Needle exchange program new haven

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Needle exchange for controlling HIV spread under endogenous infectivity. Analysing the nutrition-disease nexus: the case of malaria. Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection.

Is there a role for potential supervised injection facilities in Victoria, British Columbia, Canada? Engineering Effective Responses to Influenza Outbreaks.

Stan N. Finkelstein , Richard C. Larson , Karima Nigmatulina , Anna Teytelman. Combined prevention for persons who inject drugs in the HIV epidemic in a transitional country: the case of Tallinn, Estonia. A time since onset of injection model for hepatitis C spread amongst injecting drug users. Program Evaluation.

Needle and syringe programs in Yunnan, China yield health and financial return. Risk of Hepatitis C virus re-infection following spontaneous viral clearance in injecting drug users: A systematic review.

What if I am not sharing needles but sharing cookers, cotton balls, etc — could I still potentially get Hepatitis C? Can I bring someone who has overdosed to the SSP for help instead of calling for help? We are hopeful that will not occur. Local law enforcement is aware of the site and service and are supportive of it.

We do not foresee any repercussions occurring to participants. Studies have shown over the 20 years of operations of syringe exchange programs worldwide, drug usage does NOT increase in communities where they are established. We also work to provide referrals and on-site assistance for anyone seeking to make a change in their lifestyle.

Put them in a coffee can or laundry detergent bottle and seal securely with duct tape. Then place in the normal trash. Just click on the Facebook logo below. The focus group data were viewed as corroborating evidence for the data available from surveys arguing against an effect of needle exchange programs on increasing the community levels of injection drug use.

The University of California report addressed the potential for increased drug use in the community by reviewing the studies noted in the previous section. Researchers searched for additional data by examining established data sets of drug abuse indicators and answers to additional questions asked of focus groups of injection drug users.

The University of California researchers attempted to relate the presence or absence of needle exchange programs to ongoing statistical series like the Drug Abuse Warning Network DAWN , Drug Use Forecasting DUF , and Uniformed Crime Reports UCR , which might reflect altered patterns of drug-related events, such as drug cases in hospital emergency rooms, positive urine drug screens, and drug-related arrests, respectively.

The report noted wide variation in these drug-use indicators over time, which suggests inherent lack of precision and limits the manifestation of patterns—if any—relating to needle exchange. The University of California report also noted that, because needle exchange programs are relatively new, changes in drug use might yet appear with longer follow-up. The report concluded that Lurie et al.

The report also noted that the San Francisco and Amsterdam surveys described above provide Lurie et al. The University of California report noted that adverse community responses to needle exchange programs are likely to be centered on the issue of discarded needles and the risk to the public of accidental needlestick injury.

However, the report noted that one-for-one exchange rules cannot, in theory, increase the total number of discarded needles, although programs could affect the geographic distribution of discarded syringes. Data on a surveillance project with the Portland, Oregon, needle exchange program noted a decrease in the prevalence of discarded syringes near the program Lurie et al.

Passive surveillance of health or police department reports over time indicated either declines or small increases in needlestick injuries, with the trends due to changes in reporting patterns. The University of California report concluded that needle exchange programs "have not increased the total number of discarded syringes" and, if structured as a one-for-one exchange with no starter needles, "they cannot increase the total number of discarded needles" Lurie et al.

Using multiple data sources, the University of California reviewed a number of questions about needle exchange programs. As far as possible positive outcomes are concerned, the report concluded that the data available at the time of the report "do not … provide clear evidence that needle exchange programs decrease HIV infection rates," p.

The report goes on to state that there is no evidence that drug use among program participants increased, and there is no evidence of change in overall community levels of noninjection or injection drug use Lurie et al. This section is organized into topical areas that parallel the summaries of the GAO and University of California reports.

Study findings are categorized according to the outcomes and expectations of program effects listed in Table 7. Since the University of California report was issued, a number of studies on the impact of needle exchange programs have been presented or published. These studies utilize a variety of designs, including an ecological design; a comparison of prevalence rates between injection drug users who use and those who do not use needle exchange programs; HIV incidence rates among needle exchange program attenders; and, using data collected prospectively, a comparison of HIV incidence rates between injection drug users who attend and those who do not attend a needle exchange program.

