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THEORETICAL CONCEPTS IN COMBINED HIV
PREVENTION PROGRAMMING
Don C. Des JarlaisBeth Israel Medical Center
New York City, USA
THEORETICAL CONCEPTS IN
COMBINED HIV PREVENTION
PROGRAMMING
Don C. Des JarlaisBeth Israel Medical Center
New York City, USA
NO ONE HIV PREVENTION PROGRAM
ELIMINATES RISK BEHAVIORS
DIFFERENT PROGRAMS FOR DIFFERENT
PEOPLE:
Drug dependence treatment for persons who cannot consistently
obtain and use clean syringes
RISK ELIMINATION IS NOT NEEDED: HERD
IMMUNITY
Outside of acute HIV infection, sharing syringes still inefficient for HIV transmission (1% probability
per sharing act)Sero-sorting, Partner Restriction,
Informed Altruism
NEEDLE/SYRINGE PROGRAMS ARE FOUNDATION OF
COMBINED PROGRAMMING
How good are big needle/syringe programs?
EVIDENCE FOR NEEDLE/SYRINGE PROGRAMS: AN INTERNATIONAL
REVIEW
Don C. Des JarlaisBeth Israel Medical Center
New York City, USA
Acknowledgments
Beth Israel Medical Center: Jonathan Feelemyer, Shilpa Modi
Centers for Disease Control: Abu Abdul-Quader and Salaam Semaan
University of California, San Francisco: Ellen Stein, Gail Kennedy, Tara Horvath, Alya Briceno
NIAID Grant 0832035 NIDA Grant 003574
Preventing HIV Epidemics among Injection Drug Users (IDU)
Many successful SEP were started when HIV prevalence among injection drug users (IDU) was at a low level (less than 5%)
In almost all of these areas, HIV epidemics did not occur among IDUs, prevalence remained at less than 5%
Examples: Australia, the United Kingdom, New Zealand, Toronto Canada, and Seattle and Tacoma USA
Failures of Syringe Exchange Programs
Dundee Scotland in the late 1980’s, staff were more focused on recruiting drug users into the treatment program, users stopped attending
Vancouver Canada in the early 90’s had a limited exchange policy including only 4 syringes per visit. Cocaine epidemic occurred during same
period IDU with social and health problems were
highly concentrated in one part of the cityNew York City First Program: too small,
inconvenient
Framing the Issue
Unused syringes distributed to injectors from manufacturers do not contain blood borne viruses
One of the main obstacles to needle exchange and distribution lies in the ability to distribute enough sterile needles and syringes to drug users at both the right time and at the right place
Structural level interventions need to be able to reach a majority of the IDU in the population; creating a “herd immunity” effect
Methods
Systematic literature review of structural level interventions involving SEP were conducted following Cochrane review protocol
Over 1200 abstracts screened and over 60 articles coded for eligibility; 14 articles met inclusion criteria
Strict inclusion of SEP coverage in study, defined as greater than 50% IDU coverage in a particular location
Four continents are represented in review (North America, Australia, Europe, and Asia)
Goldberg 1998 (Scotland)Study Design
Location Population Intervention Coverage
Outcomes
Before/After Comparison
Glasgow Scotland
IDU recruited from SCIEH (Scottish Centre for Infection and Environmental Health) from 1990-1995
Policies:UK DOH Policy Change led to SEP formation Major scale up of services: 1988-1992Pharmacy distribution in tandem with SEP expansion
Coverage:Needles Distributed Annually: 200,000-300,000Population of IDU: 6000-8500Syringes distributed per IDU per year: 33-36
Overall HCV Prevalence Change: -13% (p<0.001)
Effect Modifiers
Change in HCV Prevalence by Gender Female: -18%Male: -10%
Change in HCV Prevalence by Age:15-19: -63%20-24: -16%25-29: -3%30-34: +2%35+: -9%
