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Needle Exchange and the HIV Epidemic in Vancouver : Lessons Learned from 15 years of research Hyshka, Elaine; Strathdee, Steffanie A.; Wood, Evan; Kerr, Thomas May 11, 2012

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Needle Exchange and the HIV Epidemic in Vancouver: LessonsLearned from 15 years of researchElaine Hyshka1,2, Steffanie Strathdee4, Evan Wood2,3, and Thomas Kerr2,31Addiction and Mental Health Research Lab, School of Public Health, University of Alberta2British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia3Department of Medicine, University of British Columbia4Department of Medicine, University of San Diego School of MedicineAbstractDuring the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injectiondrug users (IDU) and many questioned how this could occur in the presence of a high volumeneedle exchange program (NEP). Specific concerns were fuelled by early research demonstratingthat frequent needle exchange program attendees were more likely to be HIV positive than thosewho attended the NEP less frequently. Since then, some have misinterpreted this finding asevidence that NEPs are ineffective or potentially harmful. In light of continuing questions aboutthe Vancouver HIV epidemic, we review 15 years of peer-reviewed research on Vancouver’s NEPto describe what has been learned through this work. Our review demonstrates that: 1) NEPattendance is not causally associated with HIV infection, 2) frequent attendees of Vancouver’sNEP have higher risk profiles which explain their increased risk of HIV seroconversion, and 3) anumber of policy concerns, as well as the high prevalence of cocaine injecting contributed to thefailure of the NEP to prevent the outbreak. Additionally, we highlight several improvements toVancouver’s NEP that contributed to declines in syringe sharing and HIV incidence. Vancouver’sexperience provides a number of important lessons regarding NEP. Keys to success includerefocusing the NEP away from an emphasis on public order objectives by separating distributionand collection functions, removing syringe distribution limits and decentralizing and diversifyingNEP services. Additionally, our review highlights the importance of context when implementingNEPs, as well as ongoing evaluation to identify factors that constrain or improve access to sterilesyringes.Keywordsneedle exchange programs; injection drug use; HIV/AIDS; policing; Vancouver© 2012 Elsevier B.V. All rights reserved.Send correspondence to: Thomas Kerr, PhD, Director, Urban Health Research Initiative, B.C. Centre for Excellence in HIV/AIDS,University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada, Tel:604-806-9116, Fax: (604) 806-9044, uhri-tk@cfenet.ubc.ca.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptInt J Drug Policy. Author manuscript; available in PMC 2013 July 01.Published in final edited form as:Int J Drug Policy. 2012 July ; 23(4): 261–270. doi:10.1016/j.drugpo.2012.03.006.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptINTRODUCTIONAn estimated 15.9 million people worldwide inject drugs and approximately 3 millionpeople who inject drugs (IDUs) are estimated to be HIV positive (Mathers et al., 2008).Injection drug use accounts for approximately 5–10% of HIV infections globally andapproximately 30% of HIV infections outside Sub-Saharan Africa (Mathers et al., 2010;UNAIDS, 2008). Recognizing this, the World Health Organization, the United NationsOffice of Drug Control and the Joint UN Programme on HIV/AIDS have endorsed nineinterventions for the prevention, treatment and care of HIV/AIDS in IDUs (WHO, UNODC& UNAIDS, 2009). Needle exchange programs (NEPs) are one of these interventions.NEPs provide sterile syringes and other injection equipment to IDUs; additional healthservices or referrals are also typically available (Vlahov, Robertson & Strathdee, 2010).Numerous studies in diverse contexts have established the effectiveness of NEPs in reducingthe borrowing and lending of used syringes, and in reducing the incidence of HIV infectionamongst IDUs (Bastos and Strathdee, 2000; Des Jarlais 2000; Wodak & Cooney, 2006;Ksobiech, 2003; Vlahov, Robertson, & Strathdee, 2010). NEPs have also been shown topromote entry into addiction treatment (Brooner et al., 1998; Heimer, 1998; Strathdee et al.,1999; Strathdee et al., 2006). Several studies have found that NEPs do not increase drug use(Burring, 1991; Normand, Vlahov, & Moses, 1995; Vlahov et al. 2001) or incite youth tostart injecting drugs (Marx, Brahmbhatt, Beilenson, et al., 2001). Moreover, NEPs have notbeen shown to increase numbers of publicly discarded syringes (Doherty, Junge, Rathouz, etal., 2000), crime (Marx, Crape, Brookmeyer et al., 2000), or high risk social networks(Schechter, Strathdee, Cornelisse, et al. 1999; Lamothe, Bruneau, Franco, et al., 1998). Yetdespite the established effectiveness of NEPs, they must be implemented to scale to achievepopulation level reductions in HIV incidence. Unfortunately, although NEPs are present in82 countries that are home to approximately 80% of the estimated global IDU population,few countries have sufficient NEP coverage to effectively control HIV transmission(Mathers et al., 2010).Although a large body of scientific evidence has established the effectiveness of NEPs, thisform of intervention remains controversial and under-utilized, particularly in EasternEurope, Asia and the United States (Des Jarlais et al., 2010; Mathers et al., 2010; Smith,Bartlett, & Wang, in press). These problems persist despite international guidelinesrecommending NEPs as an essential HIV prevention program (WHO, UNODC & UNAIDS,2009). The failure to widely implement NEPs and bring these programs to scale reflects alongstanding emphasis on drug law enforcement as the primary response to illicit drug use.However, lingering misbeliefs about NEPs’ negligible or even iatrogenic effects have alsocontributed to this problem (Buchanan, Shaw, Ford & Singer, 2003). These beliefs havebeen in part fuelled by early research undertaken in settings where NEPs were firstimplemented.During the 1980s, Vancouver, Canada experienced a significant increase in injection druguse rates. In response, a large NEP was implemented in 1988 (Bardsley, Turvey, &Blatherwick, 1990). However, an early study published in AIDS in 1997 by Strathdee andcolleagues titled “Needle exchange is not enough: lessons from the Vancouver injectingdrug use study” revealed high HIV prevalence and incidence and continued needle sharingamongst frequent NEP attendees. This study and Vancouver’s experience with NEP wasrepeatedly cited as rationale for opposing NEPs (American Journal of Public Health, 2000;Bellm, 1999; Bruneau & Schecter, 1998; Schechter et al., 1999). As recently as 2005, theStrathdee et al. (1997) paper was cited by a US congressional representative calling for cutsin funding to international aid agencies that distributed sterile syringes (Wood et al. 