Recent publications on needle exchange programs in San Francisco, New York City, and Portland, Oregon, have addressed the issue of the impact of the programs on HIV drug-use risk behaviors and sexual risk behaviors Watters et al. In an ecological study in San Francisco, Watters examined the trends in risk behaviors and HIV seroprevalence over a 6.

Interviews 5, were conducted with injectors in street settings and drug detoxification clinics. During that time period, multiple prevention efforts targeting injection drug users had been implemented including outreach, education, voluntary HIV testing and counseling, bleach and condom distribution, and needle exchange programs. Among injection drug users who reported sharing needles, the proportion of those who reported ever using bleach increased from 3 percent in to 89 percent by and remained relatively constant at that level through fall Sexually active heterosexual male injectors also reported significant changes in condom use i.

However, Lewis and Watters found that a substantial proportion of sexually active male drug injectors, including heterosexuals, bisexuals, and homosexuals, reported frequently engaging in unprotected sex i.

Several trends in drug-use risk behaviors were reported. In , for example, 65 percent of injection drug users reported having used shooting galleries in the preceding 2 years; in the to survey, only 3 percent reported injecting in shooting galleries in the preceding 6 months.

Substantial reductions in sharing behavior were also observed. Use of potentially contaminated needles declined from 51 to 7 percent of injections.

Moreover, an increasing proportion of injection drug users entering the detoxification program reported using the needle exchange programs since they opened in For the to period, results also show that needle exchange participation was associated with a downward trend in the proportion of subjects reporting any injection with needles that had been used by someone else and a reduction in the percentage of study participants reporting having passed on used needles to others.

The extent to which the reductions in risk behaviors reported in the two surveys can be attributed to the needle exchange program itself is limited by the fact that the data are ecological trends. Other prevention efforts were occurring in New York City between the two time intervals.

Therefore, although the results are consistent with an inference of reduction in risk behaviors following the introduction of a needle exchange program, the study design does not exclude the possibility of contributing or alternate explanations.

In the San Francisco needle exchange program evaluation, Watters compared frequent needle exchange participants with two comparison groups—injection drug users who used the exchange less frequently and a group who did not use it at all.

These researchers found a 47 percent decline from 66 to 35 percent in reported sharing behavior among injection drug user study participants between spring and spring More refined analyses revealed that frequent needle exchange participants i. In contrast, over the 3-year study period, no change in reported rates of sharing behavior was observed among those not using the program.

In New York City, Paone et al. Participants reported a two-thirds decline in the proportion of time they injected with previously used needles 12 percent before participating in the needle exchange program, compared with 4 percent in the last 30 days while participating in the program.

Similar reductions in renting or buying used needles 73 percent decline were observed, and similar reductions in the number of participants who reported borrowing used needles were found 59 percent decline. The number of participants who reported using alcohol pads increased from 30 percent before participating in the needle exchange program to 80 percent in the most recent 30 days in the exchange.

Although the reduction in high-risk behaviors was based on self-reports of exchange users and no comparison of injection drug users not using the exchange was included in this report, this pattern of reduction in drug-use risk behaviors was found to be relatively stable in recent updates Des Jarlais et al. These authors also note in their recent updates that minimal changes in sexual risk behaviors were reported.

For example, always using a condom with a primary sexual partner increased from 36 percent in the 30 days prior to first using the needle exchange program to 37 percent for the last 30 days while using the program; whereas always using a condom with a casual sexual partner increased from 56 percent in the 30 days prior to first using the exchange program to 60 percent in the last 30 days while using the exchange.

However, due to design constraints, it cannot be stated what portion of the reduction in risk behaviors is due to the needle exchange program. An evaluation of the Portland needle exchange program Oliver et al. When drug-use risk behaviors of frequent attenders attended four or more times were compared with risk behaviors of those who attended three or fewer times, frequent attenders reported greater risk reduction on borrowing and returning used needles to the program.

Frequent needle exchange participants were found to be less likely to reuse needles without cleaning or to improperly dispose of used needles than were the NADR clients. The two groups were not found to differ on other risk behaviors assessed. It is worth noting that there was little overlap between the two groups 11 percent. The two interventions apparently are recruiting different participants. In sum, from the earliest studies of needle exchanges, there has been a dominant trend in the data showing significant and meaningful associations between participation in needle exchange programs and lower levels of drug-use risk behaviors, and small or no change in sexual risk behaviors.

