Correlates of sharing of needles and syringes among people who inject drugs in Dhaka city, Bangladesh

Introduction: This paper examines the correlates of needle and syringe sharing among People Who Inject Drugs in Dhaka city, Bangladesh, which is currently experiencing a steep increase in HIV prevalence despite the ongoing presence of Needle Exchange Programs. Methodology: This was a retrospective chart review with cross-sectional design that extracted data from 783 male People Who Inject Drugs enrolled into five Opioid Substitution Treatment clinics in Dhaka city between April 2010 and January 2016. Data were retrieved from the program’s electronic database. Needle and syringe sharing constituted the borrowing or lending of needles and syringes from others within the past month preceding data collection. Results: Buprenorphine was the preferred injection drug and 44.6% shared needles and syringes within the past month. Multivariate analysis indicated that People Who Inject Drugs who were homeless (OR = 8.1, 95% CI = 1.4-44.9, p < 0.05), living with friends (OR = 6.8, 95% CI = 2.5-18.2, p < 0.001), injecting 2-3 times/day (OR = 4.8, 95% CI = 1.2-19.7, p < 0.05), injecting more than three times/day (OR = 4.8, 95% CI = 1.1-20.0, p < 0.05), not using condom with non-commercial female sex partners (OR = 3.3, 95% CI = 1.8-6.0, p < 0.05), bought sex from female sex workers (OR = 2.9, 95% CI = 1.0-8.3, p < 0.05), and did non-suicidal self-injury (OR = 1.8, 95% CI = 1.0-3.0, p < 0.05) were more likely to share needles and syringes. Conclusions: This study demonstrates that operating a standalone harm reduction approach that just provides sterile needles and syringes may not adequately curb needle and syringe sharing among People Who Inject Drugs.

Health literacy and changes in pattern of drug use among participants at the Stockholm Needle Exchange Program during the COVID-19 pandemic

Background and aims People who inject drugs may be particularly vulnerable to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to underlying health problems, stigma and social vulnerabilities. Harm reduction services, including needle exchange programs (NEP), have been subjected to varying degrees of disruption in the world, especially in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. Compared to responses in other countries, Sweden’s initial strategy toward limiting the spread and impact of COVID-19 was less restrictive to its citizens with no imposed general societal lockdown. In this study, we investigate changes in drug use patterns, utilization of NEP associated health services, COVID-19 health literacy and the prevalence of SARS-CoV-2 antibodies among NEP clients in Stockholm during the COVID-19 pandemic. Methods NEP visits and services provided (needles/syringes, HIV and hepatitis C tests and treatment, naloxone distributed) and overall mortality among NEP clients between January 1 and October 31, 2020, were used for trend analyses in comparison with corresponding 2019 data. Between July 27 and October 2, 2020, NEP clients (n = 232) responded to a 27 item COVID-19 Health Literacy Questionnaire. SARS CoV-2 IgG antibody tests (n = 779) were performed between June 15 and October 31, 2020. Results During the COVID-19 pandemic number of clients, client visits, naloxone distribution and HCV tests remained stable compared to 2019, while distribution of needles/syringes increased (p < 0.0001); number of HIV tests and HCV treatments decreased (p < 0.05); and mortality decreased (< 0.01). Overall, the level of health literacy concerning transmission routes and protective measures was high. SARS-CoV-2 antibody prevalence was 5.4% (95% CI 4.0–7.2). Conclusions The Stockholm NEP managed to maintain a high level of clients and services during the pandemic. In general, COVID-19 health literacy was adequate and the overall SARS-CoV-2 antibody prevalence was low compared to the general population, which highlights a need for prioritized and targeted COVID-19 vaccination among PWID.

A qualitative study of facilitators and barriers to participate in a needle exchange program for women who inject drugs

Background Women who inject drugs (WWID) show higher levels of injecting risk behaviour compared to men, putting them at risk of contracting HIV and hepatitis C (HCV). Compared to men, WWID are also less present in harm reduction programs such as needle exchange programs (NEP). The aim of this study is to investigate reasons for, and barriers to, participation in NEP among WWID in Sweden, and to identify measures that could be taken to strengthen the program and increase participation among WWID. Method In-depth interviews (IDIs) were conducted with 20 WWID who had participated in the Stockholm NEP for at least six months and was over 18 years old. IDIs were audio recorded and transcribed et verbatim. Qualitative content analysis was used to identify themes. Results The need for sterile injection equipment was identified as the main driver to join and remain in the NEP program. Continuous participation in the NEP was further driven by easy access to a multitude of health-related services. The most valued service was the sexual and reproductive health services (SRHR), allowing participants to access contraceptives, cervical cancer screening and sexually transmitted infections testing (STI-testing). NEP staffs’ respectful treatment of participants further contributed to program participation. However, participants also expressed a number of concerns around NEP participation, which created barriers to joining. These included losing custody or visitation rights to children, male partner jealousy and violence, unwillingness to spend time in the waiting area and fear of receiving positive HIV/HCV test results. Practical barriers included limited opening hours and travel distance to the NEP. To strengthen the program, most participants requested additional SRHR services. Most participants also proposed some form of “women only” access to the NEP, to strengthen the feeling of the NEP as a safe space. Conclusion This study identified factors that may increase uptake of NEP among WWID. Additional SRHR services and “women only” access are recommended to be implemented and evaluated as part of NEP. These findings may inform and improve the current scale-up of NEPs in Sweden to ensure equal access to services.

