Research paper
Trends in sources and sharing of needles among people who inject drugs, San Francisco, 2005–2012

https://doi.org/10.1016/j.drugpo.2015.08.013Get rights and content

Highlights

  • Due to HIV/HCV among PWID, San Francisco has expanded needle access programs.

  • Access to clean needles is a necessary, but not sufficient, response to decrease unsafe injection.

  • Expanding needle access parallels decreased risk in our data.

  • Fewer PWID are getting their needles from drug dealers and friends.

  • More PWID are receiving needles from pharmacies and needle exchanges.

  • Additional interventions in these programs would decrease HIV/HCV transmission.

Abstract

Background

Globally, people who inject drugs (PWID) are disproportionately at risk for HIV and HCV due to risky injection drug use behaviors, such as sharing used needles and injection kits. In response, San Francisco, one of several cities with a sizable PWID population that had quickly committed to stopping the spread of HIV/HCV, have expanded needle access, including in pharmacies and hospitals, in order to ensure that PWID inject with clean needles. However, there was no current research on whether each source of needles is equally associated with always using new sterile needles in San Francisco. Furthermore, no research in San Francisco had examined behavioral trends in needle-sharing practices, the relationship between PWID and their injection partners, and knowledge of their injection partners’ HIV or HCV status.

Methods

Therefore, we analyzed data from three cycles of the National HIV Behavioral Surveillance studies from 2005 to 2012 in San Francisco among PWID.

Results

The results from our analysis suggest that overall risky drug injection practices, such as injecting with used needles, sharing used cookers or water, and dividing drugs with a used syringe, among PWID in San Francisco has decreased from 2005 to 2012. An increasing proportion of PWID are injecting with their friend/acquaintance than with their sex partner. Also, a declining portion of PWID report knowing their last injection partner's HIV-positive or HCV-positive status. In terms of sources of needles, less PWID are getting their needles from friends and drug dealers while a greater proportion are using pharmacies and needle exchanges. However, pharmacies as a source of needles are negatively associated with always using new sterile needles.

Conclusion

From 2005 to 2012, overall high-risk injection behavior among PWID in SF has decreased including PWID that are injecting with others. However, our results suggest caution over the expansion of pharmacies as a source of needles in San Francisco and in similar cities due to their negative association with always using a new sterile needle. Since more PWID are injecting with their friend/acquaintance, interventions at needle access programs at pharmacies, hospitals, and needle exchanges should stress the potential to transmit HIV and HCV even in one-on-one sharing situations. Furthermore, since a decreasing percentage of PWID know about their injection partner's HIV/HCV status, such interventions should also highlight the importance of having a conversation about HIV and HCV status with one's injecting partner.

Introduction

People who inject drugs (PWID) are at high risk for HIV and HCV infection due to injection drug use behaviors such as sharing used syringes, needles, or other injection drug equipment (Kral et al., 2001, Strathdee et al., 2001). Consequently, there are 3 million or 13.1% of PWID infected with HIV and 10 million PWID infected with HCV globally (Grebely and Dore, 2014, World Drug Report 2014, 2014). In the United States, PWID accounted for around 8% of new HIV diagnosesin 2010 and around 50% of all cases of HCV (Centers for Disease Control and Prevention, 2012, Grebely and Dore, 2014, Spach, 2014).

Globally, one of the main interventions that the research literature has shown to help prevent the spread of HIV and HCV among PWID is distributing clean needles (which from this point onwards refer to both the syringe and needle as they are distributed together) or exchanging them for used equipment with the goal that each injection is done with new, sterile equipment (Dutta et al., 2012, Turner et al., 2011). To help meet this goal, public health departments and other organizations in the United States have implemented 200 needle access programs in 34 states and expanded access to new clean needles through pharmacies, hospitals, and other locations without need of a prescription (Federal Funding for Syringe Services Programs: Saving Money, Promoting Public Safety, and Improving Public Health, 2013). Specifically, the city of San Francisco has officially been involved with needle access programs and a harm reduction model of care since 1992 and is constantly trying to expand access to clean needles in order to its population of 13,000–15,000 PWID (Knight, 2007, Seal, 2000). For example, pharmacies in San Francisco can now sell needles to people 18 years or older without a limit on the amount of needles given to each individual (Ross, 2014).

However, we do not know whether each source of needles in San Francisco (i.e. needle exchanges, pharmacies, hospitals, etc.) is equally associated with always using new sterile needles among PWID. Furthermore, no research had examined important, behavioral trends among PWID in San Francisco, such as the frequency of sharing needles and injection equipment, the kinds of relationships that PWID have with their injection partners (i.e. acquaintances or sexual partners), and whether injecting dyads know their partner's HIV or HCV status. The answers to these questions can help inform HIV/HCV prevention interventions while guiding policy concerning the expansion of needle access programs not only in San Francisco, but also in similar cities throughout the world with a significant PWID population and a vision for increasing legal access to sterile needles. Therefore, we analyzed data on injection drug use behavior and sources of needles from the three rounds of the National HIV Behavioral Surveillance (NHBS) surveys of PWID in San Francisco in 2005, 2009, and 2012.

Section snippets

Overall study design

The data for this analysis are from NHBS surveys conducted by the San Francisco Department of Public Health. The methods, sample characteristics, and use of preventive and health care services, including three indicators related to clean needle access and use have been previously published (Coffin, Jin, Huriaux, Mirzazadeh, & Raymond, 2014). The present report expands beyond the previous one to focus on details of access to clean needles, sharing of injection equipment, characteristics of

Recruitment

As previously reported, over the three rounds of the RDS surveys for NHBS in 2005, 2009, and 2012, the number of initial seeds varied from 7 to 16, the time to complete recruitment from 17 to 32 weeks, the mean number of waves from 1.7 to 7.9, recruits per wave from 35.3 to 81.4, and coupon return rate from 43.9% to 51.7% (Coffin et al., 2014). The 2005 survey round required the most seeds, took the longest time, had the fewest waves of recruitment, lowest number of recruits per wave, and

Discussion

Our study shows a shift among PWID in San Francisco in their risky injections practices, with whom they inject, and sources of needles from 2005 to 2012. Encouragingly, both sets of results about risky injection behaviors in the past year (i.e. “With how many people did you…” and “[Have you] ever used…”) show that there have been significant decreases in almost every risky injection behavior (besides sharing used cotton) including injecting with used needles, sharing used cookers and water, and

Conflict of interest

None.

Funding

The Centers for Disease Control and Prevention (CDC) funded the collection of data for the three NHBS rounds; the funder had no role in the analysis or interpretation of data, the writing of the report, or the decision to submit the manuscript for publication.

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