United States owing to outdated drug laws, attitudes, and stigma. Substance misuse treatment is too often unavailable or unaffordable for the people who want it. A criminal justice response, including requiring arrest to access health services, is ineffective and leads to other public health problems. This policy statement calls on federal, state, and local elected officials and agency staff, health care professionals, community health workers, and other stakeholders to support a full reorientation toward a health approach to drug use, including the evaluation of promising practices from other countries for domestic implementation. In addition, it recommends ending the criminalization of drugs and drug consumers, prioritizing proven treatment and harm reduction strategies, and expanding (and removing barriers to) treatment and harm reduction services, including repealing any bans on funding syringe access programs.

(2011) US Surgeon General, Department of Health and Human ServicesDetermination That a Demonstration Needle Exchange Program Would be Effective in Reducing Drug Abuse and the Risk of Acquired Immune Deficiency Syndrome Infection Among Intravenous Drug Users
(2011) US Surgeon General, Department of Health and Human ServicesDetermination That a Demonstration Needle Exchange Program Would be Effective in Reducing Drug Abuse and the Risk of Acquired Immune Deficiency Syndrome Infection Among Intravenous Drug Users
Year:
2011
Citation:
https://harmreduction.org/wp-content/uploads/2012/01/FederalRegisterVol76No36Feb232011.pdf
Study Methods:
Gap in evidence addressed:
Key Findings:

SSPs are widely considered to be an effective way of reducing HIV transmission among individuals who inject illicit drugs and there is ample evidence that SSPs also promote entry and retention into treatment. According to research that tracks individuals in treatment over extended periods of time, most people who get into and remain in treatment can reduce or stop using illegal or dangerous drugs. In addition to promoting entry to treatment, there are studies that document injection reductions for drug users who participate in SSPs. Hagan, et al., found that, not only were new SSP participants five times more likely to enter drug treatment than non-SSP participants, former SSP participants were more likely to report significant reduction in injection, to stop injecting altogether, and to remain in drug treatment. The Surgeon General of the United States Public Health Service has therefore determined that a demonstration syringe services program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for acquired immune deficiency syndrome. The Department of Health and Human Services plans to issue guidelines regarding implementation requirements for SSPs based on this determination.

Healthcare Access Point

(2018) Eckhardt, Scherer, Winkelstein, Marks, EdlinHepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program
(2018) Eckhardt, Scherer, Winkelstein, Marks, EdlinHepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program
Year:
2018
Citation:
Open Forum Infectious Disease 5(4) doi:�10.1093/ofid/ofy048
Study Methods:
SSP participants with confirmed HCV antibody positivity were eligible for enrollment. Recruitment was initially limited to those who had injected in the past 30 days, but starting in the spring of 2016, all interested WHCP participants were enrolled. Participants with clinical evidence of decompensated cirrhosis or deemed to have a life expectancy of less than 1 year were excluded from the co-located treatment program and referred to existing clinic-based services. Fifty-three participants started therapy, and 91% achieved sustained virologic response.�
Gap in evidence addressed:
Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP).�To our knowledge, this is the first study examining the effectiveness of a new model of care known as an Accessible Care Program, in which HCV treatment is co-located within an SSP and provides individualized education and support to meet participants� needs.
Key Findings:
SSPs provide an effective venue for HCV treatment. These data provide further evidence that PWID can achieve similar cure rates to those seen in clinical trials. Despite a limited sample size, high rates of SVR were seen across subgroups irrespective of sex, homelessness, active injection drug use, or the presence of advanced fibrosis.
(2017) Stopka, Hutcheson, DonahueAccess to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU ("I do") Care Collaborative
(2017) Stopka, Hutcheson, DonahueAccess to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU ("I do") Care Collaborative
Year:
2017
Citation:
Harm Reduction Journal 14:26 https://doi.org/10.1186/s12954-017-0151-4
Study Methods:

Between December 2014 and January 2015, we conducted in-depth interviews (n?=?14) with SEP staff, including both program managers and health navigators, to assess knowledge, attitudes, and beliefs related to health insurance enrollment and access to enhanced referrals among SEP clients. We developed a preliminary coding scheme from the interview guide and used a grounded theory approach to guide inclusion of subsequent thematic codes that emanated from the data. We analyzed the coded data thematically in an iterative fashion using a consensus-based approach.

Gap in evidence addressed:

Little is known about access to health insurance among people who inject drugs (PWID) who attend syringe exchange programs (SEPs). The goal of the current study was to assess perceptions of SEP staff, including health navigators and program managers, on access to health insurance and healthcare access among SEP clients following implementation of state and federal policies to enhance universal healthcare access in Massachusetts.

Key Findings:

We identified five primary themes that emerged from the qualitative interviews, including high levels of health insurance enrollment among SEP clients; barriers to enrolling in health insurance; highly needed referrals to services, including improved access to substance use disorder treatment and hepatitis C virus treatment; barriers to referring clients to these highly needed services; and recommendations for policy change. While barriers to enrollment and highly needed referrals remain, access to and enrollment in healthcare insurance plans among PWID at SEPs in Massachusetts are high. With the uncertain stability of the Affordable Care Act following the US presidential election of 2016, our findings summarize the opportunities and challenges that are connected to health insurance and healthcare access in Massachusetts. SEPs can play an important role in facilitating access to health insurance and enhancing access to preventive health and primary care.

(2016) Barocas, Linas, Kim, Fangman, WestergaardAcceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs
(2016) Barocas, Linas, Kim, Fangman, WestergaardAcceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs
Year:
2016
Citation:
Open Forum Infectious Disease 3(2): doi:�10.1093/ofid/ofw075
Study Methods:
We surveyed PWID utilizing a free, multisite SEP operating in Southern Wisconsin between June and August 2012.� Over the 8-week study period, 862 consecutive SEP participants were invited to participate in the study. Five hundred fifty-three eligible participants (64%) agree to complete the survey, and 497 participants provided information on their HCV serostatus.
Gap in evidence addressed:
People who inject drugs may benefit from point-of-care hepatitis C virus (HCV) testing offered at syringe exchanges. We sought to understand whether this population would be willing to undergo rapid HCV testing. We found that there was broad support for rapid HCV testing, especially among younger people who inject drugs with high perceived risk.
Key Findings:
Our study suggests that a rapid POC HCV test could be used at SEPs to screen a high-risk population with a high incidence of HCV. Ideally, rapid testing could be performed at SEPs because they provide continuity for many PWID who do not otherwise access the healthcare system due to mistrust, stigma, and lack of resources. As cost of HCV therapies begins to decrease and restrictions are lifted on treatment of those with active drug use, future studies should investigate the use of rapid HCV testing and direct linkage to HCV treatment.
(2012) Islam, Topp, Conigrave, White, Reid, Grummett, Haber, DayLinkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre.
(2012) Islam, Topp, Conigrave, White, Reid, Grummett, Haber, DayLinkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre.
Year:
2012
Citation:
Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007
Study Methods:

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Gap in evidence addressed:

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Key Findings:

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Infectious Disease Prevention

(2020) Rossi, Brady, Hall, WarshakEffect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence
(2020) Rossi, Brady, Hall, WarshakEffect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence
Year:
2020
Citation:

Am J Perinatol. 2020 Jan 21. doi: 10.1055/s-0039-3402753

Study Methods:

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of maternal HCV was compared before (2006-2011) and after (2012-2015) the implementation of an NEP (2011) in Portsmouth, Ohio (Scioto County). Trends in maternal HCV prevalence in neighboring counties both physically adjacent and regional to Scioto County were also evaluated before and after NEP implementation.

Gap in evidence addressed:

To quantify the prevalence of maternal hepatitis C virus (HCV) before and after implementation of the needle exchange program (NEP) in Scioto County, Ohio.

Key Findings:

Rate of maternal HCV infection increased 137% versus 12% (rate difference: 125%) between pre- and post-NEP implementation time periods in Scioto County.During the study period, there were 7,069 reported cases of maternal HCV infection at the time of delivery among 1,463,506 (0.5%) live births in Ohio. The rate of maternal HCV infection increased 137% in Scioto County between 2006 and 2011. After initiation of the NEP in Portsmouth, Ohio, in 2011, the rate of increase in the following 4 years (2012-2015) was 12%. The rate of increase in maternal HCV declined precipitously in counties physically adjacent to Scioto County, whereas regional counties continued to have substantial increases in maternal HCV.

(2019) Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, WenUsing Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia
(2019) Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, WenUsing Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia
Year:
2019
Citation:

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Study Methods:

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Gap in evidence addressed:

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Key Findings:

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

(2019) Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, MarshallImplementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study
(2019) Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, MarshallImplementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study
Year:
2019
Citation:

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

Study Methods:
In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.
Gap in evidence addressed:

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

Key Findings:

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

(2018) Paquette, Syvertsen, PolliniStigma at every turn: Health services experiences among people who inject drugs
(2018) Paquette, Syvertsen, PolliniStigma at every turn: Health services experiences among people who inject drugs
Year:
2018
Citation:
International Journal of Drug Policy Volume 57, July 2018, Pages 104-110
Study Methods:

We conducted 46 qualitative interviews with PWID in California’s Central Valley between March and December 2015, as part of a multi-phase, multi-method study examining implementation of a new pharmacy syringe access law. A “risk environment” framework guided our data collection and we used a deductive/inductive approach to analyze the qualitative data.

Gap in evidence addressed:

People who inject drugs (PWID) encounter varying forms of stigma in health services contexts, which can contribute to adverse outcomes. We explored the lived experience of stigma among PWID to elucidate pathways by which stigma influences health care access and utilization.

Key Findings:

Stigma played an undeniably important role in PWID’s experiences with health services access and utilization in the Central Valley. Our study illustrates the need to develop and test interventions that target drug use stigma at both structural and individual levels to minimize adverse effects on PWID health. Participants repeatedly cited the impact of stigma on syringe access, particularly in the context of meso-level pharmacist interactions. They described being denied syringe purchase as stigmatizing and embarrassing, and these experiences discouraged them from attempting to purchase syringes under the new pharmacy access law. Participants described feeling similarly stigmatized in their meso-level interactions with first responders and hospital staff, and associated this stigmatization with delayed and substandard medical care for overdoses and injection-related infections. Drug treatment was another area where stigma operated against PWID’s health interests; participants described macro-level public stigma towards methadone (e.g., equating methadone treatment with illicit drug use) as discouraging participation in this evidence-based treatment modality and justifying exclusion of methadone patients from recovery support services like sober living and Narcotics Anonymous.

(2018) Gonsalves, CrawfordDynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study
(2018) Gonsalves, CrawfordDynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study
Year:
2018
Citation:
Study Methods:

In this modelling study, we derived weekly case data from the HIV outbreak in Scott County, IN, and on the uptake of HIV testing, treatment, and prevention services from publicly available reports from the US Centers for Disease Control and Prevention (CDC) and researchers from Indiana. Our primary objective was to determine if an earlier response to the outbreak could have had an effect on the number of people infected. We computed upper and lower bounds for cumulative HIV incidence by digitally extracting data from published images from a CDC study using Bio-Rad avidity incidence testing to estimate the recency of each transmission event. We constructed a generalisation of the susceptible-infectious-removed model to capture the transmission dynamics of the HIV outbreak. We computed non-parametric interval estimates of the number of individuals with an undiagnosed HIV infection, the case-finding rate per undiagnosed HIV infection, and model-based bounds for the HIV transmission rate throughout the epidemic. We used these models to assess the potential effect if the same intervention had begun at two key timepoints earlier than the actual date of the initiation of efforts to control the outbreak.

Gap in evidence addressed:

In November, 2014, a cluster of HIV infections was detected among people who inject drugs in Scott County, IN, USA, with 215 HIV infections eventually attributed to the outbreak. This study examines whether earlier implementation of a public health response could have reduced the scale of the outbreak.

Key Findings:

The upper bound for undiagnosed HIV infections in Scott County peaked at 126 around Jan 10, 2015, over 2 months before the Governor of Indiana declared a public health emergency on March 26, 2015. Applying the observed case-finding rate scale-up to earlier intervention times suggests that an earlier public health response could have substantially reduced the total number of HIV infections (estimated to have been 183-184 infections by Aug 11, 2015). Initiation of a response on Jan 1, 2013, could have suppressed the number of infections to 56 or fewer, averting at least 127 infections; whereas an intervention on April 1, 2011, could have reduced the number of infections to ten or fewer, averting at least 173 infections. Early and robust surveillance efforts and case finding alone could reduce nascent epidemics. Ensuring access to HIV services and harm-reduction interventions could further reduce the likelihood of outbreaks, and substantially mitigate their severity and scope.

(2018) Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, DombrowskiCombination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment.
(2018) Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, DombrowskiCombination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment.
Year:
2018
Citation:
PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356
Study Methods:

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Gap in evidence addressed:

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Key Findings:

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

(2018) Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, VickermanScaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic.
(2018) Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, VickermanScaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic.
Year:
2018
Citation:

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

Study Methods:

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Gap in evidence addressed:

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

Key Findings:

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

(2017) Campbell, Canary, Smith, Teshale, Blythe Ryerson, WardState HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016
(2017) Campbell, Canary, Smith, Teshale, Blythe Ryerson, WardState HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016
Year:
2017
Citation:
MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2
Study Methods:

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

Gap in evidence addressed:

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Key Findings:

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

(2017) Dahlman, Hakansson, Kral, Wenger, Ball, NovakBehavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study
(2017) Dahlman, Hakansson, Kral, Wenger, Ball, NovakBehavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study
Year:
2017
Citation:
Substance Abuse 38(1):105-112. doi 10.1080/08897077.2016.1263592
Study Methods:

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

Gap in evidence addressed:

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

Key Findings:

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant. CONCLUSION SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

(2017) Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, CarneiroEffectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews
(2017) Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, CarneiroEffectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews
Year:
2017
Citation:
BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2
Study Methods:

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Gap in evidence addressed:

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

Key Findings:

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

(2015) Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, HodelState laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness
(2015) Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, HodelState laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness
Year:
2015
Citation:
Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54
Study Methods:

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Gap in evidence addressed:

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

Key Findings:

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

(2015) Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, HoltzmanSyringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013
(2015) Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, HoltzmanSyringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013
Year:
2015
Citation:
MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm
Study Methods:

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

Gap in evidence addressed:

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Key Findings:

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

(2014) MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, HutchinsonInterventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness.
(2014) MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, HutchinsonInterventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness.
Year:
2014
Citation:
International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.
Study Methods:

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Gap in evidence addressed:

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Key Findings:

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

(2014) Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, HutchinsonRapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions.
(2014) Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, HutchinsonRapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions.
Year:
2014
Citation:
PLoS One 9(8) doi: 10.1371/journal.pone.0104515.
Study Methods:

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Gap in evidence addressed:

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

Key Findings:

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

(2014) Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, HutchinsonAre needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis.
(2014) Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, HutchinsonAre needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis.
Year:
2014
Citation:
International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.
Study Methods:

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Gap in evidence addressed:

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

Key Findings:

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

(2012) Vickerman, Martin, Turner, HickmanCan needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings.
(2012) Vickerman, Martin, Turner, HickmanCan needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings.
Year:
2012
Citation:
Addiction 107(11):1984-95. doi: 10.1111/j.1360-0443.2012.03932.x.
Study Methods:

Hepatitis C virus HCV transmission modeling using U.K. estimates for effect of OST and 100% NSP on individual risk of HCV infection.

Gap in evidence addressed:

To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs).

