Synthesized Literature Review Introduction

A Literature Review of the Efficacy of Needle Exchange Clinics in Reducing HIV

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GNUR-530

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Indiana Wesleyan University

A Literature Review of the Efficacy of Needle Exchange Clinics in Reducing HIV

Newly diagnosed human immunodeficiency virus (HIV) is gaining new ground as a fast growing epidemic. According to Aspinall (2013) injection drug users (IDUs) accounted for approximately 10% of new HIV diagnosis in 2009. In many communities, this new onslaught of not only HIV infections but an increase in injection drug use (IDU) is causing financial and social strain. The use of needle exchange clinics (NECs) to supply IDUs with clean, sterile needles is an issue that is hotly debated in these same communities. This proposed study will assist and guide communities in determining if a NEC is helpful in reducing the rates of HIV, and will examine the rates of HIV before implementation of a NEC and six months after implementation of a NEC.

The use of NECs is not new, with the first NEC in the United States opening in 1985 (Barreras, 2013). There have been multiple challenges to the full implementation of NECs, and in some states. the NEC continues to be illegal. To address the growing HIV and injection drug use epidemic, it is important to define the correlation between implementation of NECs and their impact on HIV rates/incidences. According to Des Jarlais et al (2015), urban NECs exchange 4.4 million syringes per year, with rural programs exchanging 2.7 million per year.

Organization of the Review

This proposed study is designed to be an experimental study and will be designed along the lines of thesimilarly to studies found in the literature related to the dependent and independent variables. The independent variables being studied are: the geographic location of participants (urban versus rural), age, race/ethnicity, gender, drug of choice, educational level/literacy, rates of and habits related to syringe/needle borrowing and financial/economic status. The dependent value is the HIV status of the participant at the beginning of the study.

Definitions

There are several key words that are used throughout the literature review. Definitions of these words are as follows:

Injection drug user (IDU): Persons who inject drugs using needles/syringes (Des Jarlais et al, 2015).

Injection equipment: Equipment such as cookers, needles and syringes that are used to inject drugs (Rich & Adashi, 2015).

Harm reduction interventions: Interventions that “have potential to change environmental risk factors by providing places to obtain clean syringes” (Marotta, 2015, p.3). Harm reduction interventions were initially introduced in the United States by Edith Springer in the 1980s (Clarke et al, 2016).

Human immunodeficiency virus (HIV): A virus spread through certain body fluids that attacks the body’s immune system (Centers for Disease Control and Prevention, n.d.).

Needle: will be defined as a “slender, solid, usually sharp-pointed instrument used for puncturing tissues”; in this study, needles that are used to inject drugs intravenously (Medical Lexicon, n.d.). Is used with a syringe to inject drugs into the veins.

Needle exchange clinic (NEC): A community clinic run by the local health department which provides clean, sterile needles in exchange for used “dirty” syringes/needles.

Respondent driven sampling (RDS): A “sampling and recruitment method based on long-chains of peer referrals used internationally to access hard-to-reach populations for surveillance and research purposes” (Kim et al, 2015).

Structural interventions: Interventions where “changes in policy and legal environment have facilitated an increased availability of sterile syringes” (Quader, 2013, p. 2879).

Substance abuse: inappropriate use of legal and/or illegal drugs, including repeated use of the drug(s) to produce pleasure, relieve stress or to avoid reality (National Institute on Drug Abuse, 2014).

Syringe: An instrument used for injecting or withdrawing fluids, consisting of a barrel and plunger (Medical Lexicon, n.d.). Is used with needles to inject drugs into the veins.

For this literature review, the following keywords were searched using CINAHL: needle exchange clinic, syringe exchange clinic, injection drug use, implementation of needle exchange, people who inject drugs. While there were thousands of articles available in recent publications, by reducing the search parameters to articles published from 2013 forward, those with references and abstract available, and peer reviewed articles and studies, the literature was able to be narrowed down to 16 articles. Of the 16 articles utilized in this review, 13 were research articles, one was an editorial, and the remaining two were case studies from a social services viewpoint.

