To explore convergence and divergence in ethical stances of public health and of members of the population regarding acceptability of harm reduction interventions, in particular needle exchange programs.
Forty-nine semi-structured interviews were conducted with French-speaking residents of Quebec City. Content analysis was done to explore the views of the respondents with regard to injection drug users (IDUs) and interventions addressed to them, as well as Quebec policies on harm reduction.
Four main categories of social representations about IDUs have emerged from the discourses of the respondents. IDU were represented as: suffering from a disease (n = 17); victim of a situation that they could not control (n = 14); having chosen to use drugs (n = 12); or delinquent people (n = 6). Those social representations were associated with different ethical stances regarding acceptability of harm reduction interventions. Main divergences between respondents' ethical positions on harm reduction and public health discourses were related to the value of tolerance and its limits.
The Quebec City population interviewed in this study had a high level of tolerance regarding needle distribution to drug addicts. Applied ethics could be a useful way to understand citizens' interpretation of public health interventions.
Centre for Research on Drugs and Health Behaviour (CRDHB), London School of Hygiene and Tropical Medicine (LSHTM), Department of Public Health and Policy, London, UK.
OBJECTIVE: To estimate access, activity and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia. METHODS: Two data sets ('regional' and 'high-coverage sites') were used to estimate NSP provision (availability/number of sites), NSP utilization (syringes distributed/year), needle and syringe distribution (needles/syringes distributed/IDU/year), IDU reached (number/percentage of IDU contacted/year), regular reach (five or more contacts/month) and syringe coverage (percentage of injections/IDU/year administrable with new injecting equipment). RESULTS: Regional data set: results from 213 sites in 25 countries suggested that Czech Republic, Poland, Russia and Ukraine had > 10 NSP during 2001/2. Czech Republic, Kazakhstan, Latvia, Russia, Slovakia and Ukraine had >or= 10,000 IDU in contact with NSP. Ten countries reached >or= 10% of the estimated IDU population. The 25 countries distributed approximately 17 million syringes/needles. Eight countries distributed > 0.5 million syringes/year. Syringe coverage (assuming 400 injections/IDU/year) was 15% in Macedonia. Overall syringe coverage was 1.2% and when assuming 700 injections/IDU/year it decreased to 0.7%. Syringe coverage for the IDU population in contact with NSP was 60% in Croatia, Macedonia, Moldova and Tajikistan. Overall syringe coverage for the population in contact with NSP was 9.8%. High-coverage data set: Soligorsk, Pskov and Sumy's NSP reached 92.3%, 92.2% and 73.3% of their estimated IDU population, respectively (regular reach: 0.2%, 1.8% and 22.7%). The distribution levels were 47.2, 51.7 and 94.2 syringes/IDU/year, respectively. CONCLUSION: The evidence suggests suboptimal levels of NSP implementation, programme activity and coverage. This paper provides a baseline for development of indicators that could be used to monitor NSP. Strategies to increase coverage that may go beyond NSP are urgently required, as is research into understanding how NSP can contribute to better syringe coverage among IDU.
Awareness of drug use in rural communities and small towns has been growing, but we know relatively little about the challenges injection drug users (IDUs) living in such places face in accessing harm reduction services. Semi-structured interviews were conducted with 115 IDUs in urban and non-urban areas of Atlantic Canada. In many instances, geographic distance to a needle exchange program (NEP) meant that individuals living outside of urban areas and who were not provided services through an NEP's outreach program were at a disadvantage in terms of an array of supports offered through many NEPs. These include access to free clean injecting equipment, and such ancillary services as clothing, food, referrals, information and social support. The integration of the services and approaches provided by NEPs into mainstream health services in non-urban places is one possible model for improving such access.
Injection drug users (IDU) often experience barriers to conventional health-care services, and consequently might rely on acute and emergency services. This study sought to investigate IDU perspectives regarding the impact of supervised injection facility (SIF) use on access to health-care services.
Semi-structured qualitative interviews were conducted with 50 Vancouver-based IDU participating in the Scientific Evaluation of Supervised Injecting cohort. Audio-recorded interviews elicited IDU perspectives regarding the impact of SIF use on access to health and social services. Interviews were transcribed verbatim and a thematic analysis was conducted.
Fifty IDU, including 21 women, participated in this study. IDU narratives indicate that the SIF serves to facilitate access to health care by providing much-needed care on-site and connects IDU to external services through referrals. Participants' perspectives suggest that the SIF has facilitated increased uptake of health and social services among IDU.
Although challenges related to access to care remain in many settings, SIF have potential to promote health by facilitating enhanced access to health-care and social services through a model of care that is accessible to high-risk IDU.
