1. THEORETICAL CONCEPTS IN COMBINED HIV PREVENTION PROGRAMMING Don C. Des Jarlais Beth Israel Medical Center New York City, USA

2. Don C. Des Jarlais Beth Israel Medical Center New York City, USA

4. Drug dependence treatment for persons who cannot consistently obtain and use clean syringes

5. Outside of acute HIV infection, sharing syringes still inefficient for HIV transmission (1% probability per sharing act) Sero-sorting, Partner Restriction, Informed Altruism

6. How good are big needle/syringe programs?

7. Don C. Des Jarlais Beth Israel Medical Center New York City, USA

8.  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.  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. 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.  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.  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. Study Design LocationPopulationIntervention Coverage Outcomes Before/After Comparison Glasgow Scotland IDU recruited from SCIEH (Scottish Centre for Infection and Environmental Health) from 1990-1995 Policies: UK DOH Policy Change led to SEP formation Major scale up of services: 1988-1992 Pharmacy distribution in tandem with SEP expansion Coverage: Needles Distributed Annually: 200,000- 300,000 Population of IDU: 6000-8500 Syringes distributed per IDU per year: 33- 36 Overall HCV Prevalence Change: -13% (p<0.001) Effect Modifiers Change in HCV Prevalence by Gender Female: -18% Male: -10% Change in HCV Prevalence by Age: 15-19: -63% 20-24: -16% 25-29: -3% 30-34: +2% 35+: -9%

14. Study Design Location(s)PopulationIntervention Coverage Outcomes Time Series Serial Cross Sectional England & Wales United Kingdom IDU recruited from street settings from 1990-1996 Measurement of HCV prevalence was taken by year during the time period 1990- 1996 Policies: UK DOH Policy Change led to SEP formation Major scale up of services: 1988-1992 Pharmacy distribution in tandem with SEP expansion Coverage: Needles Distributed Annually: 26.7 million Population of IDU: 139391-146246 Syringes distributed per IDU per year: 183-186 Overall HIV Prevalence Change: -4.55% (p<0.001) Effect Modifiers: None

15. Study Design Location(s)PopulationIntervention Coverage Outcomes Time Series Serial Cross Sectional Lang Song Vietnam Ning Ming China IDU recruited from street settings from 1990-1996 Measurement of HCV prevalence was taken by year during the time period 1990- 1996 Policies: National Institute on Drug Abuse & Ford Foundation Support SEP began in 2002 Pharmacy distribution in tandem with SEP placement Coverage: Needles Distributed Annually: 240,000- 288,000 Population of IDU: 8000-12000, approx 30 syringes/IDU/year Coverage of IDU in both locations: 60- 65% Overall HIV Prevalence Change: Lang Song Province: - 14% (p<0.05) Ning Ming Province: - 3% (p<0.05) Effect Modifiers: Change in HIV Prevalence in New Injectors, by location: Lang Song Province: -16% (p<0.0002) Ning Ming Province: -11% (p<0.0093)

16. Study Design LocationPopulationIntervention Coverage Outcomes Time Series Serial Cross Sectional New York City, USA IDU recruited from Beth Israel Detoxification Unit, 1990- 2002) (STARHS) Policies: 1992: Legal Authorization of SEP in New York City Total Expansion Period: 1990-2001 Significant ramp up especially in mid 1990's Pharmacy sales of Needle also available Needles Distributed Annually: 2-3 million Population of IDU: 100,000 Syringes distributed per IDU/year: 30 Coverage of IDU: ~50% Overall HIV Prevalence Change: -33% Overall HIV Incidence Change: -2.78/100PY Effect Modifiers: None

17. 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 Study Design LocationPopulationIntervention Coverage Outcomes Time Series Serial Cross Sectional Montreal Canada IDU recruited from street, chain referral and community programs 1992-2008 Policies: SEP authorized in late 80's in Montreal Ramp up late 80's and early 90's Pharmacy distribution in tandem with SEP Very liberal distribution policies for IDU Coverage: Needles Distributed Annually: 800,000 Population of IDU: 12,000 Syringes distributed per IDU per year: 66 Overall HIV Incidence Change: -1.7/100PY Effect Modifiers: None

21. China Vietnam Hanoi Area of Detail Vietnam China Ning Ming City Lang Son City Puzhai Tan Thanh Dong Dang Loc Binh Tongmia n Shilang Aidian Hop Thanh CaoLoc Town Ha Giang Guigang Large Project Site Small Border Site Key: PDI Site

23. StudyLocationMeasurementOverall HCV or HIV Change (Incidence and/or Prevalence) Goldberg 1998 Glasgow, Scotland HCV Prevalence Baseline HCV Prevalence: 90% Follow-up HCV Prevalence: 77% HCV Prevalence: 13% Reduction Hope 2005England & Wales United Kingdom HIV Prevalence Baseline HIV Prevalence: 5.92% Follow-up HIV Prevalence: 1.37% HIV Prevalence: 4.55% Reduction Des Jarlais 2007 Lang Song Vietnam Ning Ming China HIV Prevalence Baseline HIV Prevalence: Ning Ming: 17%; Lang Song: 46% Follow-up HIV Prevalence Ning Ming: 14%; Lang Song: 32% HIV Prevalence Ning Ming: 3% Reduction HIV Prevalence Lang Song: 14% Reduction Des Jarlais 2005 New York City, USA HIV Prevalence HIV Incidence Baseline HIV Prevalence and Incidence: Incidence: 3.55/100PY; Prevalence: 50% Follow-up HIV Prevalence and Incidence Incidence: 0.77/100PY; Prevalence: 17% HIV Prevalence: 33% Reduction HIV Incidence: 2.78/100PY Reduction Bruneau 2011 Montreal Canada HIV Incidence Baseline HIV Incidence: 3.5/100PY Follow-up HIV Incidence: 0.8/100PY HIV Incidence: 1.7/100PY Reduction

24.  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.  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.  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.  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.

29. Planning for Combined Prevention (Idealized)  1. Initial Assessment—Rapid Assessment and Response, buy in from major stakeholders  Scale up of inexpensive highly effective interventions: needle/syringe programs, community outreach  Develop capacity for expensive effective programs: drug dependence treatment, ART  Assessment and Second Round Planning for Additional Scale-up: Program data and RDS study