Hope 2005 (UK)Study Design
Location(s)
Population
Intervention Coverage
Outcomes
Time Series Serial Cross Sectional
England & Wales United Kingdom
IDU recruited from street settings from 1990-1996
Measurement of HCV prevalence was taken by year during the time period 1990-1996
Policies:UK DOH Policy Change led to SEP formation Major scale up of services: 1988-1992Pharmacy distribution in tandem with SEP expansion
Coverage:Needles Distributed Annually: 26.7 millionPopulation of IDU: 139391-146246Syringes distributed per IDU per year: 183-186
Overall HIV Prevalence Change: -4.55% (p<0.001)
Effect Modifiers: None
Des Jarlais 2007 (Vietnam, China)Study
DesignLocation(
s)Populatio
nIntervention
CoverageOutcomes
Time Series Serial Cross Sectional
Lang Song Vietnam
Ning Ming China
IDU recruited from street settings from 1990-1996
Measurement of HCV prevalence was taken by year during the time period 1990-1996
Policies:National Institute on Drug Abuse &Ford Foundation Support SEP began in 2002 Pharmacy distribution in tandem with SEP placement
Coverage:Needles Distributed Annually: 240,000-288,000Population of IDU: 8000-12000, approx 30 syringes/IDU/yearCoverage of IDU in both locations: 60-65%
Overall HIV Prevalence Change:
Lang Song Province: -14% (p<0.05)Ning Ming Province: -3% (p<0.05)
Effect Modifiers:
Change in HIV Prevalence in New Injectors, by location:
Lang Song Province: -16% (p<0.0002)Ning Ming Province: -11% (p<0.0093)
Des Jarlais 2005(b) (USA)Study Design
Location
Population
Intervention Coverage
Outcomes
Time Series Serial Cross Sectional
New York City, USA
IDU recruited from Beth Israel Detoxification Unit, 1990-2002)
(STARHS)
Policies:1992: Legal Authorization of SEP in New York CityTotal Expansion Period: 1990-2001Significant ramp up especially in mid 1990'sPharmacy sales of Needle also available
Needles Distributed Annually: 2-3 millionPopulation of IDU: 100,000Syringes distributed per IDU/year: 30Coverage of IDU: ~50%
Overall HIV Prevalence Change: -33%
Overall HIV Incidence Change: -2.78/100PY
Effect Modifiers: None
Bruneau 2011 (Canada)
Study Design location Population Intervention Coverage Outcomes Before/After Comparison Vancouver Canada IDU recruited from street and peer based settings: 1998-2003 Policies: Health Authority authorizes syringe distribution: 2000-2002 Decentralization of SEP sites Hotel based and street distribution in tandem with SEP
Coverage: Needles Distributed Annually: 1.8 million Population of IDU: 1400 Syringes distributed per IDU per year: 1400 Coverage of IDU: 89% Adjusted Hazard Ratio (AHR) for HIV incidence comparing pre-SEP to post-SEP
participants: 0.13
Effect Modifiers: None
Study Design
Location
Population
Intervention Coverage
Outcomes
Time Series Serial Cross Sectional
MontrealCanada
IDU recruited from street, chain referral and community programs 1992-2008
Policies:SEP authorized in late 80's in MontrealRamp up late 80's and early 90'sPharmacy distribution in tandem with SEPVery liberal distribution policies for IDU
Coverage:Needles Distributed Annually: 800,000Population of IDU: 12,000Syringes distributed per IDU per year: 66
Overall HIV Incidence Change: -1.7/100PY
Effect Modifiers: None
Annual Number of Syringes Exchanged: New York City
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
1990-92 1993-95 1996-98 1999-2002
HIV Incidence from STARHS Data: New York City
0
0.5
1
1.5
2
2.5
3
3.5
4
1990-92 1993-95 1996-1998 1999-2002
HIV Seroprevalence: New York City
05
10
1520
25
30
3540
45
50
1990-92 1993-95 1996-98 1998-2002
Geographic Setting of Cross-Border Project
China
Vietnam
Hanoi
Area of Detail
Vietnam
China
