Preventing Medical Complications of Injection Drug Use Keith Heinzerling, MD, MPH UCLA Seminars in Addiction Psychiatry Course August 11, 2005

Public Heath Burden of Blood-borne Viral Infections Human immunodeficiency virus (HIV): –850,000 to 950,000 Americans infected –180,000 to 280,000 unaware of infection Hepatitis C virus (HCV): –4 million Americans infected –Leading reason for liver transplant –HIV-HCV co-infection: higher mortality

Injection Drug Use: Important Source of Transmission Sharing of contaminated drug injection equipment by injection drug users (IDUs) has resulted in: –25% of cumulative AIDS cases before 2000 (CDC, 2003) –20% of new HIV/AIDS diagnoses in 2000 (CDC, 2004) –68% of HCV infections (Alter, 2002)

Prevalence of HIV and HCV Among IDUs is High HIV seroprevalence among IDUs: –2% to 30% (Monterroso, 2000) HCV seroprevalence among IDUs: –66% to 93% in methadone patients –27% to 41% in IDUs under age 30 Average time to HCV seroconversion for IDUs is 3.4 years (Hagan, 2004)

Soft Tissue Infections (STIs): Common Among IDUs Prevalence (Binswanger, 2000): –68% (lifetime), 32% (current) Risk factors (Murphy, 2001): –Syringe reuse, Skin popping, Speedball San Francisco General (CDC, 2001): –$10 million for inpatient and ER care California, 2000 (Heinzerling, 2005): –4,152 hospital discharges for STIs

Preventing Complications With Good Injection Hygiene: Courtesy of Kristen Ochoa

Use Sterile Water and a Clean “Cooker” to Dissolve Drugs

Use Sterile “Cottons” to Filter Drugs

Find a Good Vein

Find a SAFE Vein

Missing or “Booting” Can Cause Abscesses or Cellulitis

Sharing Cookers, Cottons, Water is More Common than Syringe Sharing (Source of HCV?)

Increased HIV/HCV Risk: “Backloading”

Being Injected by Others: Frequent Syringe Sharing and Exposure to Blood

Syringe Exchange Programs: Sterile Syringes, Injection Equipment, and Health Services for IDUs

History of Syringe Exchange Programs (SEP): 1984: First SEP in Amsterdam 1988: First US SEP in Tacoma, WA 1999: Surgeon General’s SEP Report 2000: SEPs “legal” in California 2002: 148 SEPs in 32 states exchanged 25 million syringes; “Bridge to Services for IDUs”- HIV testing at 72%, HCV testing at 43%, HBV vaccination at 36% 2005: 30 SEPs in California, 7 SEPs in Los Angeles- services available 6 days a week

SEPs: Reduced Risk Behaviors for HIV and Abscesses but Maybe Not for HCV HIV: Meta-analysis (Ksobiech, 2003) –47 studies from –SEP use significantly associated with lower syringe sharing, lending, and borrowing STIs (Bluthenthal, 2004) –Syringe reuse lower for SEPs without caps on number of syringes exchanged Effectiveness for HCV Unclear (Thorpe, 2005) –SEP use associated with reductions in syringe sharing but not sharing of cookers

Comprehensive approach is needed:Comprehensive approach is needed: Sterile syringes and condoms Injection and sexual risk reduction counseling Screening for HIV, HBV, HCV, STDs Substance abuse treatment

Unmet Need for Recommended Preventive Health Services Among Syringe Exchange Program Clients in California KG Heinzerling, NM Flynn, AH Kral, RL Anderson, ML Gilbert, A Scott, SM Asch, RN Bluthenthal CDC R06/CCR UCLA / VA RWJ Clinical Scholars Program

Research Questions Are SEP clients receiving recommended preventive services from any source? What percent of preventive services are received from SEPs? What is the availability of HIV and HCV testing on-site at SEPs?

Research Questions What factors are associated with receipt of HIV and HCV testing by SEP clients? –SEP on-site testing, use of primary care or drug treatment? What is the frequency of health care linkages among SEPs with different availability of on-site HIV/HCV testing?

Methods- Sample Programs: –23 SEPs throughout California –Two-thirds of California SEPs in 2003 Clients: –Approximately 25 clients per SEP recruited by SEP staff from March to September 2003 –560 current injection drug users with at least one SEP visit in the last 30 days

Methods- Data Collection SEP Directors were interviewed about: –Availability of on-site HIV and HCV testing –SEP structural and organizational characteristics SEP Clients were interviewed about: –Demographics, medical history, risk behavior –Receipt of preventive services- past 6 months

Results: SEPs in Sample

SEP Client Characteristics Demographics Age43 years Male68% White51% Homeless51% Heath Care Uninsured56% Primary Care Visit44% Drug Treatment25% SEP Visits- 30 days4.42 Risk Behavior Unprotected Sex57% Syringe Sharing27%

Percent of Eligible Clients Who Received Each Service and Source of Care Percent of Eligible Clients Who Received Service

Availability of SEP On-site Testing Services Testing Services AvailableSEPs (%) None4 (17%) HIV Testing4 (17%) HIV + HCV Testing15 (66%)

HCV Test p=0.008 Percent of Eligible Clients Who Received Testing HIV Test p=0.002 Percent of Clients Who Received HIV and HCV Testing by Availability of SEP On-Site Testing Services

HCV Test p=0.12 Percent of Eligible Clients Who Received Testing HIV Test p=0.84 Percent of Clients Who Received HIV and HCV Testing by Use of Primary Care

HCV Test p=0.72 Percent of Eligible Clients Who Received Testing HIV Test p=0.10 Percent of Clients Who Received HIV and HCV Testing by Use of Drug Treatment

Logistic Regression Model Predicting Receipt of HIV Testing Testing AvailableOR95% CI P Value NoneRef HIV HIV + HCV Controlling for age, region, SEP visits, unprotected sex, and use of drug treatment.

Logistic Regression Model Predicting Receipt of HCV Testing Testing AvailableOR95% CI P Value NoneRef HIV HIV + HCV Controlling for age, race/ethnicity, homelessness, region, SEP visits, and use of primary care.

SEP-Health Care Linkages and On-site Testing Availability Organization TypeNoneHIVHIV+HCV Independent SEP100% (4)50%(2)33% (5) AIDS Service Organization 0% (0)50%(2)27% (4) Drug Treatment Program 0% (0) 20% (3) Clinic/Health Department 0% (0) 20% (3)

Limitations Convenience sample limited to IDUs using SEPs Self-reports of utilization Observational design

Conclusions SEPs are often the only source of preventive care for their IDU clients Primary care providers and drug treatment programs miss opportunities to test SEP clients for HIV and HCV

Conclusions Availability of on-site HIV and HCV testing may be increased by formation of structural or organizational links between SEPs and health care providers –Should drug treatment programs provide needle exchange?

Other Available Interventions Pharmacy syringe sales: –Purchase up to 10 syringes without a prescription, disposal and prevention info available from pharmacist –Approved by Los Angeles County Supervisors June 2005, implementation by October 2005 Supervised Injection facilities: –First in North America: Vancouver in 2003 –Decreases in injecting in public and publicly discarded syringes 12 weeks after facility opened (Wood E, 2004) –Pilot supervised smoking facility underway

Acknowledgements Staff and Clients of California Syringe Exchange Programs UCLA / VA RWJ Clinical Scholars Program CDC R06/CCR RAND, UC San Francisco, UC Davis Urban Health Study