Key Findings:

For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCVprevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ?80%. Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

(2011) Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, MillsonGuidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs)
(2011) Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, MillsonGuidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs)
Year:
2011
Citation:
International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007
Study Methods:

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

Gap in evidence addressed:

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

Key Findings:

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

(2011) Hagan, Pouget, Des JarlaisA systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs.
(2011) Hagan, Pouget, Des JarlaisA systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs.
Year:
2011
Citation:
Journal of Infectious Diseases 204(1):74-83. doi: 10.1093/infdis/jir196.
Study Methods:

We performed a systematic review and meta-analysis of published and unpublished studies. Eligible studies reported on the association between participation in interventions intended to reduce unsafe drug injection and HCV seroconversion in samples of PWID.

Gap in evidence addressed:

High rates of hepatitis C virus (HCV) transmission are found in samples of people who inject drugs (PWID) throughout the world. The objective of this paper was to meta-analyze the effects of risk-reduction interventions on HCV seroconversion and identify the most effective intervention types.

Key Findings:

The meta-analysis included 26 eligible studies of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions. Interventions using multiple combined strategies reduced risk of seroconversion by 75% (pooled relative risk, .25; 95% confidence interval, .07-.83). Effects of single-method interventions ranged from .6 to 1.6. Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion. Determining the effective dose and combination of interventions for specific subgroups of PWID is a research priority. However, our meta-analysis shows that HCV infection can be prevented in PWID.

(2010) Palmateer, Kimber, Hickman, Hutchinson, Rhodes, GoldbergEvidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus
(2010) Palmateer, Kimber, Hickman, Hutchinson, Rhodes, GoldbergEvidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus
Year:
2010
Citation:
Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.
Study Methods:

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

Gap in evidence addressed:

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

Key Findings:

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

(2009) Des Jarlais, McKnight, Goldblatt, PurchaseDoing harm reduction better: syringe exchange in the United States.
(2009) Des Jarlais, McKnight, Goldblatt, PurchaseDoing harm reduction better: syringe exchange in the United States.
Year:
2009
Citation:
Addiction 104(9):1441-6. doi: 10.1111/j.1360-0443.2008.02465.x.
Study 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.

Gap in evidence addressed:

To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs.

Key Findings:

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 US dollars and public funding (from state and local governments) has increased from 3.9 to 14.4 million US dollars. 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. 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.

(2009) Kwon, Iversen, Maher, Law, WilsonThe impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: a model-based analysis.
(2009) Kwon, Iversen, Maher, Law, WilsonThe impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: a model-based analysis.
Year:
2009
Citation:
Journal of Acquired Immune Deficiency Syndrome 51(4):462-9. doi: 10.1097/QAI.0b013e3181a2539a.
Study Methods:

We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

Gap in evidence addressed:

We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

Key Findings:

HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then approximately 3 times the incidence could be expected.

(2008) Wodak, McLeodThe role of harm reduction in controlling HIV among injecting drug users
(2008) Wodak, McLeodThe role of harm reduction in controlling HIV among injecting drug users
Year:
2008
Citation:
AIDS 22(Suppl 2): S81-S92. doi:10.1097/01.aids.0000327439.20914.33
Study Methods:

Literature review

Gap in evidence addressed:

The scientific debate about harm reduction is now over: harm reduction has been shown convincingly to be effective in reducing HIV, and to be safe and cost-effective. After almost 20 years of looking for possible serious harmful side effects, no rigorous evidence has yet emerged that harm reduction encourages the earlier initiation of injecting, more frequent injecting, or a more prolonged injecting career.

Key Findings:

The abundance, consistency and compelling nature of the evidence supporting harm reduction has not prevented a ferocious ideological debate between advocates of an evidence-based, public health approach and supporters of zero tolerance. At best, only 5% of IDU in the world are estimated currently to have access to HIV prevention services. Only a small number of countries, led by the USA, are still vehemently opposed to harm reduction. Excessive reliance on drug law enforcement remains the major barrier to increased adoption of harm reduction. Sometimes zealous drug law enforcement undermines harm reduction. A more balanced approach to drug law enforcement is required with illicit drug use recognized primarily as a health and social problem

(2007) Bluthenthal, Anderson, Flynn, KralHigher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients
(2007) Bluthenthal, Anderson, Flynn, KralHigher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients
Year:
2007
Citation:
Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035
Study Methods:

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

Gap in evidence addressed:

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

Key Findings:

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Injecting Risk

(2014) Beletsky, Heller, Jenness, Neaigus, Gelpi-Acosta, HaganSyringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspective
(2014) Beletsky, Heller, Jenness, Neaigus, Gelpi-Acosta, HaganSyringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspective
Year:
2014
Citation:
International Journal of Drug Policy 25(1) 105-11. https://doi.org/10.1016/j.drugpo.2013.06.005
Study Methods:

New York City IDUs recruited through respondent-driven sampling were asked about past-year police encounters and risk behaviours, as part of the National HIV Behavioural Surveillance study. Data were analysed using multiple logistic regression.

Gap in evidence addressed:

Injection drug user (IDU) experience and perceptions of police practices may alter syringe exchange program (SEP) use or influence risky behaviour. Previously, no community-level data had been collected to identify the prevalence or correlates of police encounters reported by IDUs in the United States.

Key Findings:

A majority (52%) of respondents (n=514) reported being stopped by police officers; 10% reported syringe confiscation. In multivariate modelling, IDUs reporting police stops were less likely to use SEPs consistently (adjusted odds ratio [AOR]=0.59; 95% confidence interval [CI]=0.40-0.89), and IDUs who had syringes confiscated may have been more likely to share syringes (AOR=1.76; 95% CI=0.90-3.44), though the finding did not reach statistical significance. Findings suggest that police encounters may influence consistent SEP use. The frequency of IDU-police encounters highlights the importance of including contextual and structural measures in infectious disease risk surveillance, and the need to develop approaches harmonizing structural policing and public health.

(2012) Ivsins, Chow, Macdonald, Stockwell, Vallance, Mars, Michelow, DuffAn examination of injection drug use trends in Victoria and Vancouver, BC after the closure of Victoria's only fixed-site needle and syringe programme.
(2012) Ivsins, Chow, Macdonald, Stockwell, Vallance, Mars, Michelow, DuffAn examination of injection drug use trends in Victoria and Vancouver, BC after the closure of Victoria's only fixed-site needle and syringe programme.
Year:
2012
Citation:
International Journal of Drug Policy 23(4):338-40. doi: 10.1016/j.drugpo.2011.11.004
Study Methods:

Quantitative and qualitative data were collected by interviewer-administered questionnaires conducted with injection drug users (n=579) in Victoria and Vancouver between late 2007 and late 2010.

Gap in evidence addressed:

Needle and syringe programmes (NSPs) have been established as effective harm reduction initiatives to reduce injection drug use (IDU)-related risk behaviours, including sharing needles. On May 31, 2008, Victoria, BC's only fixed site NSP was shut down due to community and political pressure. This study examines and compares IDU trends in Victoria with those in Vancouver, BC, a city which has not experienced any similar disruption of IDU-related public health measures.

Key Findings:

Needle sharing increased in Victoria from under 10% in early 2008 to 20% in late 2010, whilst rates remained relatively low in Vancouver. Participants in Victoria were significantly more likely to share needles than participants in Vancouver. Qualitative data collected in Victoria highlight the difficulty participants have experienced obtaining clean needles since the NSP closed. Recent injection of crack cocaine was independently associated with needle sharing. The closure of Victoria's fixed site NSP has likely resulted in increased engagement in high-risk behaviours, specifically needle sharing. Our findings highlight the contribution of NSPs as an essential public health measure.

(2012) Hyshka, Strathdee, Wood, KerrNeedle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research.
(2012) Hyshka, Strathdee, Wood, KerrNeedle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research.
Year:
2012
Citation:
Inernational Journal of Drug Policy 23(4):261-70. doi: 10.1016/j.drugpo.2012.03.006
Study Methods:

We review 15 years of peer-reviewed research on Vancouver's NEP to describe what has been learned through this work. Our review demonstrates that: (1) NEP attendance is not causally associated with HIV infection, (2) frequent attendees of Vancouver's NEP have higher risk profiles which explain their increased risk of HIV seroconversion, and (3) a number of policy concerns, as well as the high prevalence of cocaine injecting contributed to the failure of the NEP to prevent the outbreak.

Gap in evidence addressed:

During the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injection drug users (IDU) and many questioned how this could occur in the presence of a high volume needle exchange program (NEP). Specific concerns were fuelled by early research demonstrating that frequent needle exchange program attendees were more likely to be HIV positive than those who attended the NEP less frequently. Since then, some have misinterpreted this finding as evidence that NEPs are ineffective or potentially harmful.

Key Findings:

Keys to success include refocusing the NEP away from an emphasis on public order objectives by separating distribution and collection functions, removing syringe distribution limits and decentralizing and diversifying NEP services. Additionally, our review highlights the importance of context when implementing NEPs, as well as ongoing evaluation to identify factors that constrain or improve access to sterile syringes.

(2010) Kerr, Small, Buchner, Zhang, Li, Montaner, WoodSyringe sharing and HIV incidence among injection drug users and increased access to sterile syringes.
(2010) Kerr, Small, Buchner, Zhang, Li, Montaner, WoodSyringe sharing and HIV incidence among injection drug users and increased access to sterile syringes.
Year:
2010
Citation:
American Journal of Public Health, 100(8):1449-53. doi: 10.2105/AJPH.2009.178467
Study Methods:

Using a multivariate generalized estimating equation and Cox regression methods, we examined syringe borrowing, syringe lending, and HIV incidence among a prospective cohort of 1228 injection drug users in Vancouver, British Columbia.

Gap in evidence addressed:

We assessed the effects of syringe exchange program (SEP) policy on rates of HIV risk behavior and HIV incidence among injection drug users.

Key Findings:

We observed substantial declines in rates of syringe borrowing (from 20.1% in 1998 to 9.2% in 2003) and syringe lending (from 19.1% in 1998 to 6.8% in 2003) following SEP policy change. These declines coincided with a statistically significant increase in the proportion of participants accessing sterile syringes from nontraditional SEP sources (P< .001). In multivariate analyses, the period following the change in SEP policy was independently associated with a greater than 40% reduction in syringe borrowing (adjusted odds ratio [AOR] = 0.57; 95% confidence interval [CI] = 0.49, 0.65) and lending (AOR = 0.52; 95% CI = 0.45, 0.60), as well as declining HIV incidence (adjusted hazard ratio = 0.13; 95% CI = 0.06, 0.31). Widespread syringe distribution appears to be a more effective SEP policy than do more restrictive SEP policies that limit syringe access. Efforts should be made to ensure that SEP policies and program design serve to maximize rather than hinder syringe access.

(2009) Holtzman, Barry, Ouellet, Des Jarlais, Vlahov, Golub, Hudson, GarfeinThe influence of needle exchange programs on injection risk behaviors and infection with hepatitis C virus among young injection drug users in select cities in the United States, 1994-2004.
(2009) Holtzman, Barry, Ouellet, Des Jarlais, Vlahov, Golub, Hudson, GarfeinThe influence of needle exchange programs on injection risk behaviors and infection with hepatitis C virus among young injection drug users in select cities in the United States, 1994-2004.
Year:
2009
Citation:
Prevention Medicine 49(1):68-73. doi: 10.1016/j.ypmed.2009.04.014
Study Methods:

Data were drawn from three multi-site studies carried out in four major cities that enrolled IDUs over the period 1994-2004. Bivariate and multivariate analyses were conducted to assess relationships among sociodemographic characteristics, NEP use, injection risk behaviors, and prevalent or incident HCV infection.

Gap in evidence addressed:

Our purpose was to assess whether participation in needle exchange programs (NEPs) influenced incident hepatitis C virus (HCV) infection through effects on injection risk behaviors among young injection drug users (IDUs) in the United States.

Key Findings:

Of the total participants (n=4663), HCV seroprevalence was 37%; among those who initially tested negative and completed follow-up at three, six, or 12 months (n=1288), 12% seroconverted. Nearly half of participants reported NEP (46%) use at baseline. Multivariate results showed no significant relationship between NEP use and HCV seroconversion. Controlling for sociodemographic characteristics, IDUs reporting NEP use were significantly less likely to share needles (aOR=0.77, 95% CI=0.67-0.88). Additionally, controlling for sociodemographic characteristics and program use, sharing needles, sharing other injection paraphernalia, longer injection duration, and injecting daily were all positively related to prevalent infection. Our results suggest an indirect protective effect of NEP use on HCV infection by reducing risk behavior. We observed substantial declines in rates of syringe borrowing (from 20.1% in 1998 to 9.2% in 2003) and syringe lending (from 19.1% in 1998 to 6.8% in 2003) following SEP policy change. These declines coincided with a statistically significant increase in the proportion of participants accessing sterile syringes from nontraditional SEP sources (P < .001). In multivariate analyses, the period following the change in SEP policy was independently associated with a greater than 40% reduction in syringe borrowing (adjusted odds ratio [AOR] = 0.57; 95% confidence interval [CI] = 0.49, 0.65) and lending (AOR = 0.52; 95% CI = 0.45, 0.60), as well as declining HIV incidence (adjusted hazard ratio = 0.13; 95% CI = 0.06, 0.31).

(2007) Bluthenthal, Ridgeway, Schell, Anderson, Flynn, KralExamination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users.
(2007) Bluthenthal, Ridgeway, Schell, Anderson, Flynn, KralExamination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users.
Year:
2007
Citation:
Addiction. 2007 Apr;102(4):638-46. doi: 10.1111/j.1360-0443.2006.01741.x
Study Methods:

Cross-sectional samples of SEPs and their clients. Twenty-four SEPs and their injection drug using (IDU) clients (n = 1576). The analysis included persons aged 15-29 years who had an HCV RNA test conducted at Quest Diagnostics (Quest) or Laboratory Corporation of America (LabCorp) from 1 July 2015 through 30 June 2016, and who had detectable HCV RNA (deemed currently HCV infected). Assays used by the commercial laboratories to quantitatively and qualitatively assess presence of HCV RNA included COBAS Ampliprep/COBAS TaqMan (version 2.0), NGI QuantaSURE, Aptima, and Abbot m2000. HCV RNA tests that were known or suspected to originate from correctional facilities were excluded. Patients were mapped according to the residential (billing) zip code associated with their earliest positive HCV RNA result. For records missing a residential zip code, that of the ordering provider was used. Laboratory test results were obtained by the US Centers for Disease Control and Prevention in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Tests were deduplicated within each laboratory for records that had sufficient demographic information to assign unique anonymized patient identification numbers. Because these numbers were assigned by each laboratory independently, it was not possible to identify persons who may have been tested at both laboratories. Programs providing syringe services as of June 2016 were identified through a directory maintained by the North American Syringe Exchange Network (www.nasen.org).

Gap in evidence addressed:

To determine whether syringe exchange programs' (SEPs) dispensation policy is associated with syringe coverage among SEP clients.

Key Findings:

Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self-reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange. Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Using propensity scoring methods, we compared syringe coverage by dispensation policies while controlling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits. Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. SEPs should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage. A total of 29382 (18264 from Quest and 11118 from LabCorp) persons aged 15-29 years with current HCV infection were identified. They were tested from July 2015 through June 2016 and represented all 50 states and Washington, DC; 54% were female, and overall their median age was 25 years. The majority of persons (86.8%) could be mapped to residential zip code, though 13.1% were mapped to ordering provider zip code and 0.1% were excluded from spatial analysis owing to missing zip code. We found 80% of 29382 young persons currently infected with hepatitis C virus lived >10 miles from a syringe services program. The median distance was 37 miles, with greater distances in rural areas and Southern and Midwestern states. Strategies to improve access to preventive services are warranted.

