Courtney McKnight

Doing harm reduction better: syringe exchange in the United States.

OBJECTIVE To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs. METHODS Annual surveys of US SEPs known to North American Syringe Exchange Network (NASEN). Surveys mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. RESULTS The numbers of programs known to NASEN have increased from 68 in 1994-95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from 6.3 to 19.6 million 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. CONCLUSIONS While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing SEPs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of SEPs in the United States.

Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas

Community activism can be important in shaping public health policies. For example, political pressure and direct action from grassroots activists have been central to the formation of syringe exchange programs (SEPs) in the United States. We explored why SEPs are present in some localities but not others, hypothesizing that programs are unevenly distributed across geographic areas as a result of political, socioeconomic, and organizational characteristics of localities, including needs, resources, and local opposition. We examined the effects of these factors on whether SEPs were present in different US metropolitan statistical areas in 2000. Predictors of the presence of an SEP included percentage of the population with a college education, the existence of local AIDS Coalition to Unleash Power (ACT UP) chapters, and the percentage of men who have sex with men in the population. Need was not a predictor.

A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment

OBJECTIVES We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. METHODS We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. RESULTS Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61). CONCLUSIONS Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

Using hepatitis C virus and herpes simplex virus-2 to track HIV among injecting drug users in New York City

OBJECTIVE To explore the potential utility of hepatitis C virus (HCV) seroprevalence as a biomarker for injection risk, and herpes simplex virus-2 (HSV-2) as a biomarker for sexual risk among injecting drug users (IDUs). We examined the relationships between HCV and HIV and between HSV-2 and HIV among injecting drug users in New York City relative to the large-scale implementation of syringe exchange in the mid-1990s. METHODS 397 injecting drug users were recruited from a drug detoxification program in New York from 2005 to 2007. Informed consent was obtained, a questionnaire covering demographics, drug use and HIV risk was administered. Blood samples were tested for antibody to HIV, HCV and HSV-2. RESULTS Among all subjects, HIV prevalence was 17%, HCV prevalence 72% and HSV-2 prevalence 48%. Among IDUs who began injecting before 1995, HIV was 28%, HCV serostatus was strongly associated with HIV serostatus (AOR=8.96, 95% CI 1.16-69.04) and HSV-2 serostatus was not associated with HIV serostatus (AOR=1.31, 95% CI 0.64-2.67). Among subjects who began injecting in 1995 or later, HIV was 6%, HCV was not associated with HIV (AOR=1.04, 95% CI 0.27-4.08) and HSV-2 serostatus was strongly related to HIV serostatus (AOR=10.71, 95% CI 1.18-97.57). CONCLUSIONS HCV and HSV-2 HCV and HSV-2 may provide important new tools for monitoring evolving HIV epidemics among IDUs. Reconsideration of the current CDC hierarchical transmission risk classification system may also be warranted.

Perceptions of drug users regarding hepatitis C screening and care: a qualitative study.

BackgroundIllicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.MethodsFourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.ResultsMany drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.ConclusionDrug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.

Diffusion of the D.A.R.E and syringe exchange programs.

We examined the diffusion of the D.A.R.E program to reduce use of illicit drugs among school-aged children and youths and the diffusion of syringe exchange programs to reduce HIV transmission among injection drug users. The D.A.R.E program was diffused widely in the United States despite a lack of evidence for its effectiveness; there has been limited diffusion of syringe exchange in the United States, despite extensive scientific evidence for its effectiveness. Multiple possible associations between diffusion and evidence of effectiveness exist, from widespread diffusion without evidence of effectiveness to limited diffusion with strong evidence of effectiveness. The decision theory concepts of framing and loss aversion may be useful for further research on the diffusion of public health innovations.