2007).Controversy around NEP persists in the United States. In December 2011, the US CongressHyshka et al. Page 2Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptreinstated a ban on federal needle exchange program funding (originally ended in 2009 byPresident Obama) as part of new spending legislation (Taylor, 2011).In light of the remaining controversy around NEPs in general, and the Vancouver NEP inparticular, we review 15 years of research examining Vancouver’s experience with NEP tounpack how an explosive HIV epidemic could occur alongside one of North America’slargest and most established NEPs. We highlight subsequent research on the associationbetween frequent needle exchange attendance and HIV serostatus, and augment this analysisby reviewing additional epidemiological and ethnographic research on the impact of NEPpolicies and law enforcement practices on access to sterile syringes. We conclude bydetailing recent NEP policy changes in Vancouver and the associated impacts on rates ofsyringe sharing and HIV incidence among IDUs.BACKGROUNDMore than one third of Vancouver’s estimated 13,500 IDUs are concentrated in a lowerincome neighbourhood know n as the Downtown Eastside (DTES), which borders majortourism and business districts and is characterized by poor living conditions and significantpublic disorder (McInnes, et al., 2009; Miller, et al., 2007). In 2009, the DTES hadapproximately 4401 single room occupancy units. A typical single room occupancy unitconsists of one small room with no private bathroom or cooking facilities (City ofVancouver, 2010). Over the past decade and at any given time, approximately 50% ofVancouver’s IDUs resided in a single room occupancy unit or other unstable housingarrangement, and 10% were outright homeless (Urban Health Research Initiative [UHRI],2009). In addition to thousands of single room occupancy units, the DTES is also home to astreet-level survival sex work economy, and a substantial proportion of the city’s estimated1500 female sex workers reside there (McInnes, et al., 2009). Finally, the DTES remainsCanada’s largest public illicit drug market, despite a number of concentrated policeoperations targeting street-level buyers and sellers (Werb, Wood, Small, et al., 2008; Wood,Spittal, Small, et al., 2004). Street-level dealing and public injection are commonoccurrences in the neighbourhood (Wood & Kerr 2006; UHRI, 2009).Similar to other North American port cities, heroin injection was first documented inVancouver during the late 1960s (Wood & Kerr, 2006a). In 1988, Vancouver opened one ofNorth America’s first NEPs, which was supplemented by legal pharmacy sales of sterilesyringes. Initially, the City of Vancouver and the Federal Ministry of Health agreed to fundthe NEP to address growing rates of injection drug use in the DTES (Bardsley, Turvey &Blatherwick, 1990; Hankins, 1998). The program was implemented cautiously with thefederal government emphasizing the importance of minimizing any public disorderassociated with the NEP. This emphasis continued when the province assumed financialresponsibility for the NEP in 1992.As such, up until 2002, Vancouver’s NEP had an explicit policy of one-for-one syringeexchange, which tied clean syringe distribution to used syringe collection. The rationale forthe exchange policy was threefold: 1) emphasis was placed on reducing public disorderincluding minimizing inappropriately discarded syringes in the DTES and surroundingareas; 2) it was believed that the process of exchange promoted face-to-face contact betweenoutreach staff and IDUs and facilitated health service referrals; and 3) syringe exchangelimits were thought to curtail the practice of IDUs selling clean syringes for profit, whichwas discouraged. Irrespective of the validity of these concerns, the emphasis on syringeexchange rather than distribution would have important implications for the availability ofsterile syringes in the DTES (Hankins, 1998; Kerr et al., 2010; Kuyper et al., 2006; Spittal etal., 2004).Hyshka et al. Page 3Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptAdministered and run by the Downtown Eastside Youth Activities Society, the NEPincluded a fixed site needle exchange located in the heart of the DTES with initial tradinglimits of two syringes per day or 14 per week (Bardsley, Turvey, & Blatherwick, 1990;Spittal et al., 2004). The NEP exchanged 127 806 syringes in its first year. Two years later, amobile exchange van was added to cover evenings when the fixed site was closed, andexchange limits were increased to allow IDUs to trade one used syringe for two cleansyringes in an effort to keep up with demand. Individuals with health statuses (e.g. HIVseropositivity) that made them more likely to experience injection risk were allowed toexchange at twice the regular limit. By 1993, the NEP was exchanging over a millionsyringes a year (Archibald, Ofner, Strathdee et al., 1998). During this initial period of NEPoperation, HIV incidence in the DTES was considered to be low and stable (Strathdee et al.1997), although Hankin (1998) notes that initial resistance to NEP evaluation resulted invery limited HIV surveillance during this period.This situation changed dramatically by 1994, when a number of factors - including thedeinstitutionalization of the mentally ill, a lack of social housing, and a marked increase inthe availability of powder cocaine - combined to produce a dual epidemic of injection druguse and HIV infection that culminated in one of the highest HIV incidence rates documentedin the developed world (Strathdee et al, 1997; Wood & Kerr, 2006a). Between 1993 and1994, the proportion of Vancouver IDUs testing newly HIV positive grew from 2 to 7%(Archibald et al., 1997). Data from an early case-control study examining this increasefound that frequent NEP attendees were engaged in a number of risk behaviours (such assyringe borrowing) and more likely to be frequent cocaine injectors (Archibald et al., 1998;Strathdee et al., 1997). This finding was in line with reports of a shift from heroin to cocaineas the main illicit drug in the DTES. Whereas IDUs typically injected heroin 2–4 times perday, IDUs injecting cocaine could inject upwards of 20 times per day due to the drug’srelatively short half-life (Bourgois & Bruneau, 2000; Tyndall et al., 2003). Accordingly,demand for syringes increased significantly and the Vancouver NEP limits were doubledfrom 2 syringes to 4 syringes per day or 28 per week (3 per mobile van visit), and a secondvan was added in 1993. In response to rising HIV prevalence rates, public health officialsincreased the NEP budget significantly and by 1995 a third van had been added and theexchange limits were again doubled. That year the NEP exchanged 1 815 480 syringes(Spitall et al. 2004, p. 37). The NEP exchanged 2.3 million syringes in 1996 and more than2.5 million syringes in 1997 (Strathdee et al., 1997; City of Vancouver, 1998).Strathdee et al. reported observational data from the newly