SSP Operations Considerations

(2019) Allen, Sean T., Grieb, Suzanne M., O'Rourke, Allison, Yoder, Ryan, Planchet,  Elise,  Hamilton White,  Rebecca, Sherman Susan G.Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs.
(2019) Allen, Sean T., Grieb, Suzanne M., O'Rourke, Allison, Yoder, Ryan, Planchet,  Elise,  Hamilton White,  Rebecca, Sherman Susan G.Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs.
Year:
2019
Citation:

Harm Reduction Journal 16:33 https://doi.org/10.1186/s12954-019-0305-7

Study Methods:

We conducted semi-structured interviews with 27 PWID (59.3% male, 88.9% White) to explore access to sterile injection equipment and overdose prevention resources, high-risk injection practices, and HIV risk perceptions following the KCHD SSP suspension. Participants were recruited from street locations frequented by PWID. Interviews were audio-recorded and transcribed verbatim. We employed an iterative, modified constant comparison approach to systematically code and synthesize textual interview data.

Gap in evidence addressed:

In December 2015, the Kanawha-Charleston Health Department (KCHD) in West Virginia implemented a SSP; however, the program was indefinitely suspended in early 2018 following policy changes that would have forced the program to operate in ways that conflicted with established best practices. The purpose of this research is to explore the public health implications of the suspension of the KCHD SSP among rural PWID.

Key Findings:

This research demonstrates that the suspension of a SSP in rural West Virginia increased risks for HIV/HCV acquisition and overdose among PWID. The suspension of the SSP led to community-wide decreases in access to sterile injection equipment and naloxone among PWID. The suspension of the KCHD SSP should be viewed as a call to action for sustaining evidence-based interventions in the face of sociopolitical forces that attempt to subvert public health.

(2015) Allison, Ruiz, O'RourkeHow far will they go?: assessing the travel distance of current and former drug users to access harm reduction services
(2015) Allison, Ruiz, O'RourkeHow far will they go?: assessing the travel distance of current and former drug users to access harm reduction services
Year:
2015
Citation:
Allen et al. Harm Reduction Journal 12:3 DOI 10.1186/s12954-015-0043-4
Study Methods:
Data from a PWID population estimation study that used capture-recapture methodologies were used for this research. The population estimation study was divided into two 14-day periods of data collection with the first phase focused on collecting data among PWID who presented for services at SEP mobile distribution sites and the second phase focused on collecting data from PWID sampled from community venues (such as parks or other locations where PWID congregate). This study was conducted between March and April 2014 in partnership with two harm reduction service providers in DC. Only data from the largest mobile exchange program were used in this research as this site provides the bulk of syringes to DC PWID. Further, only data from the first phase of the population estimation study were used for this research, as this first phase of data collection sampled PWID who traveled to SEP sites to access services.
Gap in evidence addressed:
Prior research has explored spatial access to syringe exchange programs (SEPs) among people who inject drugs (PWID), but little is known about service utilization by former PWID who continue to access services (e.g., HIV screenings and referrals for social services) at harm reduction providers. The purpose of this research is to examine differences in access to SEPs between current and former PWID seeking services at a mobile SEP in Washington, DC.
Key Findings:
A geometric point distance estimation technique was applied to data collected as part of a PWID population estimation study that took place in Washington, DC, in March and April 2014. We calculated the walking distance from the centroid point of home residence zip code to the mobile exchange site where PWID presented for services. An independent samples t-test was used to examine differences in walking distance measures between current and former PWID. Differences in mean walking distance were statistically significant with current and former PWID having mean walking distances of 2.75 and 1.80 miles, respectively. The results of this study suggest that former PWID who are engaging with SEPs primarily for non-needle exchange services (e.g., medical or social services) may have decreased access to SEPs than their counterparts who are active injectors. This research provides support for expanding SEP operations such that both active and former PWID have increased access to harm reduction providers and associated health and social services. Increasing service accessibility may help resolve unmet needs among current and former PWID.
(2015) Sherman, Patel, Ramachandran, Galai, Chaulik, Serio-Chapman, GindiConsequences of a restrictive syringe exchange policy on utilization patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk
(2015) Sherman, Patel, Ramachandran, Galai, Chaulik, Serio-Chapman, GindiConsequences of a restrictive syringe exchange policy on utilization patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk
Year:
2015
Citation:

Drug & Alcohol Review. 34(6): 637-644.  doi:10.1111/dar.12276

Study Methods:

Data were derived from the Baltimore NSP, which prospectively collected data on all client visits. We examined the impact of this restrictive policy on program-level output measures (i.e., distributed:returned syringe ratio, client volume) before, during, and after the restrictive exchange policy. Through multiple logistic regression, we examined correlates of less than 1-for-1 exchange ratios at the client-level before and during the restrictive exchange policy periods.

Gap in evidence addressed:

Multi-person use of syringes continues to be a driving risk factor for acquiring HIV and viral
hepatitis infections throughout the world. Syringe distribution policies continue to be debated in many jurisdictions throughout the U.S. The Baltimore Needle and Syringe Exchange Program (NSP) operated under a 1-for-1 syringe exchange policy from its inception in 1994 through 1999, when it implemented a restrictive policy (2000–2004) that dictated less than 1-for-1 exchange for non-program syringes.

Key Findings:

During the restrictive policy period, the average annual program-level ratio of total syringes distributed:returned dropped from 0.99 to 0.88, with a low point of 0.85 in 2000. There were substantial decreases in the average number of syringes distributed, syringes returned, the total number of clients, and new clients enrolling during the restrictive compared to the preceding period. During the restrictive period, 33,508 more syringes were returned to the needle exchange than were distributed. In the presence of other variables, correlates of less than 1-for-1 exchange ratio were being white, female, and less than 30 years old. With fewer clean syringes in circulation, restrictive policies could increase the risk of exposure to HIV among IDUs and the broader community. The study provides evidence to the potentially harmful effects of such policies.

Syringe Disposal Outcomes

(2019) Levine, Bartholomew, Rea-Wilson, Onugha, Arriola, Cardenas, Forrest, Kral, Metsch, Spencer, TookesSyringe disposal among people who inject drugs before and after the implementation of a syringe services program.
(2019) Levine, Bartholomew, Rea-Wilson, Onugha, Arriola, Cardenas, Forrest, Kral, Metsch, Spencer, TookesSyringe disposal among people who inject drugs before and after the implementation of a syringe services program.
Year:
2019
Citation:
Drug & Alcohol Dependence. 202:13-17. doi: 10.1016/j.drugalcdep.2019.04.025.
Study Methods:

Visual inspection walkthroughs of randomly selected census blocks in the neighborhoods in the top quartile of narcotics-related arrests were conducted to assess improperly discarded syringes. Syringe location was geocoded in ArcGIS. Adult PWID pre-SSP (n = 448) and post-SSP (n = 482) implementation were recruited for a survey using respondent-driven sampling in Miami. A Poisson regression model was used to determine the adjusted relative risk (aRR) of improper syringe disposal pre- and post-SSP.

Gap in evidence addressed:

Due to the increase in people who use opioids in the US, there has been a steady increase in injection drug use. Without access to safe syringe disposal locations, people who inject drugs (PWID) have few options other than improper disposal, including in public places. In 2016, Florida's first legal Syringe Services Program (SSP) was established in Miami. This study aims to compare syringe disposal practices among PWID before and after the implementation of an SSP.

Key Findings:

A total of 191 syringes/1000 blocks were found post-implementation versus 371/1000 blocks pre-implementation, representing a 49% decrease after SSP implementation. In the surveys, 70% reported any improper syringe disposal post-SSP implementation versus 97% pre-SSP implementation. PWID in the post-implementation survey had 39% lower adjusted relative risk (aRR = 0.613; 95% CI = 0.546, 0.689) of improper syringe disposal as compared to pre-implementation. There was a significant decrease in the number of improperly discarded syringes in public in Miami after the implementation of an SSP. Providing PWID with proper disposal venues such as an SSP could decrease public disposal in other communities

(2014) Quinn, Chu, Wenger, Bluthenthal, KralSyringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source.
(2014) Quinn, Chu, Wenger, Bluthenthal, KralSyringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source.
Year:
2014
Citation:
International Journal of Drug Policy 25(5):905-10. doi: 10.1016/j.drugpo.2014.05.008.
Study Methods:

A cross-sectional sample of PWID (N=412) was recruited and administered a structured questionnaire between July 2011 and April 2013. Descriptive analyses investigated syringe access and disposal practices among participants. Multivariate logistic regression analysis identified adjusted associations between syringe source (syringe exchange program [SEP] or pharmacy) and improper syringe disposal.

Gap in evidence addressed:

Few recent studies have investigated the prevalence of improperly discarded syringes in community settings by people who inject drugs (PWID). We examined whether syringe source was associated with the act of improper syringe disposal and amount of syringes improperly disposed of among PWID in Los Angeles, California.

Key Findings:

Most participants were male (69%), homeless (62%) and low-income earners (64%). The majority (87%) of the sample received syringes from a SEP in the past six months, with 26% having received syringes from pharmacies and 36% from unauthorised sources (e.g., friend, drug dealer). Of more than 30,000 used syringes reportedly disposed of by participants during the past 30 days, 17% were disposed of improperly. Two percent of participants disposed of any used syringes at pharmacies, compared to 68% who used SEPs for syringe disposal. Having received sterile syringes from a SEP was independently associated with lower odds of improper syringe disposal; however, purchasing sterile syringes from pharmacies was associated with significantly higher odds of improper syringe disposal. In a city with both SEPs and pharmacies as syringe source and disposal options for PWID, these findings suggest that while pharmacies are selling syringes, they are not as readily involved in safe syringe disposal. Given limits on SEP availability and the large geographic size of Los Angeles County, augmenting current SEP services and providing other community disposal sites, including pharmacy disposal, processes could reduce improper syringe disposal among PWID in Los Angeles.

(2012) Tookes, Kral, Wenger Cardenas, Martinez, Sherman, Pereyra, Forrest, LaLot, MetschaA comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs
(2012) Tookes, Kral, Wenger Cardenas, Martinez, Sherman, Pereyra, Forrest, LaLot, MetschaA comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs
Year:
2012
Citation:
Drug and Alcohol Dependence 123(1-3): 255-259. https://doi.org/10.1016/j.drugalcdep.2011.12.001
Study Methods:

We conducted visual inspection walkthroughs in a random sample of the top-quartile of drug-affected neighborhoods in San Francisco, California (a city with NSPs) and Miami, Florida (a city without NSPs). We also conducted quantitative interviews with adult IDUs in San Francisco (N=602) and Miami (N=448).

Gap in evidence addressed:

The United States (U.S.) approved use of federal funds for needle and syringe programs (NSPs) in December 2009. This study compares syringe disposal practices in a U.S. city with NSPs to a U.S. city without NSPs by examining the prevalence of improperly discarded syringes in public places and the self-reported syringe disposal practices of injection drug users (IDUs) in the two cities.

Key Findings:

In the visual inspections, we found 44 syringes/1000 census blocks in San Francisco, and 371 syringes/1000 census blocks in Miami. Survey results showed that in San Francisco 13% of syringes IDUs reported using in the 30 days preceding the study interviews were disposed of improperly versus 95% of syringes by IDUs in Miami. In multivariable logistic regression analysis, IDUs in Miami had over 34 times the adjusted odds of public syringe disposal relative to IDUs in San Francisco (adjusted odds ratio=34.2, 95% CI=21.92, 53.47). We found eight-fold more improperly disposed syringes on walkthroughs in the city without NSPs compared to the city with NSPs, which was corroborated by survey data. NSPs may help IDUs dispose of their syringes safely in cities with large numbers of IDUs.

(2010) de Montigny, Vernez, Moudon, Leigh, KimAssessing a drop box programme: A spatial analysis of discarded needles
(2010) de Montigny, Vernez, Moudon, Leigh, KimAssessing a drop box programme: A spatial analysis of discarded needles
Year:
2010
Citation:
International Journal of Drug Policy 21(3):208-14. doi: 10.1016/j.drugpo.2009.07.003.
Study Methods:

Using a dataset containing the locations of 7274 discarded needles and syringes collected monthly in the non-park open spaces of a 2.5 km2 neighbourhood of Montreal, Canada for a period of five years, we compared levels of discards before and after the installation of 12 drop boxes. We used quasi-Poisson regression to test the effects of drop boxes on monthly counts of collected discards for areas within a walking distance of 25, 50, 100 and 200m of a drop box. We adjusted for known time-dependent covariates linearly and unknown time-dependent covariates using a smoothing function.

Gap in evidence addressed:

Distributing sterile injection equipment to injection drug users is one of few proven ways of lowering the transmission rate of blood borne viruses. Distribution of equipment has also been linked to increased needle discarding, which is a public health risk for both injectors and their host communities. Drop boxes (anonymous and public-access sharps containers) are a promising and increasingly popular means of reducing unsafe disposal, yet there is little empirical research to support or guide their implementation.

Key Findings:

We found strong evidence of reduced discarding following the installation of drop boxes; drop boxes were associated with reductions of up to 98% (95% CI: 72 100%) and significant reductions for areas up to 200m from a drop box. Reductions were inversely proportional to walking distance from drop boxes. No measure of weather or use of needle exchange programmes (NEPs) had a consistent relationship with discard counts. Our research suggests that IDUs changed their needle-disposal behaviour in response to increased safe disposal options. In addition to being relatively low-threshold, economical and rapid, drop boxes appear to be a highly effective intervention to reduce discarded needles.

(2007) Bluthenthal, Anderson, Flynn, KralHigher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients
(2007) Bluthenthal, Anderson, Flynn, KralHigher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients
Year:
2007
Citation:
Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035
Study Methods:

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

Gap in evidence addressed:

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

Key Findings:

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

(2007) Coffin, Latka, Latkin, Wu, Purcell, Metsch, Gomez, GourevitchSafe Syringe Disposal is Related to Safe Syringe Access among HIV-positive Injection Drug Users
(2007) Coffin, Latka, Latkin, Wu, Purcell, Metsch, Gomez, GourevitchSafe Syringe Disposal is Related to Safe Syringe Access among HIV-positive Injection Drug Users
Year:
2007
Citation:
AIDS and Behavior 11(5):652-62. doi: 10.1007/s10461-006-9171-x
Study Methods:
We evaluated the effect of syringe acquisition on syringe disposal among HIV-positive injection drug users (IDUs) in Baltimore, New York City, and San Francisco (N�=�680; mean age 42�years, 62% male, 59% African-American, 21% Hispanic, 12% White).�
Gap in evidence addressed:
An additional reason to focus on proper syringe disposal is that removal of syringes from circulation may itself be an important component of prevention of blood-borne disease transmission. HIV-1 may persist in syringes for up to 4�weeks (Abdala, Stephens, Griffith, & Heimer,�1999) and greater duration of syringe circulation is associated with increased HIV risk behaviors (Kaplan & Heimer,�1994). When few opportunities exist to dispose of syringes properly, they may remain in circulation for longer periods of time, elevating the risk of disease transmission.�
Key Findings:
Independent predictors of safe disposal were acquiring syringes through a safe source and ever visiting a syringe exchange program. Weaker predictors included living in San Francisco, living in the area longer, less frequent binge drinking, injecting with an HIV+ partner, peer norms supporting safe injection, and self-empowerment. Independent predictors of safe "handling"-both acquiring and disposing of syringes safely-also included being from New York and being older. HIV-positive IDUs who obtain syringes from a safe source are more likely to safely dispose; peer norms contribute to both acquisition and disposal. Our data have implications for interventions to improve the health of injectors and of the general public. Like diabetics, IDUs likely dispose of syringes by the most convenient means, suggesting that safe disposal messages and readily accessible syringe disposal units in public places would advance safe disposal practices. Interventions to improve disposal should include expanding sites of safe syringe acquisition while enhancing disposal messages, alternatives, and convenience.