The most recent data continue to reflect this trend. Moreover, this pattern of findings has also been observed in foreign cities Davoli et al. Both reported a stabilization of HIV seroprevalence rates that coincided with reductions in high-risk behaviors and the implementation of various prevention programs including outreach, education, testing and counseling, bleach and condom distribution, and needle exchange programs.

Although these ecological studies do not provide direct causal evidence of the effect of such programs, they nonetheless document a pattern in behavioral risk reduction that corresponds with stabilization of seroprevalence rates in distinct populations of injection drug users. Hagan and colleagues b reported seroprevalence rates of needle exchange participants and nonparticipants.

Because the outcome measured in this study was prevalent infection, temporal associations cannot be established with certainty, and the possibility that the results might reflect that the needle exchange program attracts lower-risk injection drug users cannot be dismissed out of hand.

However, the results are consistent with the inference that needle exchange programs are associated with a lower risk of infection. On the basis of recent updates from the International Conference on AIDS, Des Jarlais ; in press provided descriptive information on HIV incidence among injection drug users who participate in needle exchange programs across 14 different cities Table 7.

Some of these incidence rates were measured directly by testing cohorts of needle exchange participants; others were based on self-reports of prior serological tests; still others were derived from statistical modeling techniques e.

These findings are consistent with the premise that an AIDS prevention program e. Although the prevalence is moderate and has remained stable, the observed incidence is high among the needle exchange cohort being studied. The program is located in an area of the city noted for prostitution, and the program operates in the middle of the night, which makes it prone to recruiting high-risk users. That is, although the risk of seroconversion was found to be higher among needle exchange participants when compared to nonparticipants, injection drug users who used the needle exchange program as their exclusive source of sterile needles were found to be at substantially lower risk than those who used diverse sources of sterile needles.

Furthermore, the needle exchange program limit of 15 needles per visit may not be sufficient to properly address drug-use risk behaviors of individuals who inject large amounts of cocaine. There is also a high level of male prostitution among the needle exchange participants. Specific ethnographic studies are needed to better understand the primary routes of transmission implicated and their dynamics e.

This would allow the program to better tailor its services e. The potential ability of needle exchanges to attract injection drug users that are at high risk of seroconversion was also recently reported in the United States by a San Francisco research team Hahn et al. Although the disparities in observed seroincidence rates between needle exchange participants and nonparticipants could not be attributed to having been exposed to the needle exchange program, the program appeared to serve a relatively high-risk subset of injection drug users.

The authors concluded that the San Francisco program provides a unique setting for intervention because it provides direct access to a population that is at high risk. Other cities with needle exchange programs that have high seroprevalence data e. These data are consistent with the premise that AIDS prevention programs e. Obviously, these results are descriptive in nature there are no comparison groups and, as a consequence, cannot in themselves provide evidence of the direct causal effect of needle exchange programs on HIV incidence rates.

Nonetheless, they do provide valuable insight into HIV incidence rates among needle exchange participants in cities with varying levels of HIV seroprevalence among the local populations of injection drug users. The HIV seroconversion rate among high-frequency drug injectors not using the needle exchange programs ranged from 4 to 7 per person years at risk, compared with needle exchange participant groups with seroconversion rates ranging from 1 to 2 per person years at risk.

These findings suggest that the use of needle exchange programs has a substantial protective effect for preventing new HIV infections. However, the results need to be interpreted with care. That is, nonequivalence across groups being compared needle exchange users versus nonusers precludes making strong causal inferences about the direct effect of the needle exchange on HIV incidence rates. Nonetheless, these data do reflect a significant association between needle exchange participation and HIV infection Des Jarlais et al.

The most recent studies that have examined drug-use behaviors among needle exchange participants show either stable levels of reported drug injection frequency or even slight declines over time among injection drug users who continue to participate in needle exchange programs Watters et al.

In the recent New York City study, Paone et al. The only exception to this reported trend comes from an unpublished research manuscript from Chicago researchers O'Brien et al. As noted in the Preface, as the panel was concluding its deliberations, the Assistant Secretary for Health made public statements that a number of unpublished needle exchange evaluation reports had raised doubts in his mind about the effectiveness of these programs.

