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
-
Injecting Risk
- Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspective
-
Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspectiveYear:2014Citation:
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.
- An examination of injection drug use trends in Victoria and Vancouver, BC after the closure of Victoria's only fixed-site needle and syringe programme.
-
An 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:2012Citation:
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.
- Needle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research.
-
Needle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research.Year:2012Citation:
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.
- Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes.
-
Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes.Year:2010Citation:
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.
- The 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.
-
The 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:2009Citation:
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).
- Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users.
-
Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users.Year:2007Citation:
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.
- Author
- Title
-
Publication Topic: Injecting Risk
Year Citation Study Methods Gap in evidence addressed Key Findings An 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, Duff, 2012 International Journal of Drug Policy 23(4):338-40. doi: 10.1016/j.drugpo.2011.11.004
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.
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.
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.
Examination 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, Kral, 2007 Addiction. 2007 Apr;102(4):638-46. doi: 10.1111/j.1360-0443.2006.01741.x
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).
To determine whether syringe exchange programs' (SEPs) dispensation policy is associated with syringe coverage among SEP clients.
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.
Needle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research. (2012) Hyshka, Strathdee, Wood, Kerr, 2012 Inernational Journal of Drug Policy 23(4):261-70. doi: 10.1016/j.drugpo.2012.03.006
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.
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.
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.
Syringe 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, Hagan, 2014 International Journal of Drug Policy 25(1) 105-11. https://doi.org/10.1016/j.drugpo.2013.06.005
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.
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.
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.
Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes. (2010) Kerr, Small, Buchner, Zhang, Li, Montaner, Wood, 2010 American Journal of Public Health, 100(8):1449-53. doi: 10.2105/AJPH.2009.178467
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.
We assessed the effects of syringe exchange program (SEP) policy on rates of HIV risk behavior and HIV incidence among injection drug users.
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.
The 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, Garfein, 2009 Prevention Medicine 49(1):68-73. doi: 10.1016/j.ypmed.2009.04.014
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.
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.
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).
If you have questions or notice errors in this list, please contact Tim Candela, Drug User Health Coordinator: tim.candela@doh.wa.gov.