Author

Publication Topic:

Cost Effectiveness

Author Publication Title Year Author(s) Citation Study Methods Gap in evidence addressed Key Findings
Allen Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Anderson Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Belani Cost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City 2008 Belani, Hrishikesh, Muennig Journal of HIV/AIDS & Social Services, 7(3) 229-240 https://doi.org/10.1080/15381500802307492

Using data specific to the Lower East Side Harm Reduction Center in New York City, we assessed the cost-effectiveness of NSE over a range of conservative estimates of efficacy, obtained from both longitudinal and small-area studies. A decision-analysis model was created to compare the outcomes and costs associated with NSE. Model inputs included the cost of living with HIV and the seroprevalence of HIV among injection drug users in New York City. This analysis was conducted from both the government and societal perspectives.

Shared needle and syringe use among injection drug users continues to be a major mode of transmission of HIV. Needle and syringe exchange (NSE) may be a viable strategy to reduce the transmission of the virus; yet the difficulty in measuring the actual efficacy of NSE has limited attempts to evaluate the cost-effectiveness of the intervention.

Tested over a range of conservative parameter estimates, NSE appears to save money and lives. The NSE program we evaluated cost $502 per client and produced a gain of 0.01 quality adjusted life years per client. It also reduced HIV treatment costs by $325,000 per case of HIV averted, and averted 4-7 HIV infections per 1000 clients, producing a net cost savings.

Benitez Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Brady Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Chaulk Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Des Jarlais Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. 2014 Nguyen, Weir, Des Jarlais, Pinkerton, Holtgrave AIDS Behavior 18(11):2144-55. doi: 10.1007/s10461-014-0789-9.

The strategy for answering this question is to start from an equation for the number of new HIV infections due to injection drug use over a 1-year period, and to relate parameters in this equation to syringe supply. Such equation would allow us to estimate how a hypothetical increase in syringe supply would affect the number of new infections. The initial equation is based on the premise that the number of new infections in a year equals the number of uninfected (thus at risk) persons times the probability that an uninfected person becomes infected over the course of the year.

The key question is if NSP syringe supply were increased by a certain amount, what would happen to the number of people contracting HIV? If we could answer this question, we could evaluate the cost effectiveness of such hypothetical increase in NSP syringe supply by costing it and estimating savings resulting from infections averted.

In the base case scenario with no additional syringe exchange funding, an estimated 2,575 HIV infections occur in a year due to drug injection risk. Based on lifetime treatment costs of $391,223 in 2011 USD per infection, the total treatment costs for these infections is $1.01 billion. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion. These analyses indicate that it would be highly cost-saving to invest additional funds to expand syringe exchange services in the US. Over the course of 1 year an additional investment of only $10 million would avert an estimated 194 HIV infections and avoid $75.8 million in lifetime HIV treatment costs (saving $65.8 million net), representing a rate of financial return on investment of 7.58. If the investment increase were $50 million, it would also be highly cost-saving: approximately 816 HIV infections would be averted, equivalent to nearly one-third (32 %) of the annual number of new HIV infections due to drug injection risk; $319.1 million of lifetime HIV treatment costs would be avoided (net savings $269.1 million), representing a 6.38 rate of financial return on investment. Sensitivity analyses showed that when uncertainties about parameter values were accounted for, investment increase remained highly cost-saving.

Dore Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Holtgrave Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Holtgrave Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. 2014 Nguyen, Weir, Des Jarlais, Pinkerton, Holtgrave AIDS Behavior 18(11):2144-55. doi: 10.1007/s10461-014-0789-9.

The strategy for answering this question is to start from an equation for the number of new HIV infections due to injection drug use over a 1-year period, and to relate parameters in this equation to syringe supply. Such equation would allow us to estimate how a hypothetical increase in syringe supply would affect the number of new infections. The initial equation is based on the premise that the number of new infections in a year equals the number of uninfected (thus at risk) persons times the probability that an uninfected person becomes infected over the course of the year.

The key question is if NSP syringe supply were increased by a certain amount, what would happen to the number of people contracting HIV? If we could answer this question, we could evaluate the cost effectiveness of such hypothetical increase in NSP syringe supply by costing it and estimating savings resulting from infections averted.

In the base case scenario with no additional syringe exchange funding, an estimated 2,575 HIV infections occur in a year due to drug injection risk. Based on lifetime treatment costs of $391,223 in 2011 USD per infection, the total treatment costs for these infections is $1.01 billion. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion. These analyses indicate that it would be highly cost-saving to invest additional funds to expand syringe exchange services in the US. Over the course of 1 year an additional investment of only $10 million would avert an estimated 194 HIV infections and avoid $75.8 million in lifetime HIV treatment costs (saving $65.8 million net), representing a rate of financial return on investment of 7.58. If the investment increase were $50 million, it would also be highly cost-saving: approximately 816 HIV infections would be averted, equivalent to nearly one-third (32 %) of the annual number of new HIV infections due to drug injection risk; $319.1 million of lifetime HIV treatment costs would be avoided (net savings $269.1 million), representing a 6.38 rate of financial return on investment. Sensitivity analyses showed that when uncertainties about parameter values were accounted for, investment increase remained highly cost-saving.

Hrishikesh Cost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City 2008 Belani, Hrishikesh, Muennig Journal of HIV/AIDS & Social Services, 7(3) 229-240 https://doi.org/10.1080/15381500802307492

Using data specific to the Lower East Side Harm Reduction Center in New York City, we assessed the cost-effectiveness of NSE over a range of conservative estimates of efficacy, obtained from both longitudinal and small-area studies. A decision-analysis model was created to compare the outcomes and costs associated with NSE. Model inputs included the cost of living with HIV and the seroprevalence of HIV among injection drug users in New York City. This analysis was conducted from both the government and societal perspectives.

Shared needle and syringe use among injection drug users continues to be a major mode of transmission of HIV. Needle and syringe exchange (NSE) may be a viable strategy to reduce the transmission of the virus; yet the difficulty in measuring the actual efficacy of NSE has limited attempts to evaluate the cost-effectiveness of the intervention.

Tested over a range of conservative parameter estimates, NSE appears to save money and lives. The NSE program we evaluated cost $502 per client and produced a gain of 0.01 quality adjusted life years per client. It also reduced HIV treatment costs by $325,000 per case of HIV averted, and averted 4-7 HIV infections per 1000 clients, producing a net cost savings.

Iversen Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Kaldor Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Kerr Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Kwon Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Law Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Maher Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Metzger Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Muennig Cost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City 2008 Belani, Hrishikesh, Muennig Journal of HIV/AIDS & Social Services, 7(3) 229-240 https://doi.org/10.1080/15381500802307492

Using data specific to the Lower East Side Harm Reduction Center in New York City, we assessed the cost-effectiveness of NSE over a range of conservative estimates of efficacy, obtained from both longitudinal and small-area studies. A decision-analysis model was created to compare the outcomes and costs associated with NSE. Model inputs included the cost of living with HIV and the seroprevalence of HIV among injection drug users in New York City. This analysis was conducted from both the government and societal perspectives.

Shared needle and syringe use among injection drug users continues to be a major mode of transmission of HIV. Needle and syringe exchange (NSE) may be a viable strategy to reduce the transmission of the virus; yet the difficulty in measuring the actual efficacy of NSE has limited attempts to evaluate the cost-effectiveness of the intervention.

Tested over a range of conservative parameter estimates, NSE appears to save money and lives. The NSE program we evaluated cost $502 per client and produced a gain of 0.01 quality adjusted life years per client. It also reduced HIV treatment costs by $325,000 per case of HIV averted, and averted 4-7 HIV infections per 1000 clients, producing a net cost savings.

Nguyen Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. 2014 Nguyen, Weir, Des Jarlais, Pinkerton, Holtgrave AIDS Behavior 18(11):2144-55. doi: 10.1007/s10461-014-0789-9.

The strategy for answering this question is to start from an equation for the number of new HIV infections due to injection drug use over a 1-year period, and to relate parameters in this equation to syringe supply. Such equation would allow us to estimate how a hypothetical increase in syringe supply would affect the number of new infections. The initial equation is based on the premise that the number of new infections in a year equals the number of uninfected (thus at risk) persons times the probability that an uninfected person becomes infected over the course of the year.

The key question is if NSP syringe supply were increased by a certain amount, what would happen to the number of people contracting HIV? If we could answer this question, we could evaluate the cost effectiveness of such hypothetical increase in NSP syringe supply by costing it and estimating savings resulting from infections averted.

In the base case scenario with no additional syringe exchange funding, an estimated 2,575 HIV infections occur in a year due to drug injection risk. Based on lifetime treatment costs of $391,223 in 2011 USD per infection, the total treatment costs for these infections is $1.01 billion. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion. These analyses indicate that it would be highly cost-saving to invest additional funds to expand syringe exchange services in the US. Over the course of 1 year an additional investment of only $10 million would avert an estimated 194 HIV infections and avoid $75.8 million in lifetime HIV treatment costs (saving $65.8 million net), representing a rate of financial return on investment of 7.58. If the investment increase were $50 million, it would also be highly cost-saving: approximately 816 HIV infections would be averted, equivalent to nearly one-third (32 %) of the annual number of new HIV infections due to drug injection risk; $319.1 million of lifetime HIV treatment costs would be avoided (net savings $269.1 million), representing a 6.38 rate of financial return on investment. Sensitivity analyses showed that when uncertainties about parameter values were accounted for, investment increase remained highly cost-saving.

O’Rourke Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Pinkerton Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. 2014 Nguyen, Weir, Des Jarlais, Pinkerton, Holtgrave AIDS Behavior 18(11):2144-55. doi: 10.1007/s10461-014-0789-9.

The strategy for answering this question is to start from an equation for the number of new HIV infections due to injection drug use over a 1-year period, and to relate parameters in this equation to syringe supply. Such equation would allow us to estimate how a hypothetical increase in syringe supply would affect the number of new infections. The initial equation is based on the premise that the number of new infections in a year equals the number of uninfected (thus at risk) persons times the probability that an uninfected person becomes infected over the course of the year.

The key question is if NSP syringe supply were increased by a certain amount, what would happen to the number of people contracting HIV? If we could answer this question, we could evaluate the cost effectiveness of such hypothetical increase in NSP syringe supply by costing it and estimating savings resulting from infections averted.

In the base case scenario with no additional syringe exchange funding, an estimated 2,575 HIV infections occur in a year due to drug injection risk. Based on lifetime treatment costs of $391,223 in 2011 USD per infection, the total treatment costs for these infections is $1.01 billion. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion. These analyses indicate that it would be highly cost-saving to invest additional funds to expand syringe exchange services in the US. Over the course of 1 year an additional investment of only $10 million would avert an estimated 194 HIV infections and avoid $75.8 million in lifetime HIV treatment costs (saving $65.8 million net), representing a rate of financial return on investment of 7.58. If the investment increase were $50 million, it would also be highly cost-saving: approximately 816 HIV infections would be averted, equivalent to nearly one-third (32 %) of the annual number of new HIV infections due to drug injection risk; $319.1 million of lifetime HIV treatment costs would be avoided (net savings $269.1 million), representing a 6.38 rate of financial return on investment. Sensitivity analyses showed that when uncertainties about parameter values were accounted for, investment increase remained highly cost-saving.

Ruiz Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Thein Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Weir Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. 2014 Nguyen, Weir, Des Jarlais, Pinkerton, Holtgrave AIDS Behavior 18(11):2144-55. doi: 10.1007/s10461-014-0789-9.

The strategy for answering this question is to start from an equation for the number of new HIV infections due to injection drug use over a 1-year period, and to relate parameters in this equation to syringe supply. Such equation would allow us to estimate how a hypothetical increase in syringe supply would affect the number of new infections. The initial equation is based on the premise that the number of new infections in a year equals the number of uninfected (thus at risk) persons times the probability that an uninfected person becomes infected over the course of the year.

The key question is if NSP syringe supply were increased by a certain amount, what would happen to the number of people contracting HIV? If we could answer this question, we could evaluate the cost effectiveness of such hypothetical increase in NSP syringe supply by costing it and estimating savings resulting from infections averted.

In the base case scenario with no additional syringe exchange funding, an estimated 2,575 HIV infections occur in a year due to drug injection risk. Based on lifetime treatment costs of $391,223 in 2011 USD per infection, the total treatment costs for these infections is $1.01 billion. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion. These analyses indicate that it would be highly cost-saving to invest additional funds to expand syringe exchange services in the US. Over the course of 1 year an additional investment of only $10 million would avert an estimated 194 HIV infections and avoid $75.8 million in lifetime HIV treatment costs (saving $65.8 million net), representing a rate of financial return on investment of 7.58. If the investment increase were $50 million, it would also be highly cost-saving: approximately 816 HIV infections would be averted, equivalent to nearly one-third (32 %) of the annual number of new HIV infections due to drug injection risk; $319.1 million of lifetime HIV treatment costs would be avoided (net savings $269.1 million), representing a 6.38 rate of financial return on investment. Sensitivity analyses showed that when uncertainties about parameter values were accounted for, investment increase remained highly cost-saving.

Wen Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O’Rourke, Allen, Holtgrave, Metzger, Benitez, Brady, Chaulk, Wen

Journal of Acquired Immune Deficiency Syndrome. Volume 82, Supplement 2 148-154, doi 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and
significant cost savings to publicly funded HIV care.

Wilson Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Zhang Estimating the cost-effectiveness of needle-syringe programs in Australia. 2012 Kwon, Anderson, Kerr, Thein, Zhang, Iversen, Dore, Kaldor, Law, Maher, Wilson AIDS 26(17):2201-10. doi: 10.1097/QAD.0b013e3283578b5d.

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19?000-77?000 cases) during 2000-2010, leading to 20?000-66?000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

Publication Topic:

Expert Guidance

Author Publication Title Year Author(s) Citation Study Methods Gap in evidence addressed Key Findings
American Medical Association Syringe and Needle Exchange Programs H-95.958 2016 American Medical Association https://policysearch.ama-assn.org/policyfinder/detail/syringe?uri=%2FAMADoc%2FHOD.xml-0-5337.xml

Our AMA: (1) encourages all communities to establish needle exchange programs and physicians to refer their patients to such programs; (2) will initiate and support legislation providing funding for needle exchange programs for injecting drug users; and (3) strongly encourages state medical associations to initiate state legislation modifying drug paraphernalia laws so that injection drug users can purchase and possess needles and syringes without a prescription and needle exchange program employees are protected from prosecution for disseminating syringes.

American Public Health Association Defining and Implementing a Public Health Response to Drug Use and Misuse 2013 American Public Health Association https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/08/08/04/defining-and-implementing-a-public-health-response-to-drug-use-and-misuse

Drug use and misuse continue to create public health challenges in the United States, leading to overdose deaths, HIV and hepatitis C infections, and other chronic health conditions. Public health approaches offer effective, evidence-based responses, but some of the most effective interventions are not currently allowed in the United States owing to outdated drug laws, attitudes, and stigma. Substance misuse treatment is too often unavailable or unaffordable for the people who want it. A criminal justice response, including requiring arrest to access health services, is ineffective and leads to other public health problems. This policy statement calls on federal, state, and local elected officials and agency staff, health care professionals, community health workers, and other stakeholders to support a full reorientation toward a health approach to drug use, including the evaluation of promising practices from other countries for domestic implementation. In addition, it recommends ending the criminalization of drugs and drug consumers, prioritizing proven treatment and harm reduction strategies, and expanding (and removing barriers to) treatment and harm reduction services, including repealing any bans on funding syringe access programs.

