A study by researchers investigating the 2015 HIV outbreak in Scott County, Indiana, found that a syringe services programme is an important tool to control and prevent HIV outbreaks among people who inject drugs in a non-urban area, reports Medical Xpress. Researchers said the programme resulted in a rapid reduction in injection-related risk behaviours, including an 88% reduction in syringe sharing, a 79% reduction in syringe sharing to divide drugs and an 81% reduction in sharing of other injection equipment.
There were 181 HIV infections diagnosed between 18 November, 2014, and 1 November, 2015, in Scott County, making it the largest HIV outbreak in a non-urban area in the US among people who inject drugs.
The syringe services programme was initially implemented on an emergency basis to combat the outbreak. It was the first time such a programme had been tried in a non-urban area in the US. Syringe services programmes provide clients with sterile syringes along with prevention, education and social services.
Researchers discovered the HIV outbreak was linked to injection of Opana ER, an opioid pain medication. The research elicited specific characteristics of the drug which, when dissolved, resulted in multiple injection episodes per day and multiple injections per injection episode, and prompted officials from Indiana and the US Centres for Disease Control, working with the US Food and Drug Administration, to request that the drug’s manufacturer voluntarily remove the drug from the US market.
At the outset of the study, researchers knew what had happened, but not why. “An outbreak doesn’t just happen in the HIV world,” said Carrie Foote, an associate professor of sociology in the School of Liberal Arts at Indiana University – Purdue University Indianapolis (IUPUI) and the co-principal investigator of the study’s qualitative data.
Researchers gathered two kinds of data, quantitative and qualitative, a move they believe enhanced their ability to understand what had happened in Scott County. Qualitative data was gathered from focus groups and one-on-one interviews with people who were injecting drugs in Scott County. Quantitative data came from answers by clients of the syringe services program to a set of questions asked of each person who took advantage of the program.
If we just had the quantitative data, we wouldn’t have been able to dive into the unique injection practices around Opana ER, which we believe led to this outbreak of HIV,” said Dr Joan Duwve, an associate professor and associate dean of public health practice in the Richard M Fairbanks School of Public Health at IUPUI and the lead investigator of a quantitative study further exploring the risks of acquiring HIV infection in this population.
Because a single 40-milligram pill costs about $160, drug users formed networks to pool their resources to buy Opana ER, she said. Multiple people would share syringes or reuse old syringes to draw up the dissolved pill. More water was then added to rinse the pill residue off of the cooker. Reusing the same needles, rinse solution was drawn up and injected or saved to use later.
Without access to sterile syringes, people in the networks frequently shared syringes as they injected multiple times a day. One individual told the researchers he injected 50 times a day. Others described how one syringe was used over and over again until it broke off in someone’s arm.
“It’s no wonder that as soon as someone who had HIV entered into that network, HIV spread rapidly,” Foote said. “It was incredibly powerful to see how much the syringe exchange programme mattered,” Foote said. “They matter in all communities, but it made such a powerful difference in this particular community in terms of reducing the harm that comes from sharing syringes for multiple injections.”
Exploring harm-reduction measures like syringe exchange programmes is part of Indiana University’s Responding to the Addictions Crisis Grand Challenge, which brings together IU’s world-class faculty and its business, non-profit and government partners to create a comprehensive plan to reduce deaths from addiction, ease the burden of addiction on Hoosier communities, and improve health and economic outcomes. As part of IU’s Grand Challenges programme, this collaborative, state-wide initiative is the nation’s largest and most comprehensive university-led response to the opioid addiction crisis.
Objective: To describe injection-related HIV risk behaviors preimplementation and postimplementation of an emergency syringe services program (SSP) in Scott County, Indiana, after an HIV outbreak among persons who inject drugs (PWID).
Design: Mixed methods retrospective pre–post intervention analysis.
Methods: We analyzed routine SSP program data collected at first and most recent visit among clients with ≥2 visits, ≥7 days apart from April 4 to August 30, 2015, to quantify changes in injection-related risk behaviors. We also analyzed qualitative data collected from 56 PWID recruited in Scott County to understand factors contributing to these behaviors.
Results: SSP clients included in our analysis (n = 148, 62% of all SSP clients) reported significant (P < 0.001) reductions over a median 10 weeks (range 1–23) in syringe sharing to inject (18%–2%) and divide drugs (19%–4%), sharing other injection equipment (cookers) (24%–5%), and number of uses of the same syringe [2 (interquartile range: 1–4) to 1 (interquartile range: 1–1)]. Qualitative study participants described access to sterile syringes and safer injection education through the SSP, as explanatory factors for these reductions. Injection frequency findings were mixed, but overall suggested no change. The number of syringes returned by SSP clients increased from 0 at first visit to median 57. All qualitative study participants reported using sharps containers provided by the SSP.
Conclusions: Analyses of an SSP program and in-depth qualitative interview data showed rapid reduction of injection-related HIV risk behaviors among PWID post-SSP implementation. Sterile syringe access as part of comprehensive HIV prevention is an important tool to control and prevent HIV outbreaks.
Monita R Patel; Carrie Foote; Joan Duwve; Erika Chapman; Brittany Combs; Alexandra Fry; Patti Hall; Jeremy Roseberry; John T Brooks; Dita Broz