established Vancouver InjectionDrug Users Study (VIDUS) cohort in 1997. Data from the ongoing VIDUS cohort study isreferred to throughout this paper; as such, a brief description of the methods is provided (seeWood et al., 2002a for a detailed methods description). VIDUS is an open prospectivecohort, which began in May 1996. Participants are recruited through street-based outreach orself-referral, and are eligible to participate if they have injected illicit drugs at least once inthe past month, reside in the Greater Vancouver region and provide written informedconsent. The cohort includes approximately 1000 individuals who provide blood samplesand complete interviewer-administered questionnaires at baseline and semi-annually.Strathdee et al.’s (1997) initial sample included 1006 VIDUS participants of which 81%reported frequent NEP attendance. The authors estimated the baseline HIV prevalence at23.2% (95% CI, 20.6–25.8), of whom 58% were previously aware of their seropositivestatus. In terms of syringe sharing, 39% of HIV-negative and 39% of HIV-positive IDUs intheir sample reported receptive and distributive syringe sharing respectively. Using multiplelogistic regression, the authors found that attending an NEP more than once a weekindependently predicted HIV-positive serostatus, and this association persisted afteradjusting for age, gender, frequency of injecting, drug most frequently injected, etc. (TableHyshka et al. Page 4Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript1). Of the 257 participants who tested HIV-negative at baseline and attended a 6-monthfollow-up, 24 seroconverted resulting in an estimated HIV incidence rate of 18.6 per 100person-years (95% CI, 11.1–26.0). Furthermore, 23 out of the 24 seroconverters reportedthat the NEP was their primary source for sterile syringes, and 5 out of 24 reported difficultyaccessing syringes. However, the limited number of initial HIV seroconversions in the studydid not allow for sufficient statistical power to fully explore this relationship (Strathdee etal., 1997; Drucker et al. 1998). In terms of coverage, Strathdee et al. (1997) estimated thatVancouver’s NEP would have to exchange 5–10 million syringes per year to meet IDUdemand and called for the program’s further expansion. They concluded that the NEP wasan important cornerstone of HIV prevention, but it alone was insufficient for preventingHIV incidence, and called for increased funding for other health and drug treatment servicesin Vancouver (p. F63). This conclusion echoed concerns raised elsewhere in Canadaregarding the insufficiency of NEPs alone for controlling the spread of HIV/AIDS amongstIDU (Bruneau et al. 1997; Hankins 1998).Vancouver’s injection drug use problem - and the apparent failure of its NEP - gained mediaattention worldwide and generated interest from a variety of stakeholders, including the USDrug Enforcement Agency (S.A. Strathdee, personal communication, October 19, 2011).The contemporaneous publication of similar research from Montreal fueled the controversyfurther. Bruneau et al. (1997) prospectively followed 974 HIV seronegative participants andfound that those who attended the NEP at baseline were 1.7 times more likely to seroconvertduring follow -up. They also reported a positive association between exclusive NEP use andseroconversion. The authors attributed the rate of HIV infection amongst NEP attendees toserodiscordant network formation. However, this conclusion was criticized as “highlyspeculative” (Lurie, 1997, p. 1004) and was not substantiated in subsequent ethnographicand epidemiologic investigations (Bourgois & Bruneau, 2000; Lamothe et al., 1998).Following the release of Strathdee et al. (1997)’s findings, the situation in the DowntownEastside was declared a public health emergency. Approximately $7M in federal andprovincial funding was allocated to expand access to drug treatment, VCT and the NEP inthe DTES. By February of 1997, Vancouver’s exchange maximums had been increased to14 syringes per day or 98 per week and the NEP evolved into a 24-hour operation, whichincluded fixed sites, mobile vans and foot patrols (Spittal et al., 2004). Secondary exchanges—smaller, decentralized needle exchange points—were permitted to operate in the singleroom occupancy hotels and other venues to further meet the needs of IDU. The NEP wenton to exchange approximately 2.4 million syringes in 1998, 2.9 million syringes in 1999,and 3.5 million syringes in 2000 (Small et al., 2008)—numbers well short of the 5–10million annually Strathdee et al. (1997) recommended for full coverage. It would take yearsfor Vancouver’s HIV outbreak among IDUs to stabilize.EXPLAINING THE ASSOCIATION BETWEEN HIV SEROCONVERSION ANDNEP ATTENDANCEInternational reaction to the Vancouver and Montreal studies was swift. Strathdee wasapproached by the DEA after presenting the findings at the Conference on Retroviruses andOpportunistic Infections in January 1997 and asked for the yet -to-be published AIDS paper(S.A. Strathdee, personal communication, October 19, 2011). Both the US Office ofNational Drug Control and several members of Congress interpreted Strathdee et al.’s(1997) publication as evidence that NEPs promote the spread of HIV among IDUs.Additionally, the US Drug Czar, General Barry McCaffery cited the Canadian findings asevidence that NEPs were “terrible drug policy, terrible social policy, and terrible lawenforcement policy” (cited in Bourgois & Bruneau 2000, p. 331) and the Office of NationalDrug Control Policy sent a task force to Vancouver. (S.A. Strathdee, personalHyshka et al. Page 5Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptcommunication, October 19, 2011). Strathdee also testified before Congress twice on thissubject, and the 1997 paper was entered into the Congressional record with rhetoric thatconcluded that the NEP had failed. Resultantly, Bruneau and Schechter (1998) publishedand Op-Ed in the New York Times in an attempt to clarify US officials’ misinterpretation oftheir findings. Despite this and other attempts at clarification the US government opted tocontinue its ban on federal fun ding for NEPs in 1998.The Canadian studies also prompted a highly politicized academic debate (see Bruneau &Franco 1998; Fisher & Bigelow, 1998; Hahn, Moss, & Vranizan, 1998; Lowndes & Alary,1998; Lurie 1997; Lurie 1998; Lurie & Drucker, 1997; Moss & Hahn 1999; and Moss 2000for examples) in which a number of researchers published comments or interpretations ofthe findings. Many of those speculating about the observed relationships between NEPattendance and HIV seropositivity concurred with Strathdee et al. (1997)’s suggestion thatNEP may attract higher-risk users, such that observed relationships could be attributable toselection effects (Bluthenthal, et al. 2000; Des Jarlais & Friedman, 1998; Drucker et al.,1998; Hagan et al., 2000; Vlahov & Junge, 1998; Lurie, 1997). However, some researcherstook the findings as evidence that NEPs may not be effective interventions against HIV/AIDS in some contexts (Fisher & Bigelow, 1998; Moss & Hahn, 1999; Moss 1999). Finally,some have suggested that comparisons between NEP attendees and non-attendees areinappropriate because the latter may have had economic means to access sterile syringesthrough pharmacy sales and/ or secondary syringe exchange (Bluthenthal et al., 2000;Vlahov & Junge, 1998).In response to the controversy and debate, the Vancouver authors published a follow-upstudy investigating the relationship between NEP attendance and HIV seroconversion in theVIDUS cohort in 1999. Schechter et al. (1999) examined whether HIV seroconversion wascausally associated with the NEP either through network formation between serodiscordantIDUs or an increase in risk behaviours after attending the NEP. Data was collected from 870IDUs who were seronegative at baseline, of which 64 seroconverted during the 15-monthstudy period. 