Centers for Disease Control & Prevention Evidence-Based Strategies for Preventing Opioid Overdose: What�s Working in the United States An Introduction for Public Heath, Law Enforcement, Local Organizations, and Others Striving to Serve Their Community. 2018 Centers for Disease Control & Prevention, compmiled by Carroll, Green, Noonan https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf

Syringe services programs are a key component of overdose prevention strategies, because they can facilitate access to and uptake of services and interventions for reducing overdose, enhancing health and wellbeing, and improving public health and public safety. First, some, but not all, people who use drugs experience homelessness, poverty, and other social or financial insecurities that make acquiring clean injection equipment challenging, even in locations where syringes can be purchased without a prescription. The free distribution of clean injection equipment lowers the frequency of syringe sharing and re-use,89�91 with major protective impacts on the rates of infectious diseases like HIV and hepatitis C as well as other injection-related infections or soft tissue injury.92,93 Individuals who participate in syringe services programs are also more likely to seek treatment for a substance use disorder.94 Second, syringe services programs provide people who use drugs a non-judgmental environment in which they are able to build supportive and trusting relationships, talk freely about their needs and concerns, and re-enforce feelings of self-worth, empowerment, and control. Relief from the shame and judgment carried by the stigma associated with drug use gives people the freedom to think objectively about the risks their drug use may pose to themselves and others and to strategize steps they can take to mitigate those risks. For people who are socially marginalized and have internalized stigma about their drug use, these services can substantially benefit their safety and chances of survival. Third, if and when someone who uses drugs chooses to seek medical care, naloxone access, or substance abuse treatment, syringe services programs and their staff are able to help their participants connect with and navigate these services, making syringe services programs a key component of overdose prevention efforts on all fronts.

Centers for Disease Control & Prevention HIV and Injection Drug Use: Syringe Service Programs for HIV Prevention 2016 Centers for Disease Control & Prevention https://www.cdc.gov/vitalsigns/pdf/2016-12-vitalsigns.pdf

Syringe services programs (SSPs) can play a role in preventing HIV and other health problems among PWID. They provide access to sterile syringes and should also provide comprehensive services such as help with stopping substance misuse; testing and linkage to treatment for HIV, hepatitis B, and hepatitis C; education on what to do for an overdose; and other prevention services. State and local health departments can work with their lawmakers and law enforcement to make SSPs more available to PWID.

compmiled by Carroll Evidence-Based Strategies for Preventing Opioid Overdose: What�s Working in the United States An Introduction for Public Heath, Law Enforcement, Local Organizations, and Others Striving to Serve Their Community. 2018 Centers for Disease Control & Prevention, compmiled by Carroll, Green, Noonan https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf

Syringe services programs are a key component of overdose prevention strategies, because they can facilitate access to and uptake of services and interventions for reducing overdose, enhancing health and wellbeing, and improving public health and public safety. First, some, but not all, people who use drugs experience homelessness, poverty, and other social or financial insecurities that make acquiring clean injection equipment challenging, even in locations where syringes can be purchased without a prescription. The free distribution of clean injection equipment lowers the frequency of syringe sharing and re-use,89�91 with major protective impacts on the rates of infectious diseases like HIV and hepatitis C as well as other injection-related infections or soft tissue injury.92,93 Individuals who participate in syringe services programs are also more likely to seek treatment for a substance use disorder.94 Second, syringe services programs provide people who use drugs a non-judgmental environment in which they are able to build supportive and trusting relationships, talk freely about their needs and concerns, and re-enforce feelings of self-worth, empowerment, and control. Relief from the shame and judgment carried by the stigma associated with drug use gives people the freedom to think objectively about the risks their drug use may pose to themselves and others and to strategize steps they can take to mitigate those risks. For people who are socially marginalized and have internalized stigma about their drug use, these services can substantially benefit their safety and chances of survival. Third, if and when someone who uses drugs chooses to seek medical care, naloxone access, or substance abuse treatment, syringe services programs and their staff are able to help their participants connect with and navigate these services, making syringe services programs a key component of overdose prevention efforts on all fronts.

Department of Health and Human Services Determination That a Demonstration Needle Exchange Program Would be Effective in Reducing Drug Abuse and the Risk of Acquired Immune Deficiency Syndrome Infection Among Intravenous Drug Users 2011 US Surgeon General, Department of Health and Human Services https://harmreduction.org/wp-content/uploads/2012/01/FederalRegisterVol76No36Feb232011.pdf

SSPs are widely considered to be an effective way of reducing HIV transmission among individuals who inject illicit drugs and there is ample evidence that SSPs also promote entry and retention into treatment. According to research that tracks individuals in treatment over extended periods of time, most people who get into and remain in treatment can reduce or stop using illegal or dangerous drugs. In addition to promoting entry to treatment, there are studies that document injection reductions for drug users who participate in SSPs. Hagan, et al., found that, not only were new SSP participants five times more likely to enter drug treatment than non-SSP participants, former SSP participants were more likely to report significant reduction in injection, to stop injecting altogether, and to remain in drug treatment. The Surgeon General of the United States Public Health Service has therefore determined that a demonstration syringe services program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for acquired immune deficiency syndrome. The Department of Health and Human Services plans to issue guidelines regarding implementation requirements for SSPs based on this determination.

Green Evidence-Based Strategies for Preventing Opioid Overdose: What�s Working in the United States An Introduction for Public Heath, Law Enforcement, Local Organizations, and Others Striving to Serve Their Community. 2018 Centers for Disease Control & Prevention, compmiled by Carroll, Green, Noonan https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf

Syringe services programs are a key component of overdose prevention strategies, because they can facilitate access to and uptake of services and interventions for reducing overdose, enhancing health and wellbeing, and improving public health and public safety. First, some, but not all, people who use drugs experience homelessness, poverty, and other social or financial insecurities that make acquiring clean injection equipment challenging, even in locations where syringes can be purchased without a prescription. The free distribution of clean injection equipment lowers the frequency of syringe sharing and re-use,89�91 with major protective impacts on the rates of infectious diseases like HIV and hepatitis C as well as other injection-related infections or soft tissue injury.92,93 Individuals who participate in syringe services programs are also more likely to seek treatment for a substance use disorder.94 Second, syringe services programs provide people who use drugs a non-judgmental environment in which they are able to build supportive and trusting relationships, talk freely about their needs and concerns, and re-enforce feelings of self-worth, empowerment, and control. Relief from the shame and judgment carried by the stigma associated with drug use gives people the freedom to think objectively about the risks their drug use may pose to themselves and others and to strategize steps they can take to mitigate those risks. For people who are socially marginalized and have internalized stigma about their drug use, these services can substantially benefit their safety and chances of survival. Third, if and when someone who uses drugs chooses to seek medical care, naloxone access, or substance abuse treatment, syringe services programs and their staff are able to help their participants connect with and navigate these services, making syringe services programs a key component of overdose prevention efforts on all fronts.

Noonan Evidence-Based Strategies for Preventing Opioid Overdose: What�s Working in the United States An Introduction for Public Heath, Law Enforcement, Local Organizations, and Others Striving to Serve Their Community. 2018 Centers for Disease Control & Prevention, compmiled by Carroll, Green, Noonan https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf

Syringe services programs are a key component of overdose prevention strategies, because they can facilitate access to and uptake of services and interventions for reducing overdose, enhancing health and wellbeing, and improving public health and public safety. First, some, but not all, people who use drugs experience homelessness, poverty, and other social or financial insecurities that make acquiring clean injection equipment challenging, even in locations where syringes can be purchased without a prescription. The free distribution of clean injection equipment lowers the frequency of syringe sharing and re-use,89�91 with major protective impacts on the rates of infectious diseases like HIV and hepatitis C as well as other injection-related infections or soft tissue injury.92,93 Individuals who participate in syringe services programs are also more likely to seek treatment for a substance use disorder.94 Second, syringe services programs provide people who use drugs a non-judgmental environment in which they are able to build supportive and trusting relationships, talk freely about their needs and concerns, and re-enforce feelings of self-worth, empowerment, and control. Relief from the shame and judgment carried by the stigma associated with drug use gives people the freedom to think objectively about the risks their drug use may pose to themselves and others and to strategize steps they can take to mitigate those risks. For people who are socially marginalized and have internalized stigma about their drug use, these services can substantially benefit their safety and chances of survival. Third, if and when someone who uses drugs chooses to seek medical care, naloxone access, or substance abuse treatment, syringe services programs and their staff are able to help their participants connect with and navigate these services, making syringe services programs a key component of overdose prevention efforts on all fronts.

US Surgeon General Determination That a Demonstration Needle Exchange Program Would be Effective in Reducing Drug Abuse and the Risk of Acquired Immune Deficiency Syndrome Infection Among Intravenous Drug Users 2011 US Surgeon General, Department of Health and Human Services https://harmreduction.org/wp-content/uploads/2012/01/FederalRegisterVol76No36Feb232011.pdf

SSPs are widely considered to be an effective way of reducing HIV transmission among individuals who inject illicit drugs and there is ample evidence that SSPs also promote entry and retention into treatment. According to research that tracks individuals in treatment over extended periods of time, most people who get into and remain in treatment can reduce or stop using illegal or dangerous drugs. In addition to promoting entry to treatment, there are studies that document injection reductions for drug users who participate in SSPs. Hagan, et al., found that, not only were new SSP participants five times more likely to enter drug treatment than non-SSP participants, former SSP participants were more likely to report significant reduction in injection, to stop injecting altogether, and to remain in drug treatment. The Surgeon General of the United States Public Health Service has therefore determined that a demonstration syringe services program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for acquired immune deficiency syndrome. The Department of Health and Human Services plans to issue guidelines regarding implementation requirements for SSPs based on this determination.

Publication Topic:

Healthcare Access Point

Author Publication Title Year Author(s) Citation Study Methods Gap in evidence addressed Key Findings
Barocas Acceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs 2016 Barocas, Linas, Kim, Fangman, Westergaard Open Forum Infectious Disease 3(2): doi:�10.1093/ofid/ofw075 We surveyed PWID utilizing a free, multisite SEP operating in Southern Wisconsin between June and August 2012.� Over the 8-week study period, 862 consecutive SEP participants were invited to participate in the study. Five hundred fifty-three eligible participants (64%) agree to complete the survey, and 497 participants provided information on their HCV serostatus. People who inject drugs may benefit from point-of-care hepatitis C virus (HCV) testing offered at syringe exchanges. We sought to understand whether this population would be willing to undergo rapid HCV testing. We found that there was broad support for rapid HCV testing, especially among younger people who inject drugs with high perceived risk. Our study suggests that a rapid POC HCV test could be used at SEPs to screen a high-risk population with a high incidence of HCV. Ideally, rapid testing could be performed at SEPs because they provide continuity for many PWID who do not otherwise access the healthcare system due to mistrust, stigma, and lack of resources. As cost of HCV therapies begins to decrease and restrictions are lifted on treatment of those with active drug use, future studies should investigate the use of rapid HCV testing and direct linkage to HCV treatment.
Conigrave Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Day Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Donahue Access to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU ("I do") Care Collaborative 2017 Stopka, Hutcheson, Donahue Harm Reduction Journal 14:26 https://doi.org/10.1186/s12954-017-0151-4

Between December 2014 and January 2015, we conducted in-depth interviews (n?=?14) with SEP staff, including both program managers and health navigators, to assess knowledge, attitudes, and beliefs related to health insurance enrollment and access to enhanced referrals among SEP clients. We developed a preliminary coding scheme from the interview guide and used a grounded theory approach to guide inclusion of subsequent thematic codes that emanated from the data. We analyzed the coded data thematically in an iterative fashion using a consensus-based approach.

Little is known about access to health insurance among people who inject drugs (PWID) who attend syringe exchange programs (SEPs). The goal of the current study was to assess perceptions of SEP staff, including health navigators and program managers, on access to health insurance and healthcare access among SEP clients following implementation of state and federal policies to enhance universal healthcare access in Massachusetts.

We identified five primary themes that emerged from the qualitative interviews, including high levels of health insurance enrollment among SEP clients; barriers to enrolling in health insurance; highly needed referrals to services, including improved access to substance use disorder treatment and hepatitis C virus treatment; barriers to referring clients to these highly needed services; and recommendations for policy change. While barriers to enrollment and highly needed referrals remain, access to and enrollment in healthcare insurance plans among PWID at SEPs in Massachusetts are high. With the uncertain stability of the Affordable Care Act following the US presidential election of 2016, our findings summarize the opportunities and challenges that are connected to health insurance and healthcare access in Massachusetts. SEPs can play an important role in facilitating access to health insurance and enhancing access to preventive health and primary care.

Eckhardt Hepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program 2018 Eckhardt, Scherer, Winkelstein, Marks, Edlin Open Forum Infectious Disease 5(4) doi:�10.1093/ofid/ofy048 SSP participants with confirmed HCV antibody positivity were eligible for enrollment. Recruitment was initially limited to those who had injected in the past 30 days, but starting in the spring of 2016, all interested WHCP participants were enrolled. Participants with clinical evidence of decompensated cirrhosis or deemed to have a life expectancy of less than 1 year were excluded from the co-located treatment program and referred to existing clinic-based services. Fifty-three participants started therapy, and 91% achieved sustained virologic response.� Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP).�To our knowledge, this is the first study examining the effectiveness of a new model of care known as an Accessible Care Program, in which HCV treatment is co-located within an SSP and provides individualized education and support to meet participants� needs. SSPs provide an effective venue for HCV treatment. These data provide further evidence that PWID can achieve similar cure rates to those seen in clinical trials. Despite a limited sample size, high rates of SVR were seen across subgroups irrespective of sex, homelessness, active injection drug use, or the presence of advanced fibrosis.
Edlin Hepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program 2018 Eckhardt, Scherer, Winkelstein, Marks, Edlin Open Forum Infectious Disease 5(4) doi:�10.1093/ofid/ofy048 SSP participants with confirmed HCV antibody positivity were eligible for enrollment. Recruitment was initially limited to those who had injected in the past 30 days, but starting in the spring of 2016, all interested WHCP participants were enrolled. Participants with clinical evidence of decompensated cirrhosis or deemed to have a life expectancy of less than 1 year were excluded from the co-located treatment program and referred to existing clinic-based services. Fifty-three participants started therapy, and 91% achieved sustained virologic response.� Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP).�To our knowledge, this is the first study examining the effectiveness of a new model of care known as an Accessible Care Program, in which HCV treatment is co-located within an SSP and provides individualized education and support to meet participants� needs. SSPs provide an effective venue for HCV treatment. These data provide further evidence that PWID can achieve similar cure rates to those seen in clinical trials. Despite a limited sample size, high rates of SVR were seen across subgroups irrespective of sex, homelessness, active injection drug use, or the presence of advanced fibrosis.
Fangman Acceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs 2016 Barocas, Linas, Kim, Fangman, Westergaard Open Forum Infectious Disease 3(2): doi:�10.1093/ofid/ofw075 We surveyed PWID utilizing a free, multisite SEP operating in Southern Wisconsin between June and August 2012.� Over the 8-week study period, 862 consecutive SEP participants were invited to participate in the study. Five hundred fifty-three eligible participants (64%) agree to complete the survey, and 497 participants provided information on their HCV serostatus. People who inject drugs may benefit from point-of-care hepatitis C virus (HCV) testing offered at syringe exchanges. We sought to understand whether this population would be willing to undergo rapid HCV testing. We found that there was broad support for rapid HCV testing, especially among younger people who inject drugs with high perceived risk. Our study suggests that a rapid POC HCV test could be used at SEPs to screen a high-risk population with a high incidence of HCV. Ideally, rapid testing could be performed at SEPs because they provide continuity for many PWID who do not otherwise access the healthcare system due to mistrust, stigma, and lack of resources. As cost of HCV therapies begins to decrease and restrictions are lifted on treatment of those with active drug use, future studies should investigate the use of rapid HCV testing and direct linkage to HCV treatment.
Grummett Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Haber Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Hutcheson Access to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU ("I do") Care Collaborative 2017 Stopka, Hutcheson, Donahue Harm Reduction Journal 14:26 https://doi.org/10.1186/s12954-017-0151-4

Between December 2014 and January 2015, we conducted in-depth interviews (n?=?14) with SEP staff, including both program managers and health navigators, to assess knowledge, attitudes, and beliefs related to health insurance enrollment and access to enhanced referrals among SEP clients. We developed a preliminary coding scheme from the interview guide and used a grounded theory approach to guide inclusion of subsequent thematic codes that emanated from the data. We analyzed the coded data thematically in an iterative fashion using a consensus-based approach.