Nine of the articles mirrored the desired outcome of the proposed research study-to examine the correlation, if any, between NEC and reduction in HIV rates. Five of the articles examined behavioral trends in needle and injection equipment sharing practices and were helpful in that aspect. One article addressed the potential financial impact of NEC implementation and disease reduction, and one was an editorial/opinion piece supporting NEC. Ten of the articles focused on the United States, three on China, and one in Europe, China and Pakistan, which illustrates that this is not solely a local or national issue, but an issue that needs to be addressed globally. Taken together, all 16 articles added value to the literature review by presenting a multifaceted view of a complicated issue.

Quantitative Research Question

The quantitative research question being addressed with this literature review is at what rate does HIV infection decrease 6 months following the implementation of a community based, health department run needle exchange clinic (NEC)? Comment by Faculty: Did the question come from one of the studies you reviewed? Or, what prompted you to study the question?

Variables

Geographic lLocation. Comment by Faculty: This section should have headings (Level 2) and be in narrative format.

: Siddiqui et al (2014) and Kim et al (2015) studied IDUs in the San Francisco and San Diego area, both of which are densely populated. Nguyen et al (2014) addressed the United States as a whole, and focused on differences in rural versus urban rates of IDU and HIV.

Age:

IDUs in the Siddiqui et al (2014) study were between the ages of 18 and 30. In Luo et al (2014) median age of study participants was 35. An age range of 34-54 represented 50% of Clarke’s (2016) study.

Gender

: The majority of study participants who are IDU were male, with Siddiqui et al (2015) reporting 63% of participants as male. This was seen with several other studies, as Des Jarlais et al (2015) reporting 70% of participants as being male. The Tuchman (2015) study focused solely on women.

Race/Eethnicity

: Siddiqui et al (2014) showed that 71% of participants were white/Caucasian. Bahji et al (2014) echoed this, reporting 62.2% of participants as Caucasian. Tuchman (2015) reported that of study participants, 36% were African American, 16% Latina and 48% Caucasian.

Drug of cChoice:

Overwhelmingly, heroin was reported as the drug of choice. In the study conducted by Bahji et al (2014) 23.7% reported heroin as drug of choice. Heroin was also shown in Wang et al (2014) to be the drug of choice of 80% of study population. Clarke et al (2016) lists heroin as drug of choice in 70% of participants, followed by 30% reporting methamphetamine and 4% reporting cocaine as drug of choice.

Educational lLevel/lLiteracy

: In Luo et al (2014) 56.7% of NEC patients had less than a middle school education. This was seen by Bahji et al (2014) as well, with 56.7% reporting less than high school education. Wang et al (2014) had the highest rate of less than high school education, at 80%. As many as 81 (58%) of participants in the Samo et al (2013) study were illiterate. Educational needs should be considered when implementing any harm reduction interventions; issues such as reading level and ability need to be considered.

Financial/eEconomic sStatus:

Samo et al (2013) showed a mean monthly income that was equivalent to $125 and 11.4% were not employed. Siddiqui et al (2014) reported that 33% of study participants were unemployed as well. Comment by Faculty: Addiction does not seem to be a respecter of persons.

Rates of and hHabits rRelated to sSyringe/Nneedle bBorrowing

: Bahji et al (2015) found that 7.8% of participants reported sharing syringes regularly. This phenomenon was not uncommon, with several other studies such as those by Wang et al (2014) and Kim et al (2015) showeding 25% and 10.5% respectively, of participants who shared needles and/or injection equipment.

Proposed Methodology

The proposed methodology is to use a simple time-series design, as there would be no control group available, and comparisons would be made to the infection rate both before and after the implementation of the NEC. The basic question that could/would be answered is whether or not there was a statistical difference in the rate of newly diagnosed HIV infection before the implementation of a needle exchange clinic (NEC) and the rate of newly diagnosed HIV infection after the implementation of the NEC. The NEC patients would be given the option to participate or not and their information would be numerically coded to protect confidentiality. To assess variables as discussed above, a face to face interview with a trained interviewer/surveyor would be conducted with each participant in which answers to a set list of questions would be transcribed by the interviewer. The goal would be to enroll 100 study participants. Respondent driven sampling (RDS) could potentially be employed by recruiting and interviewing “seeds” and having the seeds recruit from their social networks.

