T. Stephen Jones

Cost and cost-effectiveness of increasing access to sterile syringes and needles as an HIV prevention intervention in the United States.

We determined the cost of increasing access of injection drug users (IDUs) to sterile syringes and needles as an HIV prevention intervention in the United States and the cost per HIV infection averted by such a program. We considered a hypothetical cohort of 1 million active IDUs in the United States. Standard methods were used to estimate the cost and cost-effectiveness of policies to increase access to sterile syringes and syringe disposal at various levels of coverage (e.g., a 100% coverage level would ensure access to a sterile syringe for each injection given current levels of illicit drug injection in the United States; a 50% coverage level would ensure access to one half of the required syringes). A mathematical model of HIV transmission was employed to link programmatic coverage levels with estimates of numbers of HIV infections averted. A policy of funding syringe exchange programs, pharmacy sales, and syringe disposal to cover all illicit drug injections would cost just over

Syringe Disposal Options for Injection Drug Users: A Community-Based Perspective

423 million U.S. for 1 year. One third of these costs would be paid for as out-of-pocket expenditures by IDUs purchasing syringes in pharmacies. Compared with the status quo, this policy would cost an estimated

Injection and syringe sharing among HIV-infected injection drug users : Implications for prevention of HIV transmission

34,278 U.S. per HIV infection averted, a figure well under the estimated lifetime costs of medical care for a person with HIV infection. At very high levels of coverage (>88%), the marginal cost-effectiveness of increased program coverage becomes less favorable. Although the total costs of funding large-scale IDU access to sterile syringes and disposal seem high, the economic benefits are substantial. Even at high levels of coverage, such funding would save society money. As part of a comprehensive program of HIV prevention, policies to increase IDUs access to sterile syringes urgently need further consideration by public health decision makers.

What we can learn from the INSPIRE Study about improving prevention and clinical care for injection drug users living with HIV.

This study was a qualitative exploration of syringe disposal interventions for injection drug users (IDUs). Data were collected through in-depth interviews with 26 community members who injected drugs and 32 noninjecting community members in Atlanta, Georgia. Both groups supported syringe exchange programs as syringe disposal interventions, while noninjecting community members favored a one-way drop box. IDUs identified fear of arrest for possession of syringes as the most salient barrier to safe syringe disposal, revealing the negative consequences of drug paraphernalia laws.

Community-Based Response to Fentanyl Overdose Outbreak, San Francisco, 2015

Because HIV-infected injection drug users (IDUs) can transmit HIV infection, we investigated factors associated with sharing of syringes in the past year among IDUs infected with HIV. We analyzed data from an interview survey of 11,757 persons > or = 18 years of age with HIV or AIDS between June 1990 and August 1995 who were reported to 12 state or city health departments in the United States. Of the 1527 persons who had ever shared syringes and reported injecting in the 5 years before the interview, 786 (51%) had injected in the year before interview, and of these, 391 (50%) had shared during that year. IDUs who were aware of their HIV infection for >1 year were less likely to share (43%) than those who were aware of their infection for 1 year or less (65%, adjusted odds ratio=2.15, 95% confidence interval, 1.52-3.03). The only statistically significant time trend was that the proportion of IDUs from Connecticut who shared decreased from 71% in 1992 to 29% in 1995. This trend appears to be related to the 1992 changes in Connecticut laws that allowed purchase and possession of syringes without a prescription. Because many HIV-infected IDUs continue to inject and share, prevention efforts should be aimed at HIV-infected IDUs to prevent transmission of HIV. Early HIV diagnosis and access to sterile syringes may be important methods for reducing syringe sharing by HIV-infected IDUs.

CAMPYLOBACTER ENTERITIS AT A UNIVERSITY: TRANSMISSION FROM EATINGCHICKEN AND FROM CATS

Beginning in the mid-1990s, the widespread use of effective treatments for HIV infection (highly active antiretroviral therapy [HAART]) led first to dramatic declines in AIDS incidence and deaths and then to changes in the priorities for HIV prevention and treatment. The prospects for people living with HIV infection changed from expectation of premature death to the likelihood of living a longer healthier life. With widespread availability of HAART, HIV infection is now treated as a chronic disease. With substantially increased survival, the number of people living with HIV in the United States increased to an estimated 1 million in 2003. In the United States, the increasing numbers of people living with HIV brought new urgency and opportunities to develop secondary HIV prevention initiatives for people living with HIV. In 2003, the Centers for Disease Control and Prevention (CDC) introduced the Advancing HIV Prevention initiative, which included the objective of preventing new infections by working with persons diagnosed with HIV and their partners, Also, in 2003, the CDC and the Health Resources and Services Administration (HRSA) called for increased HIV prevention efforts in the medical care of persons living with HIV. Even so, the literature of published prevention interventions for people living with HIV is limited. Two meta-analyses of HIV prevention studies among persons living with HIV were published in 2006. In the 12 studies that met inclusion criteria, Crepaz and colleagues found that there was evidence of significant reductions in unprotected sex and decreased acquisition of sexually transmitted infections. Only 1 of these studies targeted injection drug users (IDUs). Among the 15 studies of interventions to prevent sexual transmission from HIV-positive persons that met inclusion criteria, Johnson and colleagues found that the interventions led to improved use of condoms but not to reducing the number of sex partners. For people living with HIV, utilizing health care well and, when antiretroviral treatment is needed, adhering to medications schedules also are important. Being able to take multiple antiretroviral medications as prescribed and to sustain good adherence for years is essential to avoid developing resistance to 1 or more of the medications and potentially serious complications of HIV infection. For those reasons, the Interventions for Seropositive Injectors—Research and Evaluation (INSPIRE) research project was a major step in testing behavioral interventions for people living with HIV. The INSPIRE project was planned in the late 1990s and was in the field from 2001 to 2005. It was a carefully designed and well-implemented randomized controlled trial of a behavioral intervention with 966 HIV-infected IDUs, a group of people living with HIV that is less frequently studied. INSPIRE was jointly funded by the CDC and HRSA to integrate testing of behavioral interventions in 2 high-priority areas, prevention of secondary transmission and improving HIV-related health care. INSPIRE was a theory-based trial of a 10-session peer mentoring intervention, including 7 small group and 2 individual sessions and a community visit to practice peer

Morbidity and mortality associated with the July 1980 heat wave in St Louis and Kansas City, Mo.

This report documents a successful intervention by a community-based naloxone distribution program in San Francisco. The program and its partner organizations, working with participants who use drugs, first identified the appearance of illicitly made fentanyl and increased outreach and naloxone distribution. Distribution of naloxone and reported use of naloxone to reverse opioid-involved overdoses increased significantly while the number of opioid-involved and fentanyl-involved overdose deaths did not. Community-based programs that provide training and naloxone to people who use drugs can serve as an early warning system for overdose risk and adaptively respond to the rapidly changing overdose risk environment.