Little is known about access to health insurance among people who inject drugs (PWID) who attend syringe exchange programs (SEPs). The goal of the current study was to assess perceptions of SEP staff, including health navigators and program managers, on access to health insurance and healthcare access among SEP clients following implementation of state and federal policies to enhance universal healthcare access in Massachusetts.

We identified five primary themes that emerged from the qualitative interviews, including high levels of health insurance enrollment among SEP clients; barriers to enrolling in health insurance; highly needed referrals to services, including improved access to substance use disorder treatment and hepatitis C virus treatment; barriers to referring clients to these highly needed services; and recommendations for policy change. While barriers to enrollment and highly needed referrals remain, access to and enrollment in healthcare insurance plans among PWID at SEPs in Massachusetts are high. With the uncertain stability of the Affordable Care Act following the US presidential election of 2016, our findings summarize the opportunities and challenges that are connected to health insurance and healthcare access in Massachusetts. SEPs can play an important role in facilitating access to health insurance and enhancing access to preventive health and primary care.

Islam Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Kim Acceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs 2016 Barocas, Linas, Kim, Fangman, Westergaard Open Forum Infectious Disease 3(2): doi:�10.1093/ofid/ofw075 We surveyed PWID utilizing a free, multisite SEP operating in Southern Wisconsin between June and August 2012.� Over the 8-week study period, 862 consecutive SEP participants were invited to participate in the study. Five hundred fifty-three eligible participants (64%) agree to complete the survey, and 497 participants provided information on their HCV serostatus. People who inject drugs may benefit from point-of-care hepatitis C virus (HCV) testing offered at syringe exchanges. We sought to understand whether this population would be willing to undergo rapid HCV testing. We found that there was broad support for rapid HCV testing, especially among younger people who inject drugs with high perceived risk. Our study suggests that a rapid POC HCV test could be used at SEPs to screen a high-risk population with a high incidence of HCV. Ideally, rapid testing could be performed at SEPs because they provide continuity for many PWID who do not otherwise access the healthcare system due to mistrust, stigma, and lack of resources. As cost of HCV therapies begins to decrease and restrictions are lifted on treatment of those with active drug use, future studies should investigate the use of rapid HCV testing and direct linkage to HCV treatment.
Linas Acceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs 2016 Barocas, Linas, Kim, Fangman, Westergaard Open Forum Infectious Disease 3(2): doi:�10.1093/ofid/ofw075 We surveyed PWID utilizing a free, multisite SEP operating in Southern Wisconsin between June and August 2012.� Over the 8-week study period, 862 consecutive SEP participants were invited to participate in the study. Five hundred fifty-three eligible participants (64%) agree to complete the survey, and 497 participants provided information on their HCV serostatus. People who inject drugs may benefit from point-of-care hepatitis C virus (HCV) testing offered at syringe exchanges. We sought to understand whether this population would be willing to undergo rapid HCV testing. We found that there was broad support for rapid HCV testing, especially among younger people who inject drugs with high perceived risk. Our study suggests that a rapid POC HCV test could be used at SEPs to screen a high-risk population with a high incidence of HCV. Ideally, rapid testing could be performed at SEPs because they provide continuity for many PWID who do not otherwise access the healthcare system due to mistrust, stigma, and lack of resources. As cost of HCV therapies begins to decrease and restrictions are lifted on treatment of those with active drug use, future studies should investigate the use of rapid HCV testing and direct linkage to HCV treatment.
Marks Hepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program 2018 Eckhardt, Scherer, Winkelstein, Marks, Edlin Open Forum Infectious Disease 5(4) doi:�10.1093/ofid/ofy048 SSP participants with confirmed HCV antibody positivity were eligible for enrollment. Recruitment was initially limited to those who had injected in the past 30 days, but starting in the spring of 2016, all interested WHCP participants were enrolled. Participants with clinical evidence of decompensated cirrhosis or deemed to have a life expectancy of less than 1 year were excluded from the co-located treatment program and referred to existing clinic-based services. Fifty-three participants started therapy, and 91% achieved sustained virologic response.� Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP).�To our knowledge, this is the first study examining the effectiveness of a new model of care known as an Accessible Care Program, in which HCV treatment is co-located within an SSP and provides individualized education and support to meet participants� needs. SSPs provide an effective venue for HCV treatment. These data provide further evidence that PWID can achieve similar cure rates to those seen in clinical trials. Despite a limited sample size, high rates of SVR were seen across subgroups irrespective of sex, homelessness, active injection drug use, or the presence of advanced fibrosis.
Reid Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Scherer Hepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program 2018 Eckhardt, Scherer, Winkelstein, Marks, Edlin Open Forum Infectious Disease 5(4) doi:�10.1093/ofid/ofy048 SSP participants with confirmed HCV antibody positivity were eligible for enrollment. Recruitment was initially limited to those who had injected in the past 30 days, but starting in the spring of 2016, all interested WHCP participants were enrolled. Participants with clinical evidence of decompensated cirrhosis or deemed to have a life expectancy of less than 1 year were excluded from the co-located treatment program and referred to existing clinic-based services. Fifty-three participants started therapy, and 91% achieved sustained virologic response.� Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP).�To our knowledge, this is the first study examining the effectiveness of a new model of care known as an Accessible Care Program, in which HCV treatment is co-located within an SSP and provides individualized education and support to meet participants� needs. SSPs provide an effective venue for HCV treatment. These data provide further evidence that PWID can achieve similar cure rates to those seen in clinical trials. Despite a limited sample size, high rates of SVR were seen across subgroups irrespective of sex, homelessness, active injection drug use, or the presence of advanced fibrosis.
Stopka Access to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU ("I do") Care Collaborative 2017 Stopka, Hutcheson, Donahue Harm Reduction Journal 14:26 https://doi.org/10.1186/s12954-017-0151-4

Between December 2014 and January 2015, we conducted in-depth interviews (n?=?14) with SEP staff, including both program managers and health navigators, to assess knowledge, attitudes, and beliefs related to health insurance enrollment and access to enhanced referrals among SEP clients. We developed a preliminary coding scheme from the interview guide and used a grounded theory approach to guide inclusion of subsequent thematic codes that emanated from the data. We analyzed the coded data thematically in an iterative fashion using a consensus-based approach.

Little is known about access to health insurance among people who inject drugs (PWID) who attend syringe exchange programs (SEPs). The goal of the current study was to assess perceptions of SEP staff, including health navigators and program managers, on access to health insurance and healthcare access among SEP clients following implementation of state and federal policies to enhance universal healthcare access in Massachusetts.

We identified five primary themes that emerged from the qualitative interviews, including high levels of health insurance enrollment among SEP clients; barriers to enrolling in health insurance; highly needed referrals to services, including improved access to substance use disorder treatment and hepatitis C virus treatment; barriers to referring clients to these highly needed services; and recommendations for policy change. While barriers to enrollment and highly needed referrals remain, access to and enrollment in healthcare insurance plans among PWID at SEPs in Massachusetts are high. With the uncertain stability of the Affordable Care Act following the US presidential election of 2016, our findings summarize the opportunities and challenges that are connected to health insurance and healthcare access in Massachusetts. SEPs can play an important role in facilitating access to health insurance and enhancing access to preventive health and primary care.

Topp Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Westergaard Acceptability of Rapid Point-of-Care Hepatitis C Tests Among People Who Inject Drugs and Utilize Syringe-Exchange Programs 2016 Barocas, Linas, Kim, Fangman, Westergaard Open Forum Infectious Disease 3(2): doi:�10.1093/ofid/ofw075 We surveyed PWID utilizing a free, multisite SEP operating in Southern Wisconsin between June and August 2012.� Over the 8-week study period, 862 consecutive SEP participants were invited to participate in the study. Five hundred fifty-three eligible participants (64%) agree to complete the survey, and 497 participants provided information on their HCV serostatus. People who inject drugs may benefit from point-of-care hepatitis C virus (HCV) testing offered at syringe exchanges. We sought to understand whether this population would be willing to undergo rapid HCV testing. We found that there was broad support for rapid HCV testing, especially among younger people who inject drugs with high perceived risk. Our study suggests that a rapid POC HCV test could be used at SEPs to screen a high-risk population with a high incidence of HCV. Ideally, rapid testing could be performed at SEPs because they provide continuity for many PWID who do not otherwise access the healthcare system due to mistrust, stigma, and lack of resources. As cost of HCV therapies begins to decrease and restrictions are lifted on treatment of those with active drug use, future studies should investigate the use of rapid HCV testing and direct linkage to HCV treatment.
White Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre. 2012 Islam, Topp, Conigrave, White, Reid, Grummett, Haber, Day Journal of Substance Abuse Treatment 43(4):440-5. doi: 10.1016/j.jsat.2012.07.007

This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients.

Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Winkelstein Hepatitis C Treatment Outcomes for People Who Inject Drugs Treated in an Accessible Care Program Located at a Syringe Service Program 2018 Eckhardt, Scherer, Winkelstein, Marks, Edlin Open Forum Infectious Disease 5(4) doi:�10.1093/ofid/ofy048 SSP participants with confirmed HCV antibody positivity were eligible for enrollment. Recruitment was initially limited to those who had injected in the past 30 days, but starting in the spring of 2016, all interested WHCP participants were enrolled. Participants with clinical evidence of decompensated cirrhosis or deemed to have a life expectancy of less than 1 year were excluded from the co-located treatment program and referred to existing clinic-based services. Fifty-three participants started therapy, and 91% achieved sustained virologic response.� Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP).�To our knowledge, this is the first study examining the effectiveness of a new model of care known as an Accessible Care Program, in which HCV treatment is co-located within an SSP and provides individualized education and support to meet participants� needs. SSPs provide an effective venue for HCV treatment. These data provide further evidence that PWID can achieve similar cure rates to those seen in clinical trials. Despite a limited sample size, high rates of SVR were seen across subgroups irrespective of sex, homelessness, active injection drug use, or the presence of advanced fibrosis.
Publication Topic:

Infectious Disease Prevention

Author Publication Title Year Author(s) Citation Study Methods Gap in evidence addressed Key Findings
Aitken Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Alarcão Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Allen Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Anderson Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients 2007 Bluthenthal, Anderson, Flynn, Kral Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Arasteh State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

Aspinall Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Aspinall Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Ball Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study 2017 Dahlman, Hakansson, Kral, Wenger, Ball, Novak Substance Abuse 38(1):105-112. doi 10.1080/08897077.2016.1263592

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant. CONCLUSION SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Benitez Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Bluthenthal Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients 2007 Bluthenthal, Anderson, Flynn, Kral Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Blythe Ryerson State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016 2017 Campbell, Canary, Smith, Teshale, Blythe Ryerson, Ward MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

Brady Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Brady Effect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence 2020 Rossi, Brady, Hall, Warshak

Am J Perinatol. 2020 Jan 21. doi: 10.1055/s-0039-3402753

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of maternal HCV was compared before (2006-2011) and after (2012-2015) the implementation of an NEP (2011) in Portsmouth, Ohio (Scioto County). Trends in maternal HCV prevalence in neighboring counties both physically adjacent and regional to Scioto County were also evaluated before and after NEP implementation.

To quantify the prevalence of maternal hepatitis C virus (HCV) before and after implementation of the needle exchange program (NEP) in Scioto County, Ohio.

Rate of maternal HCV infection increased 137% versus 12% (rate difference: 125%) between pre- and post-NEP implementation time periods in Scioto County.During the study period, there were 7,069 reported cases of maternal HCV infection at the time of delivery among 1,463,506 (0.5%) live births in Ohio. The rate of maternal HCV infection increased 137% in Scioto County between 2006 and 2011. After initiation of the NEP in Portsmouth, Ohio, in 2011, the rate of increase in the following 4 years (2012-2015) was 12%. The rate of increase in maternal HCV declined precipitously in counties physically adjacent to Scioto County, whereas regional counties continued to have substantial increases in maternal HCV.

Bramson State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

Campbell State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016 2017 Campbell, Canary, Smith, Teshale, Blythe Ryerson, Ward MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

Canary State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016 2017 Campbell, Canary, Smith, Teshale, Blythe Ryerson, Ward MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

Carneiro Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Cary Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Chaulk Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Crawford Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study 2018 Gonsalves, Crawford

Lancet HIV 5: e569-77 http://dx.doi.org/10.1016/S2352-3018(18)30176-0

In this modelling study, we derived weekly case data from the HIV outbreak in Scott County, IN, and on the uptake of HIV testing, treatment, and prevention services from publicly available reports from the US Centers for Disease Control and Prevention (CDC) and researchers from Indiana. Our primary objective was to determine if an earlier response to the outbreak could have had an effect on the number of people infected. We computed upper and lower bounds for cumulative HIV incidence by digitally extracting data from published images from a CDC study using Bio-Rad avidity incidence testing to estimate the recency of each transmission event. We constructed a generalisation of the susceptible-infectious-removed model to capture the transmission dynamics of the HIV outbreak. We computed non-parametric interval estimates of the number of individuals with an undiagnosed HIV infection, the case-finding rate per undiagnosed HIV infection, and model-based bounds for the HIV transmission rate throughout the epidemic. We used these models to assess the potential effect if the same intervention had begun at two key timepoints earlier than the actual date of the initiation of efforts to control the outbreak.

In November, 2014, a cluster of HIV infections was detected among people who inject drugs in Scott County, IN, USA, with 215 HIV infections eventually attributed to the outbreak. This study examines whether earlier implementation of a public health response could have reduced the scale of the outbreak.

The upper bound for undiagnosed HIV infections in Scott County peaked at 126 around Jan 10, 2015, over 2 months before the Governor of Indiana declared a public health emergency on March 26, 2015. Applying the observed case-finding rate scale-up to earlier intervention times suggests that an earlier public health response could have substantially reduced the total number of HIV infections (estimated to have been 183-184 infections by Aug 11, 2015). Initiation of a response on Jan 1, 2013, could have suppressed the number of infections to 56 or fewer, averting at least 127 infections; whereas an intervention on April 1, 2011, could have reduced the number of infections to ten or fewer, averting at least 173 infections. Early and robust surveillance efforts and case finding alone could reduce nascent epidemics. Ensuring access to HIV services and harm-reduction interventions could further reduce the likelihood of outbreaks, and substantially mitigate their severity and scope.