Ning Ming City
Lang Son City
Puzhai
Tan ThanhDong Dang
Loc Binh
TongmianShilang
Aidian
Hop Thanh
CaoLoc Town
Ha Giang Guigang
Large Project Site
Small Border Site
Key:
PDI Site
HIV Incidence Among New Injectors, by Site
Changes in Biomarkers: SummaryStudy Location Measureme
ntOverall HCV or HIV Change
(Incidence and/or Prevalence)Goldberg 1998
Glasgow, Scotland
HCV Prevalence Baseline HCV Prevalence: 90% Follow-up HCV Prevalence: 77%HCV Prevalence: 13% Reduction
Hope 2005
England & Wales United Kingdom
HIV Prevalence Baseline HIV Prevalence: 5.92%Follow-up HIV Prevalence: 1.37%HIV Prevalence: 4.55% Reduction
Des Jarlais 2007
Lang Song Vietnam Ning Ming China
HIV Prevalence Baseline HIV Prevalence:Ning Ming: 17%; Lang Song: 46%Follow-up HIV PrevalenceNing Ming: 14%; Lang Song: 32% HIV Prevalence Ning Ming: 3% Reduction HIV Prevalence Lang Song: 14% Reduction
Des Jarlais 2005
New York City, USA
HIV Prevalence HIV Incidence
Baseline HIV Prevalence and Incidence:Incidence: 3.55/100PY; Prevalence: 50%Follow-up HIV Prevalence and IncidenceIncidence: 0.77/100PY; Prevalence: 17%HIV Prevalence: 33% ReductionHIV Incidence: 2.78/100PY Reduction
Bruneau 2011
Montreal Canada
HIV Incidence Baseline HIV Incidence: 3.5/100PYFollow-up HIV Incidence: 0.8/100PYHIV Incidence: 1.7/100PY Reduction
Results
Studies included as part of this review show that locations with large SEPs are associated with lower levels of HCV and HIV among the entire sample populations (incidence and prevalence). Including persons who do not use the exchanges (herd immunity effect)
Syringe exchange may be effective at approximately 30 syringes per IDU per year
Best Practices
Begin syringe programs early Operations of syringe programs should be
large scale with no limit on exchanges, encouragement of secondary exchange, and no strict one-for-one exchange limitations
Syringe programs should be user friendly, treating patients/participants with respect, convenient locations to known IDU populations, and hours of operation that are convenient
Best Practices (continued)
Provide multiple services at the syringe programs including blood borne infection testing, condom distribution, and safe injecting equipment
Involve injectors as experts in the IDU community to assist with operations and distribution
Ensure initial and continued cooperation and non-interference with local law enforcement
References Goldberg, D., Cameron, S., & McMenamin, J. (1998). Hepatitis C
virus antibody prevalence among injecting drug users in Glasgow has fallen but remains high. Commun Dis Public Health, 1(2), 95-97.
Hope, V. D., Judd, A., Hickman, M., Sutton, A., Stimson, G. V., Parry, J. V., et al. (2005). HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years. AIDS, 19(11), 1207-1214.
Des Jarlais, D. C., Kling, R., Hammett, T. M., Ngu, D., Liu, W., Chen, Y., et al. (2007). Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project. AIDS, 21 Suppl 8, S109-114.
Des Jarlais, D. C., Perlis, T., Arasteh, K., Torian, L. V., Beatrice, S., Milliken, J., et al. (2005). HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services. Am J Public Health, 95(8), 1439-1444.
Topp, L., Day, C. A., Iversen, J., Wand, H., & Maher, L. (2011). Fifteen years of HIV surveillance among people who inject drugs: the Australian Needle and Syringe Program Survey 1995-2009. AIDS, 25(6), 835-842.
Bruneau, J., Daniel, M., Abrahamowicz, M., Zang, G., Lamothe, F., & Vincelette, J. (2011). Trends in human immunodeficiency virus incidence and risk behavior among injection drug users in montreal, Canada: a 16-year longitudinal study. Am J Epidemiol, 173(9), 1049-1058.