Theoretical Framework

None of the articles and/or studies stated a specific theoretical framework i.e.; caring, adaptation, or change. However, there were theoretical questions proposed by several authors, including Aspinall et al (2014), who proposed that there is a high risk for transmission of HIV and other blood borne diseases through sharing of needles. This theory is echoed by Burt & Thiede (2016) who also theorize that IDUs frequently share needles, increasing their risk of disease transmission. Des Jarlais et al (2015) discussed the issue of an increasing number of IDU in rural areas, with a dearth of NECs available in those areas. Often, in the more rural areas, NEC are inaccessible due to lack of transportation and/or funds to pay bus or taxi fares. Nguyen et al (2014) presented a mathematical formula to show the financial aspects not only of treatment of HIV, but how investment in NEC actually saves money and resources over time.

Population, Subjects, Proposed Sample

The population that is impacted by the proposed study is the IDU and the communities they live in. With the increasing number of IDUs and the increase in new HIV infection rates, the risk is not solely the IDU’s. Communities are also at risk, both socially and financially. As IDUs tend to be less educated and less financially stable, their needs are often based around lack of access to clean needles, and lack of access to educational and job opportunities. The IDU population may also require information to be presented in ways they can easily understand i.e.; if a participant is only able to read at a third grade level and has attended school through the ninth grade only, the educator should be mindful of the potential that information would need to be presented differently than to a participant who is college educated.

Financially, caring for those with HIV is costly, and this cost is usually borne by the community via Medicaid and other social programs. Ngyuen et al (2014) found that of the 2575 new HIV infections every year, lifetime treatment costs for these patients can be as high as $1.10 billion. If an investment of $10 million into NEC and other harm reduction interventions were made, approximately 194 new cases could be averted at a cost savings of $75.8 million (Nguyen et al, 2014). An investment of $50 million per year would prevent 816 new HIV infections, thus saving $269.1 million in lifetime treatment costs (Nguyen et al, 2014).

The proposed sample will be obtained from a community based, health department run NEC, and will be selected via convenience sampling. The literature used for this review employed a wide variety of methods to obtain data, including descriptive statistics, qualitative and quantitative studies, mathematical modeling and meta-analysis. Taken together, they provide a comprehensive view of the current status of NEC and the patients they serve, as well as the financial and health costs of injection drug use.

Data Collection Tool/Instrument

The most recent data is presented by Clarke et al (2016), which states that the Centers for Disease Control and Prevention (CDC) estimate more than 1.2 million people are living with HIV currently. As recently as 2013, 7% of the 3,096 newly diagnosed HIV infections were attributable to IDUs (Centers for Disease Control and Prevention, 2015). The data obtained from the proposed study will be compared to the statistics provided by the CDC regarding HIV and injection drug use rates. If an adequate number of participants was not able to be obtained via convenience sampling, use of RDS would also be considered.

Data Analysis

The data obtained through the proposed study will be analyzed utilizing lab results that are publicly reported by the chosen needle exchange clinic (NEC) in addition to an interviewer administered questionnaire. The study will be longitudinal, with data being collected over a 6-month time frame with a goal of enrolling 100 participants (Creswell, 2014). Sample size could be increased if a larger NEC were selected for study. Paired sample t-test is “a statistical technique that is used to compare two population means in the case of two samples that are correlated” (Statistical Solutions, n.d.). Because this test is commonly used in before and after studies, it would also be effective in analyzing data. The comparison would be of the IDU population before the NEC was implemented and the rate of HIV infection versus the rate of HIV in the IDU population after implementation of the NEC.