Predictors of Skin and Soft Tissue Infections Among Sample of Rural Residents Who Inject Drugs

Introduction: Skin and soft tissue infections (SSTIs) are among the leading causes of morbidity and mortality for people who inject drugs (PWID). Studies demonstrate that certain injection practices correlate with SSTI incidence among PWID. The opioid epidemic has particularly affected rural communities, where access to prevention and treatment presents unique challenges. This study aims to understand current injection practices and SSTI history among a rural-dwelling PWID.Methods: Thirteen questions specific to SSTIs and injection practices were added to a larger study assessing unmet health care needs among PWID and were administered at six needle exchange programs in rural Wisconsin between May and July 2019. SSTI history prevalence was estimated based on infections reported within one-year prior of response and was compared to self-reported demographics and injection practices. Results: Eighty responses were collected and analyzed. Respondents were white (77.5%), males (60%), between the ages 30-39 (42.5%), and have a high school diploma or GED (38.75%). Females were over three times more likely to report SSTI history (OR=3.07, p=0.038) compared to males. Water sources for drug dilution (p=0.093) and frequency of injecting on first attempt (p=0.037), but not proper skin cleaning method (p = 0.378), were significantly associated with a history of SSTI. Injecting into skin (p=0.038) or muscle (p=0.001) significantly associated with a history of SSTI whereas injection into veins did not (p=0.333).Conclusion: Higher-risk injection practices were common among participants reporting a history of SSTIs in this rural sample. Studies exploring socio-demographic factors influencing risky injection practices and general barriers to safer injection practices to prevent SSTIs are warranted. Dissemination of education materials targeting SSTI prevention and intervention among PWID not in treatment are warranted.

Harm Reduction: Assessing the Educational Needs of Family Medicine Residents in Care of Persons Who Inject Drugs

Background and Objectives: Rates of injection drug use and associated medical complications have increased, yet engagement of persons who inject drugs (PWID) in primary care is limited, with significant barriers to care. Family physicians play an important role in caring for PWID, but residency training is limited. This study aimed to assess role responsibility, self-efficacy, and attitudes of family medicine residents in caring for PWID. Methods: Using a cross sectional design, family medicine residents in 2018 at three different programs completed Likert and open-ended survey questions assessing role responsibility, self-efficacy, and attitudes in caring for PWID. Results: Fifty-five percent (41/76) of residents completed surveys. Residents consistently agreed it is their responsibility to provide comprehensive care for PWID, while being less confident in key elements of screening, brief intervention, and referral to treatment (SBIRT). The largest gap between responsibility and confidence was in referral to treatment. Resident confidence was lowest for harm reduction strategies: discussing clean needle practices, prescribing naloxone and referral to medication-assisted treatment or needle exchange programs. Less than 60% of residents agreed they are able to work with or understand PWID. Conclusions: This study identifies gaps between provider responsibility and current graduate medical education training. We identified training that increases screening, harm reduction practices, and referrals to community resources as needs. This baseline assessment of family medicine residents can be used to develop educational interventions to meet regional and national health needs for harm reduction for PWID and workforce development.

Harm Reduction: A Concept Analysis

BackgroundOver the last 25 years, harm reduction has shifted to focus on public health and addressing the opioid crisis. Nurses working in addictions treatment utilize the principles of harm reduction to improve the health of clients. AimsConcept clarity assists healthcare providers to understand the applications and attributes of a concept. MethodA concept analysis of harm reduction using the Rodgers (1989) method of evolutionary analysis was un-dertaken. A comprehensive review of the literature was conducted using CINAHL Plus and Social Work Abstracts. FindingsThe key attributes of harm reduction include safety, supplies, education, partnerships, and policy. Applications of harm reduction include needle exchange programs, supervised consumption sites, medication-assisted treatment, and increased access to take-home naloxone kits. The main antecedent to harm reduction is the presence of harm. Consequences explored include safer injection practices, decreased transmission of blood-borne illnesses, improved client relationships, and decreased overdose-related deaths. Stigma, health promotion, and pragmatism are the related concepts discussed. A model case is provided. ConclusionThe principles of harm reduction are becoming increasingly popular as an inclusive and evidence-based nursing approach to addictions treatment and management. As using substances continues to shift and in-crease, harm reduction strategies must remain malleable and available in both the community and hospital settings to address the issue and decrease the associated healthcare costs. Future implications for nursing practice and research are provided.

Costs and consequences of the Portuguese needle-exchange program in community pharmacies

Background: Needle-exchange programs (NEPs) reduce infections in people who inject drugs. This study assesses the impact community pharmacies have had in the Needle-Exchange Program in Portugal since 2015. Methods: Health gains were measured by the number of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections averted, which were estimated, in each scenario, based on a standard model in the literature, calibrated to national data. The costs per infection were taken from national literature; costs of manufacturing, logistics and incineration of injection materials were also considered. The results were presented as net costs (i.e., incremental costs of the program with community pharmacies less the costs of additional infections avoided). Results: Considering a 5-year horizon, the Needle Exchange Program with community pharmacies would account for a 6.8% ( n = 25) and a 6.5% reduction ( n = 22) of HCV and HIV infections, respectively. The present value of net savings generated by the participation of community pharmacies in the program was estimated at €2,073,347. The average discounted net benefit per syringe exchanged is €3.01, already taking into account a payment to community pharmacies per needle exchanged. Interpretation: We estimate that the participation of community pharmacies in the Needle Exchange Program will lead to a reduction of HIV and HCV infections and will generate over €2 million in savings for the health system. Conclusions: The intervention is estimated to generate better health outcomes at lower costs, contributing to improving the efficiency of the public health system in Portugal.