What We Know

Laws Prohibiting Over-the-Counter Syringe Sales to Injection Drug Users: Relations to Population Density, HIV Prevalence, and HIV Incidence

Friedman, S. R., Perlis, T., & Des Jarlais, D. C. American Journal of Public Health (May 2000), 91(5): 791–3.

Some states in the U.S. have antidrug policies that permit the sale of syringes only to those with a prescription. Some researchers argue that such restrictions increase the extent to which people who inject drugs (PWID) share syringes and perhaps other drug paraphernalia. This cross-sectional analysis compared HIV prevalence and incidence among PWID in the 96 largest metropolitan areas in the U.S., based on whether syringes were available over the counter (OTC). The average HIV prevalence among PWID in areas allowing OTC sales of syringes was 7 percent, compared to 14 percent in those with anti-OTC laws, a statistically significant difference. The difference in estimated average HIV incidence among PWID was even greater: 61 percent in anti-OTC areas versus 17 percent in the other areas. Furthermore, there was no difference in the percentage of PWID in each area, indicating that anti-OTC policies may have no effect on drug use. While these results may have be due to other factors, this study supported the hypothesis that an association exists between anti-OTC policies and increased HIV prevalence.

Can HIV-1 Contaminated Syringes be Disinfected? Implications for Transmission among Injection Drug Users

Abdala, N., Gleghorn, A., Carney, J. M., et al. Journal of Acquired Immune Deficiency Syndromes (2001), 28(5), pp. 487–94.

In the absence of support for needle substitution programs in the United States, harm reduction programs encouraged people who inject drugs (PWID) to disinfect their syringes with bleach. Several population-based studies in the 1990s cast doubt on the effectiveness of bleach in decontaminating used syringes among PWID. This study recreated real-life situations among PWID in the United States, including common injection practices, using 2-mL syringes. Based on other studies indicating that PWID did not always follow the strict bleaching protocol, the study used multiple rinsing permutations (water only, diluted bleach, full-strength bleach; rinsing one, two, or three times; storing syringes for up to 48 days at room temperature) to assess whether these practices could remove HIV from a used syringe. While even one rinse of water could reduce the presence of HIV, increasing the number of rinses and adding bleach to the rinsing procedure furthered the decreases in amount of HIV recovered. The authors recommended encouraging needle rinsing, preferably with bleach, as part of harm reduction interventions.

Do Needle Syringe Programs Reduce HIV infection Among Injecting Drug Users: A Comprehensive Review of the International Evidence

Wodak, A., & Cooney, A. Substance Use and Misuse (February 2006), 41(6-7): 777–813.

Using commonly accepted criteria for evaluation of public health interventions, the authors reviewed evidence from 45 studies to find strong evidence that needle and syringe programs (NSPs) are effective, safe, and cost-effective. The evidence in favor of NSPs as an HIV prevention intervention is overwhelming, they said, but the availability of sterile needles and syringes from pharmacies is a common confounder in studies looking at NSP implementation and HIV prevention. Moreover, although the benefits of NSPs are proven, they are insufficient on their own to prevent HIV among people who inject drugs. The authors made recommendations for future action and also provided a useful glossary of terms.

A Review of the Efficacy and Effectiveness of Harm Reduction Strategies for Alcohol, Tobacco and Illicit Drugs

Ritter, A., and Cameron, J. Drug and Alcohol Review (November 2006), 25(6): 611–24.

This review of over 650 articles on harm reduction strategies found that most strategies concerned illicit drugs. The review found compelling evidence to show that needle substitution programs and outreach are useful and cost-effective, but findings to support noninjecting routes of administration, supervised injecting facilities, and naloxone distribution are only beginning to emerge. The existing evidence on brief interventions, HIV testing, and education is not conclusive, the authors said. The review also evaluated harm reduction as a policy approach and found that despite difficulties interpreting data, the evidence supports harm reduction as a driver of policy, rather than simply the basis of individual interventions.

Interventions to Address HIV in Prisons: HIV Care, Treatment and Support

Jürgens, R. (World Health Organization Evidence for Action Technical Papers, 2007).

This technical paper states the case for implementing HIV prevention interventions in prisons. It reviews existing evidence to determine whether prison-based HIV interventions: are effective; avoid unintended negative consequences; are acceptable to the target group; have any additional benefits; and are feasible in diverse prison settings. The author presents evidence from both the community and prisons to make recommendations for action at international, country, and local levels—in particular, making opioid substitution therapy, antiretroviral therapy, and HIV testing and counseling available in prisons. The report also highlights the counterproductive nature of mandatory HIV testing and segregation of people living with HIV. 

