An emergency syringe exchange program implemented after an outbreak of HIV earlier this year in the state of Indiana led to a decrease in risk behaviours including needle sharing during its first five months, researchers reported at IDWeek 2015 this month in San Diego. These findings add to the evidence that needle exchange is an effective harm reduction intervention for people who inject drugs.
In January 2015 the Indiana State Department of Health, later joined by the U.S. Centers for Disease Control and Prevention (CDC), began investigating an outbreak of HIV after disease intervention specialists confirmed nearly a dozen new infections in a rural community in Scott County. The CDC issued an official health advisory about the outbreak in April and CDC and Indiana investigators published a report in the May 1 edition of Morbidity and Mortality Weekly Report.
Investigators traced the new HIV infections – as well as hepatitis C virus (HCV) infections – to people who inject oxymorphone (brand name Opana), a prescription opioid painkiller.
At the International AIDS Society conference this summer John Brooks from the CDC's HIV Epidemiology Team described efforts to determine the source of the outbreak, trace patterns of transmission, halt further infections and bring affected people into care.
Monita Patel of the CDC presented a report – selected as an IDWeek featured abstract – on an emergency syringe exchange program implemented on April 6 in response to the outbreak, after Indiana Governor Mike Pence declared a public health emergency on March 26 allowing local governments to establish otherwise-illegal needle exchanges.
Investigators with the CDC, Scott County Department of Health and Indiana State Department of Health looked at changes in injection-related risk behaviour over time.
At each exchange visit clients received sterile syringes, a wound kit, harm reduction education and referrals to health and substance abuse services, and were surveyed about their current risk behaviours.
To date the outbreak has involved 181 new HIV infections, with the last seen in late August, according to Patel. Researchers estimate that there are more than 500 people who inject drugs in Scott County. As noted in the earlier reports, injection drug use in this community is often multi-generational, and family and community members frequently inject together and share syringes and other equipment.
The researchers analysed data from 148 participants (62% of all exchange clients) who made more than two exchange visits at least seven days apart through August 30. More than half (56%) were men, almost all were white and heterosexual, and the median age was 34 years. While 89% reported injecting oxymorphone, just 17% said they injected heroin.
These participants together made 854 visits, with a median of four visits per person, or 0.58 visits per week. The median interval between the first and the most recent visit was 10 weeks.
Based on client self-reports, sharing syringes declined significantly, from 18% at the first visit to 2% at the most recent visit. Participants also reported declines in sharing syringes to divide drugs (from 19% to 4%) and sharing other injection equipment such as spoons and filters (from 24% to 5%). The frequency of a single person reusing the same syringe declined significantly, from two uses to one use.
There were significant increases in the number of syringes per person distributed (from 35 to 63) and returned (from 0 to 57), associated with a rise in the daily frequency of injection from five to nine times a day.
"Emergency needle exchange was necessary, feasible, and successful," the researchers concluded. They added that complementary HIV prevention interventions are also essential, including pre-exposure prophylaxis (PrEP) and antiretroviral therapy for people found to be HIV-positive (treatment as prevention).
Patel MR et al. Reduction in injection risk behaviors after institution of an emergency syringe exchange program during an HIV outbreak among persons who inject drugs, Indiana 2015. IDWeek 2015, abstract 638a, 2015.