Epidemiology of Pain among Outpatients in Methadone Maintenance Treatment Programs

BACKGROUND This analysis explored the prevalence and correlates of pain in patients enrolled in methadone maintenance treatment (MMT). METHODS Patients in two MMT programs starting a hepatitis care coordination randomized controlled trial completed the Brief Pain Inventory Short-Form and other questionnaires. Associations between clinically significant pain (average daily pain≥5 or mean pain interference≥5 during the past week) and sociodemographic data, medical status, depressive symptoms, and health-related quality of life, and current substance use were evaluated in multivariate analyses. RESULTS The 489 patients included 31.8% women; 30.3% Hispanics, 29.4% non-Hispanic Blacks, and 36.0% non-Hispanic Whites; 60.1% had hepatitis C, 10.6% had HIV, and 46.8% had moderate or severe depressive symptomatology. Mean methadone dose was 95.7mg (SD 48.9) and urine drug screening (UDS) was positive for opiates, cocaine, and amphetamines in 32.9%, 40.1%, and 2.9%, respectively. Overall, 237 (48.5%) reported clinically significant pain. Pain treatments included prescribed opioids (38.8%) and non-opioids (48.9%), and self-management approaches (60.8%), including prayer (33.8%), vitamins (29.5%), and distraction (12.7%). Pain was associated with higher methadone dose, more medical comorbidities, prescribed opioid therapy, and more severe depressive symptomatology; it was not associated with UDS or self-reported substance use. CONCLUSIONS Clinically significant pain was reported by almost half of the patients in MMT programs and was associated with medical and psychological comorbidity. Pain was often treated with opioids and was not associated with measures of drug use. Studies are needed to further clarify these associations and determine their importance for pain treatment strategies.

Incidence and prevalence of hepatitis c virus infection among persons who inject drugs in New York City: 2006-2013

BACKGROUND Hepatitis C virus infection is a source of significant preventable morbidity and mortality among persons who inject drugs (PWID). We sought to assess trends in hepatitis C virus (HCV) infection among PWID from 2006 to 2013 in New York City (NYC). METHODS Annual cross-sectional surveys of PWID entering a large drug abuse treatment program were performed. Risk behavior questionnaires were administered, and HIV and HCV testing were conducted. Comparisons were made with prior prevalence and incidence estimates in 1990-1991 and 2000-2001 reflecting different periods of combined prevention and treatment efforts. RESULTS HCV prevalence among PWID (N: 1535) was 67% (95% CI: 66-70%) during the study period, and was not significantly different from that observed in 2000-2001. The estimated HCV incidence among new injectors (persons injecting for ≤6 years) during 2006-2013 was 19.5/100 PYO (95% CI: 17-23) and did not differ from that observed in 2000-2001 (18/100 PYO, 95% CI: 14-23/100). CONCLUSIONS Despite the expansion of combined prevention programming between 2000-2001 and 2006-2013, HCV prevalence remained high. Estimated HCV incidence among new injectors also remained high, and not significantly lower than in 2000-2001, indicating that expanded combined prevention efforts are needed to control the HCV epidemic among PWID in NYC.

Transitions from injecting to non-injecting drug use: Potential protection against HCV infection

Transitions from injecting to non-injecting drug use have been reported from many different areas, particularly in areas with large human immunodeficiency virus (HIV) epidemics. The extent to which such transitions actually protect against HIV and HCV has not been determined. A cross-sectional survey with HIV and hepatitis C (HCV) testing was conducted with 322 former injectors (persons who had injected illicit drugs but permanently transitioned to non-injecting use) and 801 current injectors recruited in New York City between 2007 and 2012. There were no differences in HIV prevalence, while HCV prevalence was significantly lower among former injectors compared to current injectors. Years injecting functioned as a mediating variable linking former injector status to lower HCV prevalence. Transitions have continued well beyond the reduction in the threat of AIDS to injectors in the city. New interventions to support transitions to non-injecting drug use should be developed and supported by both drug treatment and syringe exchange programs.

Public funding of US syringe exchange programs.

Although there has been no federal government funding of syringe exchange, there is substantial state and local government funding. We report here on program characteristics associated with receiving state and local government funding. Annual telephone surveys were made of program directors of syringe exchange programs known to the North American Syringe Exchange Network. The number of syringe exchange programs known to this network has increased from 63 in 1994–1995 to 127 in 2000. Approximately 80% of programs participated in each of the surveys. Approximately 50% of programs receive state and local government funding, and this has remained constant from 1994 to 2000. Receiving state and local government funding was associated with larger numbers of syringes exchanged per year and providing more on-site services. Among programs that received state or local government funding, this funding accounted for a mean of 87% of the budget for syringe exchange services. In the absence of federal funding, state and local government support is associated with better syringe exchange performance.