Dahlman Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study 2017 Dahlman, Hakansson, Kral, Wenger, Ball, Novak Substance Abuse 38(1):105-112. doi 10.1080/08897077.2016.1263592

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant. CONCLUSION SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Des Jarlais Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013 2015 Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, Holtzman MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

Des Jarlais A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. 2011 Hagan, Pouget, Des Jarlais Journal of Infectious Diseases 204(1):74-83. doi: 10.1093/infdis/jir196.

We performed a systematic review and meta-analysis of published and unpublished studies. Eligible studies reported on the association between participation in interventions intended to reduce unsafe drug injection and HCV seroconversion in samples of PWID.

High rates of hepatitis C virus (HCV) transmission are found in samples of people who inject drugs (PWID) throughout the world. The objective of this paper was to meta-analyze the effects of risk-reduction interventions on HCV seroconversion and identify the most effective intervention types.

The meta-analysis included 26 eligible studies of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions. Interventions using multiple combined strategies reduced risk of seroconversion by 75% (pooled relative risk, .25; 95% confidence interval, .07-.83). Effects of single-method interventions ranged from .6 to 1.6. Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion. Determining the effective dose and combination of interventions for specific subgroups of PWID is a research priority. However, our meta-analysis shows that HCV infection can be prevented in PWID.

Des Jarlais Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Des Jarlais State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

Des Jarlais Doing harm reduction better: syringe exchange in the United States. 2009 Des Jarlais, McKnight, Goldblatt, Purchase Addiction 104(9):1441-6. doi: 10.1111/j.1360-0443.2008.02465.x.

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.

To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs.

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 US dollars and public funding (from state and local governments) has increased from 3.9 to 14.4 million US dollars. 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. 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.

Dombrowski Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Doyle Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Duarte Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Duncan Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Feelemyer Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013 2015 Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, Holtzman MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

Feelemyer State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

Fernandes Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Flynn Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients 2007 Bluthenthal, Anderson, Flynn, Kral Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Fraser Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Friedman Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Galea Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Galvani Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Goedel Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Goldberg Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus 2010 Palmateer, Kimber, Hickman, Hutchinson, Rhodes, Goldberg Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Goldberg Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Goldberg Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Goldberg Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Goldblatt Doing harm reduction better: syringe exchange in the United States. 2009 Des Jarlais, McKnight, Goldblatt, Purchase Addiction 104(9):1441-6. doi: 10.1111/j.1360-0443.2008.02465.x.

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.

To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs.

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 US dollars and public funding (from state and local governments) has increased from 3.9 to 14.4 million US dollars. 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. 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.

Gonsalves Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study 2018 Gonsalves, Crawford

Lancet HIV 5: e569-77 http://dx.doi.org/10.1016/S2352-3018(18)30176-0

In this modelling study, we derived weekly case data from the HIV outbreak in Scott County, IN, and on the uptake of HIV testing, treatment, and prevention services from publicly available reports from the US Centers for Disease Control and Prevention (CDC) and researchers from Indiana. Our primary objective was to determine if an earlier response to the outbreak could have had an effect on the number of people infected. We computed upper and lower bounds for cumulative HIV incidence by digitally extracting data from published images from a CDC study using Bio-Rad avidity incidence testing to estimate the recency of each transmission event. We constructed a generalisation of the susceptible-infectious-removed model to capture the transmission dynamics of the HIV outbreak. We computed non-parametric interval estimates of the number of individuals with an undiagnosed HIV infection, the case-finding rate per undiagnosed HIV infection, and model-based bounds for the HIV transmission rate throughout the epidemic. We used these models to assess the potential effect if the same intervention had begun at two key timepoints earlier than the actual date of the initiation of efforts to control the outbreak.

In November, 2014, a cluster of HIV infections was detected among people who inject drugs in Scott County, IN, USA, with 215 HIV infections eventually attributed to the outbreak. This study examines whether earlier implementation of a public health response could have reduced the scale of the outbreak.

The upper bound for undiagnosed HIV infections in Scott County peaked at 126 around Jan 10, 2015, over 2 months before the Governor of Indiana declared a public health emergency on March 26, 2015. Applying the observed case-finding rate scale-up to earlier intervention times suggests that an earlier public health response could have substantially reduced the total number of HIV infections (estimated to have been 183-184 infections by Aug 11, 2015). Initiation of a response on Jan 1, 2013, could have suppressed the number of infections to 56 or fewer, averting at least 127 infections; whereas an intervention on April 1, 2011, could have reduced the number of infections to ten or fewer, averting at least 173 infections. Early and robust surveillance efforts and case finding alone could reduce nascent epidemics. Ensuring access to HIV services and harm-reduction interventions could further reduce the likelihood of outbreaks, and substantially mitigate their severity and scope.

Guardino State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

Gunson Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Hagan A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. 2011 Hagan, Pouget, Des Jarlais Journal of Infectious Diseases 204(1):74-83. doi: 10.1093/infdis/jir196.

We performed a systematic review and meta-analysis of published and unpublished studies. Eligible studies reported on the association between participation in interventions intended to reduce unsafe drug injection and HCV seroconversion in samples of PWID.

High rates of hepatitis C virus (HCV) transmission are found in samples of people who inject drugs (PWID) throughout the world. The objective of this paper was to meta-analyze the effects of risk-reduction interventions on HCV seroconversion and identify the most effective intervention types.

The meta-analysis included 26 eligible studies of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions. Interventions using multiple combined strategies reduced risk of seroconversion by 75% (pooled relative risk, .25; 95% confidence interval, .07-.83). Effects of single-method interventions ranged from .6 to 1.6. Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion. Determining the effective dose and combination of interventions for specific subgroups of PWID is a research priority. However, our meta-analysis shows that HCV infection can be prevented in PWID.

Hagan Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Hakansson Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study 2017 Dahlman, Hakansson, Kral, Wenger, Ball, Novak Substance Abuse 38(1):105-112. doi 10.1080/08897077.2016.1263592

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant. CONCLUSION SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Hall Effect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence 2020 Rossi, Brady, Hall, Warshak

Am J Perinatol. 2020 Jan 21. doi: 10.1055/s-0039-3402753

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of maternal HCV was compared before (2006-2011) and after (2012-2015) the implementation of an NEP (2011) in Portsmouth, Ohio (Scioto County). Trends in maternal HCV prevalence in neighboring counties both physically adjacent and regional to Scioto County were also evaluated before and after NEP implementation.

To quantify the prevalence of maternal hepatitis C virus (HCV) before and after implementation of the needle exchange program (NEP) in Scioto County, Ohio.

Rate of maternal HCV infection increased 137% versus 12% (rate difference: 125%) between pre- and post-NEP implementation time periods in Scioto County.During the study period, there were 7,069 reported cases of maternal HCV infection at the time of delivery among 1,463,506 (0.5%) live births in Ohio. The rate of maternal HCV infection increased 137% in Scioto County between 2006 and 2011. After initiation of the NEP in Portsmouth, Ohio, in 2011, the rate of increase in the following 4 years (2012-2015) was 12%. The rate of increase in maternal HCV declined precipitously in counties physically adjacent to Scioto County, whereas regional counties continued to have substantial increases in maternal HCV.

Hariri Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Hedrich Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Hellard Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Hickman Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Hickman Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Hickman Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings. 2012 Vickerman, Martin, Turner, Hickman Addiction 107(11):1984-95. doi: 10.1111/j.1360-0443.2012.03932.x.

Hepatitis C virus HCV transmission modeling using U.K. estimates for effect of OST and 100% NSP on individual risk of HCV infection.

To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs).

For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCVprevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ?80%. Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

Hickman Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Hickman Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus 2010 Palmateer, Kimber, Hickman, Hutchinson, Rhodes, Goldberg Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Hodel State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

Hoerger Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Holtgrave Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Holtzman Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013 2015 Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, Holtzman MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

Hope Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Hopkins Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Hutchinson Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Hutchinson Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Hutchinson Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus 2010 Palmateer, Kimber, Hickman, Hutchinson, Rhodes, Goldberg Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Hutchinson Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Iversen The impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: a model-based analysis. 2009 Kwon, Iversen, Maher, Law, Wilson Journal of Acquired Immune Deficiency Syndrome 51(4):462-9. doi: 10.1097/QAI.0b013e3181a2539a.

We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then approximately 3 times the incidence could be expected.

J Costa Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Jesus Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Jordan Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Khan Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Kimber Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus 2010 Palmateer, Kimber, Hickman, Hutchinson, Rhodes, Goldberg Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Kimber Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

King Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Kral Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study 2017 Dahlman, Hakansson, Kral, Wenger, Ball, Novak Substance Abuse 38(1):105-112. doi 10.1080/08897077.2016.1263592

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant. CONCLUSION SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Kral Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients 2007 Bluthenthal, Anderson, Flynn, Kral Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Kral Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Kwon The impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: a model-based analysis. 2009 Kwon, Iversen, Maher, Law, Wilson Journal of Acquired Immune Deficiency Syndrome 51(4):462-9. doi: 10.1097/QAI.0b013e3181a2539a.

We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then approximately 3 times the incidence could be expected.

Lavigne Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Law The impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: a model-based analysis. 2009 Kwon, Iversen, Maher, Law, Wilson Journal of Acquired Immune Deficiency Syndrome 51(4):462-9. doi: 10.1097/QAI.0b013e3181a2539a.

We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then approximately 3 times the incidence could be expected.

Leonard Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Lurie Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

MacArthur Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Maher The impact of needle and syringe programs on HIV and HCV transmissions in injecting drug users in Australia: a model-based analysis. 2009 Kwon, Iversen, Maher, Law, Wilson Journal of Acquired Immune Deficiency Syndrome 51(4):462-9. doi: 10.1097/QAI.0b013e3181a2539a.

We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then approximately 3 times the incidence could be expected.

Marshall Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Martin Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings. 2012 Vickerman, Martin, Turner, Hickman Addiction 107(11):1984-95. doi: 10.1111/j.1360-0443.2012.03932.x.

Hepatitis C virus HCV transmission modeling using U.K. estimates for effect of OST and 100% NSP on individual risk of HCV infection.

To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs).

For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCVprevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ?80%. Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

Martin Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

McAllister Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

McKnight Doing harm reduction better: syringe exchange in the United States. 2009 Des Jarlais, McKnight, Goldblatt, Purchase Addiction 104(9):1441-6. doi: 10.1111/j.1360-0443.2008.02465.x.

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.

To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs.

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 US dollars and public funding (from state and local governments) has increased from 3.9 to 14.4 million US dollars. 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. 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.

McLeod The role of harm reduction in controlling HIV among injecting drug users 2008 Wodak, McLeod AIDS 22(Suppl 2): S81-S92. doi:10.1097/01.aids.0000327439.20914.33

Literature review

The scientific debate about harm reduction is now over: harm reduction has been shown convincingly to be effective in reducing HIV, and to be safe and cost-effective. After almost 20 years of looking for possible serious harmful side effects, no rigorous evidence has yet emerged that harm reduction encourages the earlier initiation of injecting, more frequent injecting, or a more prolonged injecting career.

The abundance, consistency and compelling nature of the evidence supporting harm reduction has not prevented a ferocious ideological debate between advocates of an evidence-based, public health approach and supporters of zero tolerance. At best, only 5% of IDU in the world are estimated currently to have access to HIV prevention services. Only a small number of countries, led by the USA, are still vehemently opposed to harm reduction. Excessive reliance on drug law enforcement remains the major barrier to increased adoption of harm reduction. Sometimes zealous drug law enforcement undermines harm reduction. A more balanced approach to drug law enforcement is required with illicit drug use recognized primarily as a health and social problem

Mermin Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013 2015 Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, Holtzman MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

Metzge Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Millson Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Munro Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Nambiar Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Neaigus Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Novak Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study 2017 Dahlman, Hakansson, Kral, Wenger, Ball, Novak Substance Abuse 38(1):105-112. doi 10.1080/08897077.2016.1263592

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant. CONCLUSION SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Nugent Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013 2015 Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, Holtzman MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

Nugent State laws, syringe exchange, and HIV among persons who inject drugs in the United States: History and effectiveness 2015 Bramson, Des Jarlais, Arasteh, Nugent, Guardino, Feelemyer, Hodel Journal of Public Health Policy 36(2):212-230 doi 10.1057/jphp.2014.54

A systematic review was conducted to document state laws focused on syringe and drug paraphernalia possession, drug possession, and syringe pharmacy sales between 1980 and 2012 in 30 states, the District of Columbia and Puerto Rico in conjunction with syringe exchange data through the National Survey of Syringe Exchange Programs, and estimated state-level HIV incidence data for PWID. States were categorized into three HIV incidence trend groups: highremaining-high, changing from high-to-low, and low-remaining-low. Public funding of SEPs was examined in relation to: 1) state-level trends in estimated HIV incidence, 2) current very high numbers of newly diagnosed cases of HIV among PWID, 3) the numbers of needles and syringes distributed by SEPs, and 4) the provision of multiple services at SEPs.

Providing safe and unimpeded access to sterile injecting equipment is a primary method for preventing HIV transmission among people who inject drugs (PWID). We examined legal changes related to possession of needles and syringes for injecting drugs over time in the US.

All 15 states with public funding of syringe exchange were in the high-to-low or low-tolow HIV incidence categories. None of the four states in the high-remaining-high category provided public funding for syringe exchange. OTC sales were also present in 11 of the 22 states in the high-to-low or low-to-low HIV incidence trend groups; only one state in the highremaining-high category had OTC sales. Lack of public funding for syringe exchange was also associated with high absolute numbers of newly diagnosed cases of HIV among PWID. There was a strong positive association between a syringe exchange program's receipt of public funding and the number of syringes distributed (R2 =0.42), the number of on-site services provided (R2 =0.52), and whether SEPs provided HIV counseling and testing (R2 =0.45). There are positive associations between publicly funded syringe exchange and low HIV incidence and low absolute numbers of new cases of HIV, as well as with greater service provision. Distribution of large numbers of needles and syringes is a potential causal mechanism linking public funding of SEPs to low HIV incidence. Public funding of SEPs is possible only when such programs are legal. SEPs and OTC sales of syringes will be most successful in reducing HIV transmission when legal barriers limiting their expansion, including the ban on federal funding of syringe exchange, are eliminated.

O'Rourke Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Palmateer Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Palmateer Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus 2010 Palmateer, Kimber, Hickman, Hutchinson, Rhodes, Goldberg Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Palmateer Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Palmateer Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Paquette Stigma at every turn: Health services experiences among people who inject drugs 2018 Paquette, Syvertsen, Pollini International Journal of Drug Policy Volume 57, July 2018, Pages 104-110

We conducted 46 qualitative interviews with PWID in California’s Central Valley between March and December 2015, as part of a multi-phase, multi-method study examining implementation of a new pharmacy syringe access law. A “risk environment” framework guided our data collection and we used a deductive/inductive approach to analyze the qualitative data.

People who inject drugs (PWID) encounter varying forms of stigma in health services contexts, which can contribute to adverse outcomes. We explored the lived experience of stigma among PWID to elucidate pathways by which stigma influences health care access and utilization.