Awareness of hepatitis C virus (HCV) infection status is expected to influence risk behaviors. In 2004-2005, injection drug users (IDUs) recruited from syringe exchange programs (SEPs) and methadone clinics in Montreal, Canada, were interviewed on drug use behaviors (past 6 months) and HCV testing. Subjects (n = 230) were classified as low/intermediate risk (20.4% borrowed drug preparation equipment only) and high risk (19.6% borrowed syringes), and 54.5% reported being HCV positive. Logistic regression modeling showed that compared to no risk (60% borrowed nothing), low/intermediate risk was associated with fewer noninjecting social network members, poor physical health, and problems obtaining sterile injecting equipment. High risk was associated with all of these factors except social networks. HCV status was not associated with any level of risk. Improved access to sterile injecting equipment may be more important than knowledge of HCV status in reducing injection risks among this IDU population. The study limitations are noted and recommendations discussed.
We report findings from a multi-method study investigating drug injectors' access to needles and syringes in three large Russian cities (Moscow, Volgograd, Barnaul).
We undertook 209 qualitative interviews among drug injectors, and supplemented these with baseline data from a community-recruited survey of 1473 drug injectors.
Almost all (93%; 1277) injectors used pharmacies as their main source of clean injecting equipment, and only 7% (105) reported ever having had contact with city syringe exchange projects. Good access to syringes has coincided with the expansion of private pharmacies. Key factors contributing to pharmacy access included: geographic proximity; low cost; and the restrictive policies of exchange instituted at local syringe exchanges. A fear of police interference surrounded the use of pharmacies and syringe exchanges, and fed a reluctance to carry used needles and syringes, which in turn acted as a disincentive to syringe exchange attendance. The perceived benefits of syringe exchanges over pharmacies included the additional health services on offer and the social support provided, but these benefits were over-shadowed by disadvantages. Multivariable analyses of survey data in two cities show no differences on account of risk behaviour among injectors sourcing equipment from pharmacies compared to syringe exchanges.
HIV prevention coverage indicators need to include measures of pharmacy-based syringe distribution and not only measures of syringe exchange coverage. There is an urgent need to pilot pharmacy-based distribution and exchange projects in Russia as well as other forms of secondary syringe distribution. Alongside expanding the reach of dedicated syringe exchange projects, pharmacy-based syringe distribution, and exchange, may help improve coverage of cost effective HIV prevention measures targeting drug injectors.
Advocacy and coverage of needle exchange programs: results of a comparative study of harm reduction programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation, and China.
To prevent or mitigate an AIDS epidemic among injecting drug users (IDUs), effective activities need to be implemented on a large enough scale to reach and assist sufficient numbers of drug users and thereby change their risk behaviors related to drug use and sex. Recent work by UNAIDS on "high coverage sites", adopting the above strategies, has shown that one of the key elements in achieving high coverage is ongoing and sophisticated advocacy. High coverage harm reduction sites were studied through literature search and site visits, including key informant interviews, review of service statistics, and data analysis, in order to document the steps that led to scaling up, the way coverage was defined in these sites, and the lessons learned from their efforts. Syringe-exchange programs can achieve high coverage of IDUs. Monitoring to determine regular reach (those who are in regular contact with harm reduction services) should be added to uniform data collection carried out by harm reduction programs. Advocacy is crucial to achieving high coverage.
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.
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.
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 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.
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, Canada.
Vancouver, Canada has been the site of an epidemic of human immunodeficiency virus (HIV) amongst injection drug users (IDU). In response, the Vancouver Area Network of Drug Users (VANDU) initiated a peer-run outreach-based syringe exchange programme (SEP) called the Alley Patrol. We conducted an external evaluation of this programme, using data obtained from the Vancouver Injection Drug Users Study (VIDUS).
Using generalised estimating equations (GEE) we examined the prevalence and correlates of use of the SEP amongst VIDUS participants followed from 1 December 2000 to 30 November 2003.
Of 854 IDU, 233 (27.3%) participants reported use of the SEP during the study period. In multivariate GEE analyses, service use was positively associated with living in unstable housing (adjusted odds ratio [AOR]=1.83, 95% confidence interval [CI]: 1.39-2.40), daily heroin injection (AOR=1.31, 95% CI: 1.01-1.70), daily cocaine injection (AOR=1.34, 95% CI: 1.03-1.73), injecting in public (AOR=3.07, 95% CI: 2.32-4.06), and negatively associated with needle reuse (AOR=0.65, 95% CI: 0.46-0.92).
The VANDU Alley Patrol SEP succeeded in reaching a group of IDU at heightened risk for adverse health outcomes. Importantly, access to this service was associated with lower levels of needle reuse. This form of peer-based SEP may extend the reach of HIV prevention programmes by contacting IDU traditionally underserved by conventional syringe exchange programmes.