47 of these seroconversions occurred amongst frequent NEP attendees and 17occurred amongst infrequent NEP attendees, a difference that was statistically significant.Frequent NEP attendees were more likely to report: unstable housing and hotel living, theDTES as their primary injection site, cocaine injection at least once per day, and needingassistance injecting (Table 2). Using Cox regression modeling the authors demonstrated thatthe number of new seroconversions “observed among frequent NEP attendees is close to thatexpected based on their higher risk profile at baseline” (p. F49). Furthermore, the authorsdid not find any evidence of network formation or increased risk behaviours resulting fromNEP attendance. They concluded that there was no evidence supporting a causal associationbetween NEP attendance and HIV incidence and that the observed relationship was indeedlikely due to selection effects. Unfortunately, 47 seroconversions did not yield sufficientstatistical power to fully examine the relationship and allow for adjustment of variouspotential confounders (Schechter et al., 1999).A follow-up study to Schechter et al. (1999) analyzed data from 1996–2000 including anadditional 61 VIDUS seroconversions, and demonstrated that frequent injection cocaine use,rather than NEP attendance, was the strongest predictor of HIV seroconversion among localIDUs [adjusted hazard ratio (95% CI) 3.72(2.44–5.67) p = 0.001]. Indeed, injection cocaineuse predicted seroconversion in a dose-dependent fashion with participants who averagedmore than three injections per day being seven times more likely to contract HIV (Tyndall etal., 2003, p. 887). Cocaine injection was also found to be an important risk factor for HIVinfection in Montreal (Bourgois & Bruneau, 1999; Brogly et al., 2000). In summary, thefollow -up research conducted in response to Strathdee et al. (1997) provided no evidence tosupport a causal link between NEP attendance and HIV seroconversion, and rather indicatedHyshka et al. Page 6Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptthat the high risk profile of IDUs - including high rates of cocaine injection, syringe sharing,and inadequate NEP access likely played important roles in driving the Vancouver HIV/AIDS epidemic. However, definitive answers concerning the HIV epidemic and the localNEP remained out of reach.CONTEXTUAL FACTORS CONTRIBUTING TO THE LIMITEDEFFECTIVENESS OF VANCOUVER’S NEPSince the 1997 Strathdee et al. paper was first published, several epidemiological andethnographic research studies have explored a number of contextual factors with potential toaffect sterile syringes access in Vancouver. These factors can be divided broadly into twocategories: NEP policy concerns and Vancouver policing practices.Vancouver needle exchange program policy concernsMany of the second-generation NEP studies in Vancouver pointed to various programmaticlimitations associated with local NEP delivery. For example, Wood et al. (2002a) reportedthat ongoing high rates of syringe sharing were being driven by problems with access tosterile syringes (see Table 3). However, this study also revealed that IDUs who obtainedtheir syringes exclusively from the NEP were significantly less likely to report syringesharing. These findings pointed to the possibility that the Vancouver NEP was having aprotective effect, rather than an iatrogenic one, for many of the IDUs who were able toaccess it regularly and that program expansion could potentially address ongoing HIV riskbehaviour in this setting.In a follow-up study examining VIDUS data collected between 2000–2001, Wood et al(2002b) revealed a number of programmatic deficiencies of the local NEP and helped revealsome reasons behind continued syringe-sharing. Among IDUs who primarily obtained theirsyringes from the fixed site NEP, the most common reasons given for experiencingdifficulty accessing syringes were: fixed site being closed (71.0%), missing the exchangevan (36.2%), and being out of the area where the NEP operates (31.9%). Among IDUs whoprimarily obtained their syringes from the NEP exchange vans, missing the van (57.6%), thefixed site being closed (51.5%), being incarcerated (30.3%) and being out of the area whereNEP operate (21.2%) were the most common reasons cited for experiencing difficultyaccessing syringes (Figure 1).Thus, a significant proportion of IDU experienced difficulty accessing sterile syringes due tothe restrictive operating hours (8:00am to 8:00pm) of the NEP. This finding was furthersupported in subsequent research (Kerr et al., 2006; Kuyper et al., 2006; Wood et al., 2002b;Wood et al., 2003a;). Notably, the NEP’s daylight operating hours were established in aneffort to “reduce drug use in the vicinity of the exchange at night,” implying “priority wasgiven to making the program acceptable to local politicians and community members overoptimizing syringe accessibility” (Wood and Kerr 2006b, p. 841). In addition to insufficientoperating hours, Wood et al. (2002b) demonstrated that poor NEP coverage and service gapsalso contributed to restricted access to sterile syringes amongst some IDUs. NEP mobilevans would visit areas with a high prevalence of injection drug use during the evening hoursto supplement the fixed site. The number of exchange vans and routes in operation at anygiven time fluctuated with budget constraints and perceived demand (Spittal et al., 2004).Despite often being the only source for sterile syringes during the evening hours, manyIDUs experienced trouble meeting up with the exchange van or spent their time in areas notcovered by the fixed and mobile NEP sites.In response to the NEP’s restrictive operating hours, other policy concerns, and the ongoingproblems with syringe access, a local drug user organization, the Vancouver Network ofHyshka et al. Page 7Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDrug Users (VANDU), set up an unsanctioned, user-run, evening needle exchange tent oneblock away from the fixed site (Figure 2). This NEP tent operated in the heart of the opendrug scene between September 