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Theoretical concepts in combined hiv prevention programming

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 Jarlais Beth Israel Medical Center New York City, USA.

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Theoretical concepts in combined hiv prevention programming

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  1. Theoretical concepts in combined hiv prevention programming Don C. Des Jarlais Beth Israel Medical Center New York City, USA

  2. Theoretical concepts in combined hiv prevention programming Don C. Des Jarlais Beth Israel Medical Center New York City, USA

  3. No one HIV prevention program eliminates risk behaviors

  4. Different programs for Different people: Drug dependence treatment for persons who cannot consistently obtain and use clean syringes

  5. 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

  6. Needle/syringe programs are foundation of combined programming How good are big needle/syringe programs?

  7. Evidence for Needle/syringe programs: An international Review Don C. Des Jarlais Beth Israel Medical Center New York City, USA

  8. 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

  9. 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

  10. 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 city New York City First Program: too small, inconvenient

  11. 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

  12. 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)

  13. Goldberg 1998 (Scotland)

  14. Hope 2005 (UK)

  15. Des Jarlais 2007 (Vietnam, China)

  16. Des Jarlais 2005(b) (USA)

  17. 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

  18. Annual Number of Syringes Exchanged: New York City

  19. HIV Incidence from STARHS Data: New York City

  20. HIV Seroprevalence: New York City

  21. Geographic Setting of Cross-Border Project China Ha Giang Guigang Area of Detail Hanoi Vietnam China Ning Ming City Puzhai Shilang TanThanh Aidian Tongmian Dong Dang CaoLoc Town Key: Loc Binh Hop Thanh Large Project Site Lang Son City Vietnam Small Border Site PDI Site

  22. HIV Incidence Among New Injectors, by Site

  23. Changes in Biomarkers: Summary

  24. 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

  25. 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

  26. 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

  27. 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.

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