Overall, the majority of the articles reviewed showed a direct link between implementation of NEC and declines in new HIV infections. Rich & Adashi (2015) showed that states that operate NEC have shown significant drops in HIV infection rates. Rates of sharing of injection equipment was also lower after implementation of NEC (Burt & Thiede, 2016). Quader at al (2013) suggests that distribution of sterile equipment such as needles and syringes, with a “coverage” of more than 10 syringes per IDU per year has a significant impact on rates of sharing of equipment and rates of HIV. There are various ways to obtain clean, sterile syringes, but NEC appears to be the most common. Pharmacies are being used by IDUs; however, there is a negative connotation related to pharmacies as places to obtain clean needles/syringes (Siddiqui et al, 2015). The reasons for this are not clearly known or stated; however, there is the potential that this is because of the stigma attached to injection drug use, and IDUs may not feel as comfortable in the pharmacy setting as they do in the NEC setting.

Other Considerations Related to the Proposed Study

There are considerations and limitations to the proposed study that should be addressed. Samo et al (2013) also used a convenience sampling method, which increased the risk of selection bias, and this would need to be taken into consideration. There is also the concern that information obtained relies on self- reporting from study participants, which could result in under reporting of injection drug use related to the stigma against injection drug use (Samo et al, 2013 and Wang et al 2014). It may be most helpful to have trained interviewers conduct face to face interviews to complete questionnaires, as was done in several studies. Interviewers would be trained not only in interview techniques, but also given instruction/training as to how to best obtain information in a nonjudgmental way.

Summary

In summary, the question proposed for this study is how do NEC impact the rate of newly diagnosed HIV in IDUs. The variables to be addressed include age, gender, geographic location, drug of choice, financial/economic status, race/ethnicity, education/literacy, and rates of and habits related to syringe and needle borrowing. This longitudinal study is designed to analyze data obtained from a NEC and rates of HIV infection after implementation of the NEC versus prior to implementation. Up to 100 participants will be enrolled, and results will be compared with the CDC data from the corresponding year. Data will be analyzed utilizing a paired t-test. The rationale for using these methods to analyze the data is based on methodology used by the article authors.

References

Aspinall, E. J., Nambiar, D., Goldberg, D. J., Hickman, M., Weir, A., Van Velzen, E., … Hutchinson, S. J. (2014). Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: aA systematic review and meta-analysis. International Journal of Epidemiology, 43(235-248). http://dx.doi.org/10.1093/ije/dyt243

Bahji, A., Wood, E., Ahamad, K., Dong, H., DeBeck, K., Milloy, M.-J.,…Hayashi, K. (2015). Increasing awareness about HIV prevention among young people who initiated injection drug use in a Canadian setting, 1988-2014. International Journal of Drug Policy, 26(2015). http://dx.doi.org/10.1016/j.drugpo.2015.09.010

Barreras, R. E. & Torruella, R. A. (2013). New York City’s struggle over syringe exchange: A case study of the intersection of science, activism, and political change. Journal of Social Issues, 69(1). http://dx.doi.org/10.1111/josi.12037

Burt, R. D., & Thiede, H. (2016). Reduction in Needle Sharing Among Seattle-Area Injection Drug Users Across 4 Surveys, 1994-2013. American Journal of Public Health, 106(2), 301-307 7p. http://dx.doi.org/10.2105/AJPH.2015.302959

Centers for Disease Control and Prevention (n.d.). About HIV/AIDS. Retrieved from http://www.cdc.gov/hiv/basics/whatishiv.html

Centers for Disease Control and Prevention (2015). HIV and injection drug use. Retrieved from https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-sheet.pdf

Clarke, K., Harris, D., Zweifler, J. A., Lasher, M., Mortimer, R. B. & Hughes, S. (2016). The significance of harm reduction as a social and health care intervention for injecting drug users: An exploratory study of a needle exchange program in Fresno, California. Social Work in Public Health, 31(5). http://dx.doi.org/10.1080/19371918.2015.1137522

Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Thousand Oakes, CA: SAGE

Des Jarlais, D. C., Nugent, A., Solberg, A., Feelemyer, J., Mermin, J., & Holtzman, D. (2015). Syringe Sservice Pprograms for Ppersons Wwho Iinject Ddrugs in Uurban, Ssuburban, and Rrural aAreas - United States, 2013. MMWR: Morbidity & Mortality Weekly Report, 64(48), 1337-1341 5p. http://dx.doi.org/10.15585/mmwr.mm6448a3

Kim, N. J., Jin, H., McFarland, W. & Raymond, H. F. (2015). Trends in sources and sharing of needles among people who inject drugs, San Francisco, 2005-2012. International Journal of Drug Policy, 26(2015). http://dx.doi.org/10.106/j.drugpo.2015.08.013

Luo, W., Wu, Z., Poundstone, K., McGoogan, J. M., Dong, W.,…Cao, X. (2014). Needle and syringe exchange programmes and prevalence of HIV infection among intravenous drug users in China. Addiction Research Report, 110(1). http://dx.doi.org/10.1111/add.12783

Marotta, P.L. & McCullagh, C.A. (2016). A cross-national analysis of the effects of methadone maintenance and needle and syringe program implementation on incidence rates of HIV in Europe from 1995 to 2011. International Journal of Drug Policy, 32(1). http://dx.doi.org/10.1016/j.drugpo.2016.02.007

Medical Lexicon (n.d.). Retrieved August 13, 2016 from http://www.medilexicon.com/medicaldictionary.php?t=58990

National Institute on Drug Abuse (2014). The science of drug abuse and addiction: The basics. Retrieved from https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics

Nyguyen, T. Q., Weir, B. W., Des Jarlais, D. C., Pinkerton, S. D. & Holtgrave, D. R. (2014). Syringe exchange in the United States: A national level economic evaluation of hypothetical increases in investment. Aids Behavior, 18(2014). http://dx.doi.org/10.1007/s10461-014-0789-9 Comment by Faculty: Not cited in narrative and therefore cannot be listed as a reference.

Quadar, A. S., Feelemyer, J., Shilpa, M., Stein, E. S., Briceno, A., Semaan, S.,…. Des Jarlais, D. C. (2013). Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: A systematic review. Aids Behavior, 17(1). http://dx.doi.org/10.1007/s10461-013-0593-y Comment by Faculty: Not cited in narrative and therefore cannot be listed as a reference.

Rich, J. D. & Adashi, E. Y. (2015). Ideological anachronism involving needle and syringe exchange programs: Lessons from the Indiana HIV outbreak. Journal of American Medical Association, 314(1). Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=2299643

Samo, R.N., Altaf, A., Memon, A. & Shah, S.A. (2013). Determinants of HIV sero-conversion among male injection drug users enrolled in a needle exchange programme at Karachi, Pakistan. The Journal of the Pakistan Medical Association, 63(1). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23865140

Siddiqui, S. S., Armenta, R. F., Evans, J. L., Yu, M., Cuevas-Mota, J., Page, K.,…Garfein. R. (2015). Effect of legal status of pharmacy syringe sales on syringe purchases by persons who inject drugs in San Francisco and San Diego, CA. International Journal of Drug Policy, 26(2015). http://dx.doi.org/10.1016/j.drugpo.2015.06.002

Statistical Solutions (n.d.). Paired t-test sample. Retrieved August 4, 2016 from www.statisticssolutions.com/manova-analysis-paired-sample-t-test/

Tuchman, J. (2015). Women’s injection drug practices in their own words: a qualitative study. Harm Reduction Journal, 12(6). http://dx.doi.org/10.1186/s12954-015-0041-6

Wang, K., Fu, H., Longfield, K., Modi, S., Mundy, G. & Firestone, P. (2014). Do community-based strategies reduce HIV risk among people who inject drugs in China? A quasi-experimental study in Yunnan and Guangxi provinces. Harm Reduction Journal, 11(15). http://dx.doi.org/10.1186/1477-7517-11-15

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