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Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.

Needle-syringe programs (NSP) have been effective in reducing HIV and hepatitis C (HCV) infection among people who inject drugs (PWID). Achieving sustainable reductions in these blood-borne infections requires addressing structural factors so PWID can legally access NSP services. Systematic literature searches collected information on NSP coverage and changes in HIV or HCV infection prevalence or incidence at the population level. Included studies had to document biomarkers (HIV or HCV) coupled with structural-level NSP, defined by a minimum 50 % coverage of PWID and distribution of 10 or more needles/syringe per PWID per year. Fifteen studies reported structural-level NSP and changes in HIV or HCV infection prevalence/incidence. Nine reported decreases in HIV prevalence, six in HCV infection prevalence, and three reported decreases in HIV incidence. The results support NSP as a structural-level intervention to reduce population-level infection and implementation of NSP for prevention and treatment of HIV and HCV infection.

An HIV outbreak in rural Indiana provides a cautionary tale. An aggressive, multipronged strategy is needed to prevent similar outbreaks, and it requires permanently lifting the ban on using federal funds to support needle-exchange programs. Many observers were surprised when Indiana Governor Mike Pence issued an executive order on March 26, 2015, declaring a public health emergency after a rapidly escalating outbreak of human immunodeficiency virus (HIV) was identified in Scott County, a rural region on the Kentucky border. 1 Others, however, had seen it coming. Over the years, a growing number of young people in Scott County — like those in surrounding counties and states — had begun abusing opiates such as oxymorphone, an opioid analgesic prescribed by local medical providers, until a more tamper-resistant formulation and policy reform began limiting its abuse. Facing the . . .

The community-based AERLI intervention provided training and education to people who inject drugs (PWID) about HIV and HCV transmission risk reduction, with a focus on drug injecting practices, other injection-related complications, and access to HIV and HCV testing and care. We hypothesized that in such a population where HCV prevalence is very high and where few know their HCV serostatus, AERLI would lead to increased HCV testing. The national multisite intervention study ANRS-AERLI consisted in assessing the impact of an injection-centered face-to-face educational session offered in volunteer harm reduction (HR) centers (\"with intervention\") compared with standard HR centers (\"without intervention\"). The study included 271 PWID interviewed on three occasions: enrolment, 6 and 12 months. Participants in the intervention group received at least one face-to-face educational session during the first 6 months. The primary outcome of this analysis was reporting to have been tested for HCV during the previous 6 months. Statistical analyses used a two-step Heckman approach to account for bias arising from the non-randomized clustering design. This approach identified factors associated with HCV testing during the previous 6 months. Of the 271 participants, 127 and 144 were enrolled in the control and intervention groups, respectively. Of the latter, 113 received at least one educational session. For the present analysis, we selected 114 and 88 participants eligible for HCV testing in the control and intervention groups, respectively. In the intervention group, 44% of participants reported having being tested for HCV during the previous 6 months at enrolment and 85% at 6 months or 12 months. In the control group, these percentages were 51% at enrolment and 78% at 12 months. Multivariable analyses showed that participants who received at least one educational session during follow-up were more likely to report HCV testing, compared with those who did not receive any intervention (95%[CI] = 4.13[1.03;16.60]). The educational intervention AERLI had already shown efficiency in reducing HCV at-risk practices and associated cutaneous complications and also seems to have a positive impact in increasing HCV testing in PWID.

Background In 2018–2019, Canada introduced a Prison Needle Exchange Program (PNEP) across nine federal facilities to mitigate the harms associated with drug injection among incarcerated people. However, program uptake has been limited. We explored the barriers and facilitators to improving PNEP services among key stakeholders in prison. Methods Stakeholders in nine federal prisons with active PNEP participated in focus groups using nominal group technique to achieve rapid consensus. Responses were generated, rank-ordered, and prioritized by each stakeholder group (correctional officers, healthcare workers, and people in prison). We identified the highest-ranking responses to questions about barriers and solutions to PNEP uptake and described them using the five levels of the Socioecological Model: individual, interpersonal, organizational, system, and structural/policy. Results Between September 2023 and February 2024, 34 focus groups were conducted with 215 participants ( n  = 51 correctional officers (24%); n  = 67 healthcare workers (31%); n  = 97 people in prison (45%)). Key barriers identified were lack of confidentiality and privacy across all levels and fear of repercussions from drug use and fear of being targeted at the individual-interpersonal levels. Preferred solutions included comprehensive education across all levels, and establishment of supervised/safe injection sites and external program management, potentially involving peers, at the structural level. Conclusions Several multi-level modifiable barriers to improving PNEP uptake in Canadian federal prisons were shared among key stakeholders. Structural changes to PNEP delivery, including supervised/safe injecting sites and peer-led programs, were proposed as solution-driven enablers to increasing PNEP uptake among incarcerated people who inject drugs. These data will inform Canadian efforts to expand PNEP provision.

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16–0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22–0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

Objectives. This study assessed the differential effects of face-to-face interviewing and audio-computer assisted self-interviewing (audio-CASI) on categories of questions. Methods. Syringe exchange program participants (n = 1417) completed face-to-face interviews or audio-CASI. The questionnaire was categorized into the groups “stigmatized behaviors,” “neutral behaviors,” and “psychological distress.” Interview modes were compared for questions from each category. Results. Audio-CASI elicited more frequent reporting of “stigmatized behaviors” than face-to-face interviews. Face-to-face interviewing elicited more frequent reporting of “psychological distress” than audio-CASI. Conclusions. Responding to potentially sensitive questions should not be seen as merely “providing data,” but rather as an activity with complex motivations. These motivations can include maintaining social respect, obtaining social support, and altruism. Ideally, procedures for collecting self-report data would maximize altruistic motivation while accommodating the other motives.

To examine whether increasing investment in needle/syringe exchange programs (NSPs) in the US would be cost-effective for HIV prevention, we modeled HIV incidence in hypothetical cases with higher NSP syringe supply than current levels, and estimated number of infections averted, cost per infection averted, treatment costs saved, and financial return on investment. We modified Pinkerton’s model, which was an adaptation of Kaplan’s simplified needle circulation theory model, to compare different syringe supply levels, account for syringes from non-NSP sources, and reflect reduction in syringe sharing and contamination. With an annual $10 to $50 million funding increase, 194–816 HIV infections would be averted (cost per infection averted $51,601–$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58–6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion.

Background In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. Methods We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. Results We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. Conclusions We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Amid an opioid epidemic and increasing HIV and hepatitis C virus (HCV) concerns, the Louisville Metro Department of Public Health and Wellness developed syringe exchange programming (SEP) to reduce HIV and HCV transmission, increase linkage to health care, and provide health education to clients in Louisville, Kentucky. We describe organizational, community, and policy factors contributing to SEP development. Approximately 8000 clients received SEP services from June 2015 to December 2016. Coalition building, timely advocacy, and media engagement are integral to successful SEP development and uptake.