The panel deemed these statements to be significant in the public debate, therefore necessitating appropriate consideration in order for the panel to be fully responsive to its charge. The panel therefore reviewed the unpublished studies, one of which was the aforementioned O'Brien et al. As unpublished findings, this research lacks the authority provided by the peer review and publication process. For this reason, the panel gave special attention to scrutinizing and describing in detail results reported by the researchers, as well as appraising their probative value see Appendix A.

The investigators infer from their findings that those who participate in needle exchange programs spend more money and inject more frequently than nonparticipants as a result of their participation in the program. Their assertion is based on data that, according to these authors, support the contention that program participation is economically driven i. The panel's review raised serious concerns about the tenability of their inferences.

For instance, a clearly insufficient theoretical and empirical development of the underlying models is used. That is, there are numerous other plausible models that could explain their data. From an economic standpoint, it would seem that individual socioeconomic status may be causally related to both drug abuse and use of the needle exchange program, rather than to the explanation that needle exchange programs cause drug use.

Nonetheless, the authors do not test any alternative plausible models to assess the relative fit of their models compared with other viable competing models. Moreover, a weak theoretical justification is provided of their postulated model e. The empirical information provided on key variables is inadequate. Properties of the distributions of key variables are absent and aggregate summary statistics are used in various models without attention to the possible adverse effect of outliers. The presence of such outliers can severely distort the results and challenges the viability of the inferences drawn by these investigators.

Substantial inconsistencies between data on key variables self-report presented in the manuscript and information extracted from the needle exchange program records raised serious concerns among panel members.

Moreover, as discussed in some detail in Appendix A , the panel had serious reservations about the appropriateness of the modeling techniques as implemented by these researchers. Although this particular study suffers from serious limitations, the conclusions reached by the authors raise interesting questions and hypotheses that should be subjected to sound empirical testing.

These issues should be further studied with adequate designs, measures, and analytical methods. In the meantime, in the panel's opinion, these difficulties are serious enough to preclude making causal inferences about the effect of needle exchange programs.

The concern that having the opportunity to use a needle exchange may lead persons who are not currently injecting to begin injecting demands attention, and some information about this is available.

If the opportunity to participate in needle exchange programs were to lead to an increase in the number of new injection drug users, one would expect to see relatively large numbers of young newer injectors at the needle exchange programs. This has not been observed in any of the earlier studies e. Investigators in Amsterdam have recently published data that permit examination of the hypothesis that "mixing" of injecting and noninjecting drug users at needle exchanges will lead noninjectors to begin injecting behavior van Ameijden et al.

Many of the Amsterdam needle exchanges are operated out of the "low-threshold" methadone programs. These programs provide services to both heroin injectors and heroin smokers and do not require abstinence from illicit drug use as a condition for remaining in the program. Thus, these combined methadone treatment and needle exchange sites do provide frequent opportunities for social interactions between heroin injectors and heroin smokers.

Despite this, the proportions of heroin users who smoke and those who inject have remained constant since the exchanges were implemented. Recent U. The recent San Francisco study Watters, found an increase in the mean age of injection drug users in the city during the years of operation of the needle exchange programs i. Moreover, the author reported that during that 5. In Portland Oliver et al. The average duration of injection drug use was 14 years, and more than 75 percent had been injecting for 5 years or more.

The presence of a needle exchange program does not appear to cause any increase in the number of new initiates to drug injection. Identifying what factors lead individuals to initiate injection drug use, despite knowing about AIDS, remains an important question for future research. Since the University of California report was issued, only one study has dealt with needle exchange programs and improperly discarded needles.

Doherty et al.. After extended legislative debate, Public Act allowed the City of New Haven, Connecticut, to implement—on an experimental basis—a legal needle exchange for injection drug users.

This program operated from a van, typically 6 hours a day, 4 days a week, and traveled to specific sites known to involve high levels of drug activity. The needle exchange program operated on an anonymous basis. Specifically, participants were assigned a fictitious name as a means of identification and tracking. New enrollees who did not have a needle and syringe to exchange at their first encounter with the needle exchange program were provided with a single ''rig.