Stigma played an undeniably important role in PWID’s experiences with health services access and utilization in the Central Valley. Our study illustrates the need to develop and test interventions that target drug use stigma at both structural and individual levels to minimize adverse effects on PWID health. Participants repeatedly cited the impact of stigma on syringe access, particularly in the context of meso-level pharmacist interactions. They described being denied syringe purchase as stigmatizing and embarrassing, and these experiences discouraged them from attempting to purchase syringes under the new pharmacy access law. Participants described feeling similarly stigmatized in their meso-level interactions with first responders and hospital staff, and associated this stigmatization with delayed and substandard medical care for overdoses and injection-related infections. Drug treatment was another area where stigma operated against PWID’s health interests; participants described macro-level public stigma towards methadone (e.g., equating methadone treatment with illicit drug use) as discouraging participation in this evidence-based treatment modality and justifying exclusion of methadone patients from recovery support services like sober living and Narcotics Anonymous.

Pharris Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Pollini Stigma at every turn: Health services experiences among people who inject drugs 2018 Paquette, Syvertsen, Pollini International Journal of Drug Policy Volume 57, July 2018, Pages 104-110

We conducted 46 qualitative interviews with PWID in California’s Central Valley between March and December 2015, as part of a multi-phase, multi-method study examining implementation of a new pharmacy syringe access law. A “risk environment” framework guided our data collection and we used a deductive/inductive approach to analyze the qualitative data.

People who inject drugs (PWID) encounter varying forms of stigma in health services contexts, which can contribute to adverse outcomes. We explored the lived experience of stigma among PWID to elucidate pathways by which stigma influences health care access and utilization.

Stigma played an undeniably important role in PWID’s experiences with health services access and utilization in the Central Valley. Our study illustrates the need to develop and test interventions that target drug use stigma at both structural and individual levels to minimize adverse effects on PWID health. Participants repeatedly cited the impact of stigma on syringe access, particularly in the context of meso-level pharmacist interactions. They described being denied syringe purchase as stigmatizing and embarrassing, and these experiences discouraged them from attempting to purchase syringes under the new pharmacy access law. Participants described feeling similarly stigmatized in their meso-level interactions with first responders and hospital staff, and associated this stigmatization with delayed and substandard medical care for overdoses and injection-related infections. Drug treatment was another area where stigma operated against PWID’s health interests; participants described macro-level public stigma towards methadone (e.g., equating methadone treatment with illicit drug use) as discouraging participation in this evidence-based treatment modality and justifying exclusion of methadone patients from recovery support services like sober living and Narcotics Anonymous.

Pouget A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. 2011 Hagan, Pouget, Des Jarlais Journal of Infectious Diseases 204(1):74-83. doi: 10.1093/infdis/jir196.

We performed a systematic review and meta-analysis of published and unpublished studies. Eligible studies reported on the association between participation in interventions intended to reduce unsafe drug injection and HCV seroconversion in samples of PWID.

High rates of hepatitis C virus (HCV) transmission are found in samples of people who inject drugs (PWID) throughout the world. The objective of this paper was to meta-analyze the effects of risk-reduction interventions on HCV seroconversion and identify the most effective intervention types.

The meta-analysis included 26 eligible studies of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions. Interventions using multiple combined strategies reduced risk of seroconversion by 75% (pooled relative risk, .25; 95% confidence interval, .07-.83). Effects of single-method interventions ranged from .6 to 1.6. Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion. Determining the effective dose and combination of interventions for specific subgroups of PWID is a research priority. However, our meta-analysis shows that HCV infection can be prevented in PWID.

Purchase Doing harm reduction better: syringe exchange in the United States. 2009 Des Jarlais, McKnight, Goldblatt, Purchase Addiction 104(9):1441-6. doi: 10.1111/j.1360-0443.2008.02465.x.

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.

To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs.

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 US dollars and public funding (from state and local governments) has increased from 3.9 to 14.4 million US dollars. 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. 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.

Rhodes Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus 2010 Palmateer, Kimber, Hickman, Hutchinson, Rhodes, Goldberg Addiction. 2010 May;105(5):844-59. doi: 10.1111/j.1360-0443.2009.02888.x.

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

NOTE: WHEN THEY SAY LITTLE EVIDENCE, IT MEANS IT HASN'T BEEN STUDIED ENOUGH TO BE STATISTICALLY SIGNIFICANT Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-a-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Rhodes Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Rossi Effect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence 2020 Rossi, Brady, Hall, Warshak

Am J Perinatol. 2020 Jan 21. doi: 10.1055/s-0039-3402753

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of maternal HCV was compared before (2006-2011) and after (2012-2015) the implementation of an NEP (2011) in Portsmouth, Ohio (Scioto County). Trends in maternal HCV prevalence in neighboring counties both physically adjacent and regional to Scioto County were also evaluated before and after NEP implementation.

To quantify the prevalence of maternal hepatitis C virus (HCV) before and after implementation of the needle exchange program (NEP) in Scioto County, Ohio.

Rate of maternal HCV infection increased 137% versus 12% (rate difference: 125%) between pre- and post-NEP implementation time periods in Scioto County.During the study period, there were 7,069 reported cases of maternal HCV infection at the time of delivery among 1,463,506 (0.5%) live births in Ohio. The rate of maternal HCV infection increased 137% in Scioto County between 2006 and 2011. After initiation of the NEP in Portsmouth, Ohio, in 2011, the rate of increase in the following 4 years (2012-2015) was 12%. The rate of increase in maternal HCV declined precipitously in counties physically adjacent to Scioto County, whereas regional counties continued to have substantial increases in maternal HCV.

Roy Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Ruiz Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.

Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.

Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care. The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).

Saad Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Salminen Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Schaefer Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

SCosta Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Shepherd Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Shore Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Smith State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016 2017 Campbell, Canary, Smith, Teshale, Blythe Ryerson, Ward MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

Smith Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. 2018 Khan, Duncan, Saad, Schaefer, Jordan, Smith, Neaigus, Des Jarlais, Hagan, Dombrowski PLoS One 13(11):e0206356. doi: 10.1371/journal.pone.0206356

This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies.

Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Solberg Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas -- United States, 2013 2015 Des Jarlais, Nugent, Solberg, Feelemyer, Mermin, Holtzman MMWR Morbidity and Mortality Weekly. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm

Data from a recent survey of SSPs were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services were less available to PWID outside urban settings. As of March 2014, 204 SSPs were known to be operating in the United States in 2013. Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

A survey of SSPs identified notable differences (e.g., location, size, budgets, staffing, and drugs injected) and certain key similarities (e.g., offering HIV and HCV testing) among urban and nonurban SSPs. Substantially fewer SSPs were located in rural or suburban than in urban areas, making harm reduction services less available to PWID outside urban settings.

Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

Strike Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Syvertsen Stigma at every turn: Health services experiences among people who inject drugs 2018 Paquette, Syvertsen, Pollini International Journal of Drug Policy Volume 57, July 2018, Pages 104-110

We conducted 46 qualitative interviews with PWID in California’s Central Valley between March and December 2015, as part of a multi-phase, multi-method study examining implementation of a new pharmacy syringe access law. A “risk environment” framework guided our data collection and we used a deductive/inductive approach to analyze the qualitative data.

People who inject drugs (PWID) encounter varying forms of stigma in health services contexts, which can contribute to adverse outcomes. We explored the lived experience of stigma among PWID to elucidate pathways by which stigma influences health care access and utilization.

Stigma played an undeniably important role in PWID’s experiences with health services access and utilization in the Central Valley. Our study illustrates the need to develop and test interventions that target drug use stigma at both structural and individual levels to minimize adverse effects on PWID health. Participants repeatedly cited the impact of stigma on syringe access, particularly in the context of meso-level pharmacist interactions. They described being denied syringe purchase as stigmatizing and embarrassing, and these experiences discouraged them from attempting to purchase syringes under the new pharmacy access law. Participants described feeling similarly stigmatized in their meso-level interactions with first responders and hospital staff, and associated this stigmatization with delayed and substandard medical care for overdoses and injection-related infections. Drug treatment was another area where stigma operated against PWID’s health interests; participants described macro-level public stigma towards methadone (e.g., equating methadone treatment with illicit drug use) as discouraging participation in this evidence-based treatment modality and justifying exclusion of methadone patients from recovery support services like sober living and Narcotics Anonymous.

Taylor Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Taylor Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions. 2014 Palmateer, Taylor, Goldberg, Munro, Aitken, Shepherd, McAllister, Gunson, Hutchinson PLoS One 9(8) doi: 10.1371/journal.pone.0104515.

We used a framework to triangulate different types of evidence: 'group-level/ecological' and 'individual-level'. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1-2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1-20.1) in 2008-09 to 7.3 (3.0-12.9) in 2011-12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11-0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01-0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008-2012.

Government policy has precipitated recent changes in the provision of harm reduction interventions - injecting equipment provision (IEP) and opiate substitution therapy (OST) - for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID.

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Teshale State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016 2017 Campbell, Canary, Smith, Teshale, Blythe Ryerson, Ward MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

Torre Effectiveness of needle and syringe Programmes in people who inject drugs – An overview of systematic reviews 2017 Fernandes, Cary, Duarte, Jesus, Alarcão, Torre, SCosta, J Costa, Carneiro BMC Public Health. 2017; 17: 309. doi: 10.1186/s12889-017-4210-2

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial. The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

Townsend Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study 2019 Goedel, King, Lurie, Galea, Townsend, Galvani, Friedman, Marshall

Clinical Infectious Diseases, ciz321, https://doi.org/10.1093/cid/ciz321

In the current study, we used an agent-based model to estimate the relative benefits of pre-existing and reactive SSP implementation on HIV transmission within a virtual population representative of a rural county in the United States.  Agent-based modeling is an individual-based simulation approach used to understand how microlevel interactions generate and influence macrolevel phenomena. Our model simulated HIV transmission for 5 years within a population of 24,110 residents of a rural county in the United States. This model simulated a population of adults in steady state, where individuals left the population at death or due to aging out at 65 years old.

To our knowledge, this study is the first to model the relative benefits of reactive and proactive implementation of SSPs in reducing HIV transmission among PWID. In the absence of an SSP, the model predicted large outbreaks among PWID following the introduction of HIV into the network, with incidence rates reaching levels observed among PWID in many urban settings in the United States in the early 1990s before the advent of antiretroviral treatment. The eventual size of the outbreak could be reduced if an SSP was implemented proactively before the introduction of HIV into the network. Our model also suggests that SSP implementation may have spillover effects. In averting infections occurring via injection drug use, we are likely also averting transmission between PWID and their partners who do not inject drugs.

In the absence of an SSP, the model predicted 210 incident infections (95% simulation interval [SI], 206–214 infections) in the entire population over 5 years, corresponding to an incidence of 0.18 infections per 100 person-years (95% SI, 1.07–1.13 infections) and resulting in a prevalence of 0.96% (95% SI, 0.94–0.98%) after 5 years.  Proactive implementation of an SSP reduced the size of the outbreak. In this scenario, the model predicted 32 incident infections (95% SI, 31–33 infections) over 5 years, corresponding to an incidence of 0.03 infections per 100 person-years (95% SI, 0.02–0.03 infections) and resulting in a prevalence of 0.22% (95% SI, 0.22–0.23%) after 5 years. Among PWID, 154 infections (95% SI, 152–155 infections) were averted, decreasing the incidence by 90.3% to 1.17 infections per 100 person-years (95% SI, 1.11–1.23 infections). The average prevalence among PWID after 5 years decreased by 86.0% to 6.1% (95% SI, 5.8–6.4%). People who did not inject drugs also benefited in this scenario.

Turner Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings. 2012 Vickerman, Martin, Turner, Hickman Addiction 107(11):1984-95. doi: 10.1111/j.1360-0443.2012.03932.x.

Hepatitis C virus HCV transmission modeling using U.K. estimates for effect of OST and 100% NSP on individual risk of HCV infection.

To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs).

For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCVprevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ?80%. Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

Van Velzen Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

van Velzen Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. 2014 MacArthur, van Velzen, Palmateer, Kimber, Pharris, Hope, Taylor, Roy, Aspinall, Goldberg, Rhodes, Hedrich, Salminen, Hickman, Hutchinson International Journal of Drug Policy. 25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001.

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Vellozzi Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Vickerman Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings. 2012 Vickerman, Martin, Turner, Hickman Addiction 107(11):1984-95. doi: 10.1111/j.1360-0443.2012.03932.x.

Hepatitis C virus HCV transmission modeling using U.K. estimates for effect of OST and 100% NSP on individual risk of HCV infection.

To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs).

For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCVprevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ?80%. Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.

Vickerman Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Ward Scaling-up HCV prevention and treatment interventions in rural United States-model projections for tackling an increasing epidemic. 2018 Fraser, Zibbell, Hoerger, Hariri, Vellozzi, Martin, Kral, Hickman, Ward, Vickerman

Addiction. 2018 Jan;113(1):173-182. doi: 10.1111/add.13948

An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from an HIV outbreak investigation in Indiana.

Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States. We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting.

To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 24.9% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 14.5%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (19.9%) need treatment annually. These treatment requirements are threefold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. Combined scale-up of hepatitis C virus treatment and prevention interventions is needed to decrease the increasing burden of hepatitis C virus incidence and prevalence in rural Indiana, USA, by 90% by 2025/30.

Ward State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs--United States, 2015-2016 2017 Campbell, Canary, Smith, Teshale, Blythe Ryerson, Ward MMWR Morbidity and Mortality Weekly Report 66(18);465-469. doi: http://dx.doi.org/10.15585/mmwr.mm6618a2

Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements.

To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs.

Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drug. Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies. Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

Warshak Effect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence 2020 Rossi, Brady, Hall, Warshak

Am J Perinatol. 2020 Jan 21. doi: 10.1055/s-0039-3402753

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of maternal HCV was compared before (2006-2011) and after (2012-2015) the implementation of an NEP (2011) in Portsmouth, Ohio (Scioto County). Trends in maternal HCV prevalence in neighboring counties both physically adjacent and regional to Scioto County were also evaluated before and after NEP implementation.

To quantify the prevalence of maternal hepatitis C virus (HCV) before and after implementation of the needle exchange program (NEP) in Scioto County, Ohio.

Rate of maternal HCV infection increased 137% versus 12% (rate difference: 125%) between pre- and post-NEP implementation time periods in Scioto County.During the study period, there were 7,069 reported cases of maternal HCV infection at the time of delivery among 1,463,506 (0.5%) live births in Ohio. The rate of maternal HCV infection increased 137% in Scioto County between 2006 and 2011. After initiation of the NEP in Portsmouth, Ohio, in 2011, the rate of increase in the following 4 years (2012-2015) was 12%. The rate of increase in maternal HCV declined precipitously in counties physically adjacent to Scioto County, whereas regional counties continued to have substantial increases in maternal HCV.

Watson Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs) 2011 Strike, Watson, Lavigne, Hopkins, Shore, Young, Leonard, Millson International Journal of Drug Policy 22(1):34-40 doi: 10.1016/j.drugpo.2010.03.007

An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.

The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.

The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%,n=28) and satellite NSPs (84%,n=52) distributed cookers following the dissemination of the document. All core NSPs (100%,n=32) and nearly all satellite NSPs (97%,n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%,n=27) distributed glass stems than the core NSPs (16%,n=5). Commonly cited implementation barriers included funding, senior management and decision-making. Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Weir Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 2014 Aspinall, Nambiar, Goldberg, Hickman, Weir, Van Velzen, Palmateer, Doyle, Hellard, Hutchinson International Journal of Epidemiology 43(1):235-48. doi: 10.1093/ije/dyt243.

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Wen Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia 2019 Ruiz, O'Rourke, Allen, Holtgrave, Metzge, Benitez, Brady, Chaulk, Wen

J Acquir Immune Defic Syndr. 2019 Dec 1; 82(2): S148–S154. doi: 10.1097/QAI.0000000000002176

Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an es