The Impact of Adherence to Preexposure Prophylaxis on the Risk of HIV Infection among People Who Inject Drugs

Martin, M., Vanichseni, S., Suntharasamai, P., et al. AIDS (April 2015), Vol. 29 Issue 7, pp. 819–824.

The 2005–2012 Bangkok Tenofovir Study, a randomized, double-blind, placebo-controlled study, examined participants' adherence to daily oral tenofovir in an HIV pre-exposure prophylaxis (PrEP) trial; identified factors associated with adherence; and assessed the impact of adherence on the risk of HIV infection among people who inject drugs (PWID). The study took place in 17 Bangkok Metropolitan Administration drug treatment facilities that offer an HIV-prevention package, social services, and medical care. The 2,413 participants attended either daily or monthly visits during which nurses observed participants swallowing the study drug, and participants from both groups initialed a diary, which the authors used to assess adherence. Higher levels of adherence were associated with reduced risk of HIV infection (83.5 percent among participants with at least 97.5 percent adherence, compared to a 48.9 percent reduction overall). Analysis showed better adherence among participants aged 40 years and over, and among women. Participants who had been incarcerated or had injected methamphetamine before enrollment were more likely to report below 95 percent adherence, suggesting poor adherence among some at-risk participants. These findings were consistent with findings from trials among men who have sex with men and HIV-discordant heterosexual couples. The authors suggested that PrEP could provide high levels of protection against HIV for PWID, provided adherence is high.

Women, Harm Reduction and HIV

Pinkham, S. & Malinowska-Sempruch, K. Reproductive Health Matters (2008), 16(31), pp. 168–81.

This paper examined the unique issues that increase women’s risk of acquiring HIV through injecting drug use and impede their ability to seek support, treatment, and care. Among people who inject drugs (PWID), women are more likely to be HIV-positive than their male counterparts because of both sexual and injection practices. Furthermore, commercial sex work and injecting drug use overlap in many countries, with PWID more likely to work on the street and experience physical violence. Sexual health services for PWID are rare. Female PWID who are pregnant or mothers often lack proper antenatal care and treatment, and suffer punitive actions from the medical and law enforcement establishments. Programs can address the issues unique to female PWID by adopting policies that encourage women to seek services for drug treatment and harm reduction; incorporating sexual and reproductive health and other women’s services into harm reduction programs; and establishing strong links among services for harm reduction, drug treatment, women’s shelters, and domestic violence and rape prevention.

HIV Prevention among Injecting Drug Users: Strengthening U.S. Support for Core Interventions

Needle, R. H., and Zhao, L. (Center for Strategic and International Studies Africa Program Roundtable, June 2010).

This presentation presented big-picture data on injecting drug use in 151 countries and the situation of the 3 million (mid-range estimate) people who inject drugs (PWID) who were HIV-positive. Using data sourced from a review of official reports and a survey of country experts, the presenters found that only 1 in 10 PWID in PEPFAR (U.S. President's Emergency Program for AIDS Relief) countries use needle substitution services, and that those that have access to these services do not receive a sufficient annual supply of needles. Antiretroviral therapy and medication-assisted treatment are also only available to a tiny minority of PWID in PEPFAR countries. The presentation highlighted the barriers to service implementation and the cost of scaling up services, concluding with recommendations for future service provision targets.

HIV Prevention, Treatment, and Care Services for People Who Inject Drugs: A Systematic Review of Global, Regional, and National Coverage

Mathers, B. M., Degenhardt, L., Ali, H., et al. The Lancet (February 2010), 375(9719), pp. 1014–28.

This seminal review of estimated national, regional, and global coverage of HIV services for people who inject drugs (PWID) examines the extent to which needle and syringe programs (NSPs), opioid substitution therapy (OST), and antiretroviral therapy have been implemented. The review spelled out the wide regional variations in access to harm reduction and HIV treatment services. Despite the large number of countries with HIV prevention services (with NSPs implemented in 82 countries and OST in 70 as of 2009), coverage of PWID is too low to prevent HIV transmission in most countries. The authors explained the policy implications of their findings and called for similar reviews of other health problems affecting PWID, such as tuberculosis and viral hepatitis

The Lancet Series: HIV in People Who Use Drugs

The Lancet. (July 2010).

This collection of 13 articles represented a call to arms for greater efforts to tackle HIV among people who use drugs. Commentaries addressed the myths surrounding drug use and HIV, and the special burden borne by women. The papers covered the risk environment for people who inject drugs (PWID), HIV prevention in this population, and treatment of comorbidities among drug users living with HIV. The series examined biomedical issues such as antiretroviral HIV treatment, opioid substitution, and needle and syringe programs, and also included social issues that prevent effective HIV prevention among PWID; and proposed a human rights-based approach to prevent HIV among PWID.

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