2001 and May 2002 (Kerr et al. 2006; Wood et al. 2003).The well-attended tent operated 7 nights a week until 4:00am for 9 months before being shutdown by police (Small, Glickman, Rigter, & Walter, 2010). An evaluation of the VANDUtent indicated that this NEP was meeting an unmet need by reaching IDUs with higher HIVrisk profiles, including those who frequently injected cocaine, injected in public, or requiredassistance injecting, during the evening hours (Wood et al. 2003). This evaluation alsorevealed that the program was promoting safe syringe disposal.A third NEP deficiency that contributed to restricted access to sterile syringes was the strictone-for-one or ‘loaner’ policies, which emphasized syringe exchange and used syringerecovery (Spittal et al., 2004; Kerr et al., 2006; Miller et al., 2006; Kuyper et al., 2006;Wood et al., 2003a). Spittal et al. (2004) examined this problem via ethnographic fieldworkin and around various NEP sites, including the mobile exchange vans, over a one-yearperiod. They found that although an informal, widespread loaner system existed wherebyNEP clients could access around 1–3 sterile syringes without providing used syringes forexchange, there remained a heavy emphasis on point-for-point exchange as demonstrated bynightly syringe counts and the significant pressure placed on workers to keep loanernumbers down. Moreover, the loaner system was contingent on worker’s subjectiveassessment of client need and willingness to return used syringes. As one NEP worker put it“…some drivers think these clients are just throwing them away. So they don’twant to just hand them out. They tell clients to go get one…go find one in the alley.I don’t do that. I’m not gonna make them crawl around in the alley looking for a rigin the dirt. That’s just humiliating.” (Spittal et al., 2004, p. 40)A supplementary quantitative analysis demonstrated that 86.7% of participants in VIDUSreported receiving loaners from the needle exchange over a six-month period (Spittal et al.,2004, p. 41). Spittal et al. (2004) demonstrated considerable demand for sterile syringesamongst IDUs who had no used syringes to exchange, particularly amongst mobile vanclients who were already more vulnerable to HIV risk. These findings suggest that the NEPmight have better met demand through syringe distribution rather than exchange and that “ineffect, clean syringes [were] being denied to those who need[ed] them most” (Spittal et al.2004, p. 42; Wood et al., 2002a). Notably, despite a number of studies that have cited one-for-one exchange policies as problematic in constraining the availability of clean syringes(Heimer, Khoshnood, Biff, Guydish, & Junge, 1998; Kral, Anderson, Flynn, & Bluthenthal,2004; Schechter et al. 1999; Spittal et al. 2004; Wood et al., 2001), Wood et al. (2002b)found that neither ‘one-for-one-exchange’ nor ‘having no needles to exchange’ emerged as acommon issue for the 19% (69) of NEP attendees in their sample who reported experiencingdifficulty in accessing syringes. Additionally, Tyndall et al. (2002) found that Vancouver’srestrictive exchange policy did not significantly restrict the number of syringes obtained perNEP visit, in comparison to Montreal where such a policy had been rescinded. This suggeststhat other program deficiencies (operating hours, site location, etc.) may have played a moresignificant role in driving the problems with syringe access in this setting.Policing practicesIn addition to NEP policy concerns, Vancouver Police Department policies contributed toconstrained availability of sterile syringes in the DTES, unwillingness to carry sterilesyringes, and increased injection risk behaviours, such as syringe-sharing. Several studieshave examined the impact of police ‘crackdowns’ on IDUs (Kerr et al., 2005; Small et al.,2006; Wood et al., 2003a; Wood et al., 2003c; Wood et al., 2004). A crackdown is a periodof large-scale, intensive police activity targeting a particular illegal activity (Sherman,Hyshka et al. Page 8Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript1990). In the DTES, crackdowns have generally aimed to disrupt the open retail drug marketand interrupt drug use and drug use-related crime (Wood et al. 2004). However, existingevaluations indicate that rather than decrease illegal drug use, police crackdowns tend todisplace drug activity to neighbouring areas and thereby disrupt access to public healthprograms, including NEP (Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Best, Strang,Beswick, & Gossop, 2001; Small et al., 2006; Wood et al., 2003; Wood et al., 2004).Wood et al. (2004) examined VIDUS data from January – June 2003. Beginning in April2003, 50 additional officers were deployed in a DTES crackdown that resulted in more than236 trafficking charges laid against 162 individuals (p. 1551). Consistent with other studies(Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Best, Strang, Beswick, & Gossop, 2001;Shannon et al. 2008; Small et al., 2006; Wood et al., 2003), Wood et al. (2004) found thatthe police crackdown in the DTES resulted in the displacement of drug use to neighbouringareas (p.1554), and decreased attendance at local NEPs. Moreover, another study (Figure 3)found that a police operation was associated with a 27% reduction in NEP attendance in theDTES (Wood et al., 2003c).Additional ethnographic research undertaken has demonstrated that increased policepresence associated with crackdowns in Vancouver served to increase a number ofconditions and behaviours with potential to increase risk among IDUs, such as:unwillingness to carry sterile syringes (Small et al., 2006), increased borrowing and lendingof syringes (Kerr et al., 2005), improper syringe disposal (Small et al., 2006), being rushed/less cautious while injecting (Small et al., 2006), accidental syringe sharing (Small et al.,2006), and decreased access to health and social services (Wood et al. 2003a; Small et al.2006). This anecdote from Small et al.’s (2006) interviews with IDUs is but one example ofthe heightened injection risk scenarios associated with increased police presence“We were in the alley getting ready to fix. I was with my fixing partner, Tommy.I’m not sure if he has AIDS—but he is HIV+ for sure. I had just loaded the rig withmy dope and the water. Tommy had just finished fixing his when all of a sudden-boom! A cop car pulls around the corner. So I dropped my rig, well actually I hid itin the side of the dumpster where that hollow is—I put it in there. And then withoutme realizing it, Tommy hid his in the same place. So the cops stopped and jackedus up. They asked our names and questioned us about what we were doing. So afterthe jack up they left and we got back to business. I reached into the hiding spot andgrabbed my rig. What I thought was my rig. And I stuck it into my arm and realizedthere was no dope in it. It wasn’t my rig! In the confusion I ended up using his rigbecause we tried to hide them from the cops.” (p. 89)In addition to