Syringes that were distributed were coded to enable tracking and evaluation. The program accepted syringes that had not originated from the program.

All returned equipment was placed in a metal canister, and all returned equipment was turned over to an evaluation team at Yale University for assessment. In particular, a sample of returned syringes were assessed for the prevalence of HIV.

In addition to exchanging used sterile equipment, program staff provided AIDS education and information on risk reduction. Condoms and bleach packets were provided to all participants at each encounter.

All participants were also provided information on drug treatment and a broad range of other relevant services e. In July , syringe possession without a prescription was decriminalized. This was followed by a reduction in the monthly volume of exchanges at the program from about 4, to a little more than half that number. The importance of the evidence from the New Haven studies is twofold.

They provide: 1 direct evidence of lower levels of HIV infection among needles in use and 2 indirect, model-based estimates of changes in the incidence of new HIV infections among needle exchange program participants. The direct evidence involves the impact of the needle exchange program on the critical features of program process. Specifically, the evaluation reveals significant and substantial reductions in the infectivity of the syringes exchanged through the needle exchange program.

The data also reveal increases in referral to drug treatment and no change in the number of injection drug users. Prior to the distribution of sterile injection equipment, extremely sensitive DNA analyses using the polymerase chain reaction PCR to detect the presence of HIV-infected peripheral blood cells in the returned syringes of existing "street" syringes showed an HIV-positive rate of 0. During the first month of the exchange, HIV-positive rate for needles turned into the exchange was 0.

That is, the prevalence of HIV in needles decreased by one-third. Measures of syringe infectivity gradually declined over time, with the sharpest decline occurring in the first 3 months after the implementation of the needle exchange program.

If the reduction in the infectivity of needles is due to the activities of the program, it is reasonable to expect changes in program operations that parallel the pattern of reductions in needle infectivity. Data about program operations tend to support the plausibility that reductions in infectivity are connected to the activities of the clients of the needle exchange program and the program itself. In particular, the number of visits increased more rapidly than the number of clients, suggesting that the same clients were exchanging needles more frequently.

Specifically, in December there were about clients and visits. By June there were clients and visits. Program data are also consistent with a fundamental concept of the circulation theory advanced by Kaplan—namely, the law of conservation of needles. Specifically, there was a close match between the number of inbound and outbound needles, and there was a substantial increase in the volume of exchanges between December and June That is, the volume of exchanges increased from less than to over 4, in June After decriminalization in , the volume of exchanges decreased to between 2, and 2, Over the entire study period November through June , a total of 80, needles were distributed; for the same period, the total number of needles that were returned was 78, That is, It appears that these figures include the "return" of nonprogram needles.

In other papers e. Subsequent legislative acts in and expanded the needle exchange program to other locales. Currently, six needle exchange programs are operating throughout the state; in addition to New Haven, they are in Bridgeport, Windham County, Hartford, Danbury, and Stamford. The Danbury and Stamford programs began operations this year. Demonstration Program—PA The program had to: 1 be in, and established with the assistance of, the local health department; 2 be incorporated into existing AIDS prevention and outreach projects in the city; 3 provide for free and anonymous exchanges of needles and syringes, with program participants receiving the number of needles and syringes equal to those returned, up to five per exchange since amended to 10; see below ; 4 require the marking of needles and syringes distributed and a check on return rates; and 5 offer education on transmission and prevention of HIV and assist participants in getting drug treatment services.

DPH, with assistance from the selected health department, had to establish protocols in accordance with the above provisions. The demonstration program had to have a mechanism for the local health department and DPH to evaluate its effectiveness. The program had to monitor: 1 return rates of the distributed needles and syringes, 2 behavioral changes of participants, 3 participation rates and the number and status of those entering treatment as a result of the program, and 4 the incidence of intravenous drug use to see if the program has had an effect.

The act also required the selected city health department to submit an evaluation report to DPH and to the legislature ' s Public Health and Appropriations committees. PA of the May Special Session expanded the demonstration needle and syringe exchange program to two more cities Hartford and Bridgeport.

Under the legislation, the participating cities including New Haven must have had the highest total number of AIDS cases among intravenous drug users as of December 31, The act also allowed DPH to authorize up to three additional exchange programs in Connecticut, as determined by the state health commissioner.