THEORETICAL CONCEPTS IN COMBINED HIV PREVENTION PROGRAMMING Don C. Des Jarlais Beth 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

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.