crackdowns, other police practices contributed to restricted availability ofsterile syringes and increased risky injecting amongst IDUs. Werb et al. (2008) reported onthe impact of discretionary policing practices whereby police confiscate illegal drugs andinjecting equipment in the absence of a formal arrest. In a sample of 465 active IDUs drawnfrom VIDUS, 130 participants (28%) reported being stopped, searched or detained by policewithout arrest within the previous six months, of which 51% had syringes confiscated.Among the participants who reported having syringes confiscated, 6% indicated that theyimmediately borrowed a used syringe after their encounter with police.In summary, the available evidence indicates that a number of policing practices restrictedaccess to sterile syringes and contributed to increased risky injection practices in Vancouver.These contextual factors were often rooted in the prioritization of public order over IDUhealth outcomes. This was apparent in the police department’s motivation for crackdowninitiatives and discretionary policing tactics. Additionally, NEP program deficiencies suchas restricted operating hours, service gaps, and point -for-point exchange/loaners were oftenHyshka et al. Page 9Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripta result of a desire to reduce public injection, disperse IDUs in the evening, and prevent theinappropriate disposal of syringes. This emphasis on public order objectives helps explainhow this particular HIV outbreak occurred in the presence of an established, high-volumeNEP program.EXPLAINING THE ASSOCIATION BETWEEN HIV SEROCONVERSION ANDNEP ATTENDANCE: PART IITen years after the original Strathdee et al. (1997) article, Wood and colleagues (2007) hadsufficient data on incident HIV infections in the VIDUS cohort to publish a research articlethat more fully unpacked the relationship between NEP attendance and HIV seroconversion.Building on Schechter et al. (1999), the authors examined data collected between May 1996to December 2004. Multivariate analyses of 1035 IDUs who were HIV negative at baselineindicated that daily NEP attendees, when compared to non-daily NEP attendees, were morelikely to: be female (OR = 1.8; 95% CI: 1.4–2.3), Aboriginal/American Indian (OR = 1.4;95% CI: 1.0–1.9), in unstable housing (OR = 2.2; 95% CI: 1.7–3.0), DTES residents (OR =2.8; 95% CI: 2.1–3.7), have unsuccessfully sought addiction treatment (OR = 1.8; 95% CI:1.3–2.4), be involved in sex work (OR = 2.4; 95% CI: 1.8–3.2), be daily heroin users (OR =3.3; 95% CI: 2.5–4.3), be daily cocaine users (OR = 4.7; 95% CI: 3.6–6.3), and be “shootinggallery” users (OR = 1.8; 95% CI: 1.4–2.4) (all p < 0.05). Additionally, daily NEP attendeeswere less likely to be receiving methadone (OR = 0.3; 95% CI: 0.2–0.5). These findingssupported earlier research demonstrating that frequent NEP attendees had higher riskprofiles, which made them more vulnerable to contracting HIV (Schechter et al. 1999).By December 2004, 133 of the 1035 HIV negative at baseline participants seroconverted.Using Cox proportional hazard regression analysis, Wood et al. (2007) examined the time toHIV infection for daily vs. non -daily NEP attendance amongst seroconverters. Unadjusted,the relative hazard of HIV seroconversion for daily vs. non -daily NEP attendees was 2.69(95% CI: 1.89–3.83; p < 0.001) (Figure 4). However, after adjusting for daily cocaine use,the relative hazard changed to 1.89 (95% CI: 1.11–2.38; p = 0.013). The authors thenadjusted for variables significantly associated with HIV seroconversion (sex, ethnicity,unstable housing, DTES residency, syringe borrowing, requiring help injection, binge druguse, cocaine injection, “shooting gallery” attendance, sex trade involvement, and having anHIV-infected sex partner) and the relative hazard of HIV seroconversion for daily versusnon -daily needle exchange attendance dropped to 1.41 (95% CI, 0.95–2.09; p = .088)(Figure 5). The authors concluded that differential HIV incidence rates between daily andnon -daily NEP attendees could be explained by the higher risk profiles of the former.Despite the observational nature of Wood et al.’s (2007) study, their findings help counterpersistent misinformation and controversy around NEPs that has been fuelled by research inVancouver and elsewhere. Their results also further reinforce the idea that both individualand contextual factors played a major role in Vancouver’s HIV/AIDS outbreak.PUTTING RESEARCH EVIDENCE INTO POLICY AND PRACTICE: CHANGESTO VANCOUVER’S NEPAside from countering negative beliefs about NEPs, the epidemiological and ethnographicresearch reviewed above has also been used to inform policy and program changes to theway needle exchanges operate in the city of Vancouver. Although the provincial governmenthas not always adequately supported Vancouver’s NEP, between 2000 and 2002 and inconsultation with the VIDUS investigators, they began a positive shift in NEP focus towardsdistribution rather than exchange (Kerr et al., 2010; Small et al., 2010). This shift echoedreforms which occurred in Montreal after 1997 (Bourgois & Bruneau, 2000; Hankins 1998;Hyshka et al. Page 10Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptTyndall et al., 2002) and was achieved through a number of programmatic changesincluding: 1) removing NEP administration from DEYAS’ purview and placing it under thelocal health authority (Vancouver Coastal Health); 2) separating the syringe distribution andcollection functions; 3) decentralizing NEP services by increasing distribution sites; 4)diversifying syringe distribution methods (e.g. using foot patrols, SROs, etc.); and 5)removing all syringe distribution limits (British Columbia Centre for Disease Control, 2003;Kerr et al.2010; Spittal, et al. 2004).The province also facilitated the involvement of a number of innovative, peer-run NEPservices designed to access especially hard -to-reach IDU populations. One such programwas the VANDU Alley Patrol needle exchange program. Here, volunteers patrolled thealleys and other public places in pairs, distributing sterile syringes, providing harm reductioneducation to IDUs, and collecting used syringes (Hayashi et al., 2010). Although thevolunteers faced many challenges, including locating IDUs displaced by police activity, theprogram ran until 2005 (a similar peer -driven program picked up where it left off). A recentevaluation of the VANDU Alley Patrol program found that it “succeeded in reaching a sub-population of local IDUs at a high risk of HIV infection” even during police crackdownswhen drug use and IDUs were displaced into neighbouring areas (Hayashi et al., 2010, p.420). Specifically, individuals who received syringes from the Alley Patrol program werelikely to be unstably housed (AOR = 1.83; 95% CI: 1.39–2.40), frequent heroin injectors(AOR = 1.31; 95% CI: 1.01–1.70), frequent cocaine injectors (AOR = 1.34, 95% CI: 1.03–1.73), injecting in public (AOR = 3.07, 95% CI: 2.32 – 4.06), and