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Widening Needle Distribution Cuts New HIV Cases in Baltimore
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9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris
Mark Mascolini
Broadening the needle distribution policy from a one-for-one exchange to as-needed distribution more than doubled the number of needles distributed monthly and cut new injection-related HIV infections by 2 per month in a 2012-2016 Baltimore analysis [1]. Johns Hopkins University researchers called the lowered HIV incidence "remarkable" in a city that has had a syringe service program for more than 2 decades.
Johns Hopkins investigators noted that 1 in 10 US HIV diagnoses involve people who inject drugs. By one estimate, 1 in 23 women and 1 in 36 men who inject drugs will get an HIV diagnosis in their lifetime. Syringe service programs aim to cut circulation of contaminated syringes. These programs also affect HIV incidence through education and referral to drug treatment programs. Syringe distribution policies have evolved over the years from a strict one-for-one exchange, to one-for-one or more, to needs-based distribution that provides as many syringes as a person needs. Analysis in cities across Europe, North America, and Asia found that HIV prevalence rose 5.9% yearly in 52 cities without syringe service programs, while falling 5.8% yearly in 29 cities with such programs.
Since 1994 the Baltimore City Health Department has run the sole syringe service program in the city. From January 2005 through September 2014, the program relied on a one-for-one exchange policy. From October 2014 onward, needs-based distribution has been in place. The Johns Hopkins team scrutinized the impact of this policy change on syringe distribution and HIV incidence among drug injectors.
The researchers collected syringe distribution data from April 2012 to November 2016 and divided the findings into monthly segments. They forecast the number of syringes that would have been expected to be distributed in the 26 months after the distribution policy change. Then they compared that estimate with observed monthly syringe distribution to assess the impact of the policy change.
The Hopkins investigators used Maryland Department of Health and Mental Hygiene data to determine monthly HIV incidence (the new-infection rate) in drug injectors and men who have sex with men (MSM). They created a monthly variable reflecting the sum of HIV infections attributable to injecting drugs plus 75% of infections attributable to both injecting drugs and sexual exposure in MSM. Finally, they compared the number of HIV infections in the 30 months before the syringe distribution policy change and in the 15 months after the change.
With these methods, the researchers calculated that the average number of syringes distributed monthly more than doubled from 44,410 before the distribution policy change to 96,187 after the change (P < 0.05). Total observed distributions after the policy change far exceeded the total forecast: 2,500,857 versus 1,786,174. Before the syringe distribution policy change, new injection-associated HIV infections averaged 5.2 per month (standard deviation 2.4). After the policy change, that rate dropped to 3.1 new HIV infections per month (standard deviation 1.8).
In a city with a syringe service program in place for more than two decades and already-low HIV incidence in drug injectors, the researchers concluded, a decrease of 2.1 new infections per month "is remarkable and a sign of progress toward the goal of eliminating HIV transmission among people who inject drugs entirely." They proposed that "needs-based syringe distribution policies should be considered best practice."
Reference
1. Allen S, Park J, Weir B, Holtgrave D, Sherman S. Effects of syringe distribution policy change at a syringe services program in Baltimore, MD: a forecast analysis. 9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris. Abstract TUAC0405.
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