less likely to reuse needles(AOR = 0.65, 95% CI: 0.46–0.92).Examining the impact of Vancouver’s NEP policy changesTo assess the effects of Vancouver’s new NEP policy on HIV risk behaviour and HIVincidence, Kerr et al. (2010) looked at rates of syringe borrowing/lending, and HIVincidence amongst a prospective cohort of 1228 IDUs. Using a multivariate generalizedestimating equations and Cox regression (Figure 6), they found that the period following theNEP policy changes was independently associated with a larger than 40% reduction insyringe borrowing [adjusted OR = 0.57; 95% CI = 0.49, 0.65] and lending [AOR = 0.52;95% CI = 0.45, 0.60] and declining HIV incidence [adjusted hazard ratio = 0.13; 95%CI=0.06, 0.31]. Moreover they found an increase in participants reported use of non-traditional NEP sources, suggesting that the Vancouver policy changes were resulting inimproved access to sterile syringes for IDUs.It should be noted that the absolute number of syringes distributed by the NEP appears tohave declined after the new policy changes took effect. The Vancouver NEP distributedapproximately 3.3 million syringes in 2001, 2.7 million syringes in 2002, 2 million syringesin 2003, 2.2 million syringes in 2004, and 1.9 million in 2005. However, the number ofsyringes exchanged before 2003 should not be compared to the number of syringesdistributed in 2003 or later, because the change in service providers (from DEYAS toVancouver Coastal Health) resulted in a change in data collection methods (Buxton, 2005).Moreover, a decrease in syringe distribution could be attributable to other factors whichcaused a decrease in injection drug use, such as age effects, or a shift away from powdercocaine injecting towards crack cocaine smoking (Gilbert, Buxton and Tupper, 2011).CONCLUSIONOur review of 15 years of research on needle exchange in Vancouver’s DTES clarifies anumber of misconceptions regarding the HIV epidemic among IDUs and the NEP in thissetting. Specifically it demonstrates that the observed relationship between frequent NEPattendance and HIV positive status is best understood as reflecting the higher risk profile ofHyshka et al. Page 11Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptthose accessing NEP services. IDUs who used Vancouver’s NEP during the late 1990s andearly 2000s were not at increased risk of contracting HIV/AIDS because of their NEPattendance. Rather, the IDUs who frequented the NEP were more likely to contract HIV/AIDS because of several characteristics, including frequent cocaine injection, whichcomprised a vulnerable risk profile.If the NEP did not produce iatrogenic effects, why was it unable to prevent the HIV/AIDSoutbreak? Answering this question definitively is difficult because unobserved confoundingfactors might explain the epidemic patterns that were observed. However this reviewsuggests that a host of contextual factors, including NEP operating hours, NEP service gaps,one-for-one exchange policies, a lack of prevention and treatment services, as well as policecrackdowns, closing of peer-run services, and other practices exacerbated the spread of HIV/AIDS in the DTES by significantly constraining the availability of sterile syringes andpromoting HIV risk behaviours such as syringe sharing. These challenges help explain whythe NEP alone was unable to prevent the HIV/AIDS outbreak.The response to these NEP challenges highlights a number of lessons, specific toVancouver, which can be taken from our review. First, an emphasis on reducing publicdisorder rather than distributing sterile syringes to IDUs who needed them was ill-advised.This focus resulted in a number of NEP policy and program features that constrained theavailability of sterile syringes in the DTES and motivated police practices that aimed toreduce drug use and public disorder without considering the potential impacts on publichealth. Second, shifting the focus of the NEP away from public order objectives byseparating NEP distribution and exchange functions, and removing all distribution limitsimproved access to sterile syringes in the DTES. Third, further decentralizing NEP sites,promoting peer-run initiatives, and diversifying syringe distribution methods helped theNEP better access hard-to-reach populations of IDU with particularly high risk-profiles.Lastly, the involvement of people who use drugs in the delivery of NEPs can help extend thereach of conventional NEPs and thereby ensure that those at highest risk of HIV infectionare being reached.There are also several more universal lessons regarding NEP gleaned from Vancouver’sexperience. First, program staff, researchers and policymakers should pay considerableattention to local context when designing and implementing NEP. Understanding andanticipating how internal aspects (program policies, logistics, etc.) and external aspects(local IDU population characteristics, policing practices, drug markets, etc.) impact the NEPis crucial for success. Second, ongoing evaluation and monitoring of the NEP and itschanging context using both quantitative and qualitative methods can identify factors thatconstrain and promote sterile syringe access. Third, those assessing the merits of an NEP asa public health intervention need to consider how implementation and local environmentfeatures impact on the program’s ability to reach IDU and prevent the spread of HIV.Thus, jurisdictions looking to expand NEPs to scale as a means to curtail HIV transmissionassociated with injection drug use might benefit from reviewing Vancouver’s experiencewith NEP from the early days to its eventual expansion and overhaul. Irrespective of theirundue controversy, NEPs represent an important tool in an arsenal of HIV prevention, drugtreatment, and health services, and have the potential to drastically reduce HIV incidence ifimplemented effectively.AcknowledgmentsThe authors thank Will Small, Tricia Collingham, Deborah Graham and Peter Vann for their research assistance.Hyshka et al. Page 12Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptReferencesAitken C, Moore D, Higgs P, Kelsall J, Kerger M. The impact of a police crackdown on a street drugscene: evidence from the street. International Journal of Drug Policy. 2002; 13:189–98.Archibald CP, Ofner M, Strathdee SA, Patrick DM, Sutherland D, Rekart ML, Schechter MR,O’Shaughnessy MV. Factors associated with frequent needle exchange program attendance ininjection drug users in Vancouver, Canada. 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[Accessed on June 24 2011] UNAIDS report on the global AIDS epidemic. 2010. fromhttp://www.unaids.org.login.ezproxy.library.ualberta.ca/globalreport/global_report.htm#Urban Health Research Initiative. [Accessed March 7 2012] Drug situation in Vancouver. 2009. fromhttp://www.cfenet.ubc.ca/publications/drug-situation-vancouver-uhri-reportVlahov D, Des Jarlais DC, Goosby E, Hollinger PC, Lurie PG, Shriver MD, Strathdee SA. NeedleExchange Programs for the Prevention of Human Immunodeficiency Virus Infection:Epidemiology and Policy. American Journal of Epidemiology. 2001; 154(12):S70–S77.10.1093/aje/154.12.S70 [PubMed: 11744532]Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: acomprehensive review of the international evidence. Substance Use & Misuse. 2006; 41(6–7):777–813.10.1080/10826080600669579 [PubMed: 16809167]Werb D, Wood E, Small W, Strathdee S, Li K, Montaner J, Kerr T. Effects of police confiscation ofillicit drugs and syringes among injection drug users in Vancouver. International Journal of DrugPolicy. 2008; 19(4):332–338. [PubMed: 17900888]Wood E, Kerr T. What do you do when you hit rock bottom? Responding to drugs in the city ofVancouver. International Journal of Drug Policy. 2006a; 17(2):55–60.10.1016/j.drugpo.2005.12.007Wood E, Kerr T. Needle exchange and the HIV outbreak among injection drug users in Vancouver,Canada. Substance Use & Misuse. 2006b; 41(6–7):841–843.10.1080/10826080600669595[PubMed: 16809174]Wood E, Kerr T, Spittal PM, Small W, Tyndall MW, O’Shaughnessy MV, Schechter MT. An ExternalEvaluation of a Peer-Run “Unsanctioned” Syringe Exchange Program. Journal of Urban Health.2003a; 80(3):455–464.10.1093/jurban/jtg052 [PubMed: 12930883]Wood E, Kerr T, Spittal PM, Tyndall MW, O’Shaughnessy MV, Schechter MT. The health care andfiscal costs of the illicit drug use epidemic: The impact of conventional drug control strategies, andthe potential of a comprehensive approach. BC Medical Journal. 2003b; 45(3)Wood E, Kerr T, Small W, Jones J, Schechter MT, Tyndall MW. The impact of police presence onaccess to needle exchange programs. Journal of Acquired Immune Deficiency Syndorme. 2003c;34(1):116–117.Wood E, Spittal PM, Small W, Kerr T, Li K, Hogg RS, Tyndall MW, Montaner JSG, Schechter MT.Displacement of Canada’s larget public illicit drug market in response to a police crackdown.Canadian Medical Association Journal. 2004; 170(10):1551–1556. [PubMed: 15136548]Wood, Evan; Lloyd-Smith, E.; Li, K.; Strathdee, SA.; Small, W.; Tyndall, MW.; Montaner, JSG., et al.Frequent needle exchange use and HIV incidence in Vancouver, Canada. The American Journal ofMedicine. 2007; 120(2):172–179.10.1016/j.amjmed.2006.02.030 [PubMed: 17275459]Hyshka et al. Page 16Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptWood E, Tyndall MW, Spittal P, Li K, O’Shaughnessy M, Schechter MT. Perdictors of persistenthigh-risk syringe sharing during an ongoing HIV epidemic. Canadian Journal of Infectiousdiseases. 2001; 12(suppl B)Wood E, Tyndall MW, Spittal PM, Li K, Hogg RS, Montaner JSG, O’Shaughnessy MV, SchechterMT. Factors associated with persistent high-risk syringe sharing in the presence of an establishedneedle exchange programme. AIDS. 2002a; 16(6):941–943. [PubMed: 11919503]Wood E, Tyndall MW, Spittal PM, Li K, Hogg RS, O’Shaughnessy MV, Schechter MT. Needleexchange and difficulty with needle access during an ongoing HIV epidemic. International Journalof Drug Policy. 2002b; 13(2):95–102.10.1016/S0955-3959(02)00008-7World Health Organization, United Nations Office on Drugs Crime & Joint United NationsProgramme on HIV/AIDS. [Accessed on August 23 2011 ] WHO, UNODC, UNAIDS technicalguide for countries to set targets for universal access to HIV prevention, treatment and care forinjecting drug users. 2009. fromhttp://www.unodc.org/documents/hivaids/idu_target_setting_guide.pdfHyshka et al. Page 17Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 1.Figure 1 (a+b). Frequencies of responses to the question regarding why participants haddifficulty accessing sterile needles among the 69 participants who acquired most of theirneedles from the fixed site exchange (1a) or from the vans (1b). Reprinted from Wood et al.(2002b).Hyshka et al. Page 18Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 2.the VANDU needle exchange table at the corner of Main and Hastings Streets. Reprintedfrom Kerr et al. 2006.Hyshka et al. Page 19Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 3.Average number of sterile syringes providing during each 4-week period to and afteroperation 24/7. Reprinted from Wood et al. (2003c).Hyshka et al. Page 20Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 4.The Kaplan-Meier cumulative HIV incidence rate among injection drug users stratified bydaily NEP use and restricted to those that did and did not report daily cocaine injection atbaseline. Reprinted from Wood et al. 2007.Hyshka et al. Page 21Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 5.Hazard ratios and 95% CI for HIV infection associated with daily NEP use after thestepwise inclusion of potential confounders. Reprinted from Wood et al. (2007).Hyshka et al. Page 22Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 6.Proportion of VIDUS participants reporting (a) syringe borrowing and (b) syringe lending:Vancouver, British Columbia, 1998–2003. Reprinted from Kerr et al. 2010.Hyshka et al. Page 23Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptHyshka et al. Page 24Table 1Final multivariate logistic regression model predictors of HIV-positive serostatus at baseline among injectingdrug users (IDU) in Vancouver. Reprinted from Strathdee et al. 1997Variable Adjusted odds ratio (95% CI) PUnstable housing* 1.61 (1.15–2.98) 0.005Education (< high school) 1.79(1.14–2.82) 0.006Commercial sex* 1.66(1.18–2.35) 0.008Ever used borrowed needles 1.49 (1.04–2.14) 0.03Inject with others* 1.62 (1.13–2.32) 0.008Established injector† 2.24 (1.34–3.74) 0.002Frequent NEP* attendance (more than once per week) 1.68(1.13–2.5) 0.011*Based on previous 6 months.†First injection >2 years previously.NEP, Needle exchange programme.Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptHyshka et al. Page 25Table 2Comparison of frequent versus infrequent attendees at the Vancouver NEP with respect to risk behaviourprofile at the baseline visit and follow -up duration odds ratio Kaplan-Meier HIV Incidence curves fromenrolment to 15 months for frequent and infrequent NEP attendees. Reprinted from Schechter et al. (1999).Variable Infrequent attendee (n = 289) Frequent attendee (n = 405)Median age (years) 37 35Unstable housing 188 (65%) 346 (85%)Living in a hotel 144(50%) 272 (68%)DTES as main injecting site 183 (63%) 311 (77%)Inject four or more times per day 42 (14%) 171 (42%)Inject heroin at least once per day 69 (24%) 205 (51%)Inject cocaine at least once per day 62 (22%) 249 (62%)Injecting in ‘shooting galleries’ 66 (23%) 170 (42%)Incarceration in past 6 months 67 (23%) 154 (38%)Involved in the sex trade 47 (16%) 109 (27%)Any illegal income (excluding sex trade) 83 (29%) 176 (44%)Currently enrolled in methadone treatment 47 (16%) 34 (8%)Pharmacy as primary needle source 50 (17%) 6 (1%)Person-semesters of follow-up Prior to December 1996 149 (23%) 224 (25%) January 1997–June 1997 241 (38%) 345 (38%) After July 1997 248 (39%) 330 (37%)*Wilcoxon’s rank sum test.DTES, Downtown eastside.Int J Drug Policy. Author manuscript; available in PMC 2013 July 01.

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