Research paper
The effect of on-site and outreach-based needle and syringe programs in people who inject drugs in Kermanshah, Iran

https://doi.org/10.1016/j.drugpo.2015.10.011Get rights and content

Abstract

Background

Needle and syringe programs (NSPs) are widely used to reduce harms associated with drug injecting. This study assessed the effect of facility-based (on-site services at drop-in centre) and outreach models of NSP on injection risk behaviours.

Methods

Self-reported data from 455 people who injected drugs (PWID) during 2014 in Kermanshah, Iran, were examined to measure demographic characteristics and risk behaviors. Self-reported and program data were also assessed to identify their main source of injection equipment. Participants were divided into three sub-groups: facility-based NSP users, outreach NSP users and non-users (comparison group). Coarsened exact matching was used to make the three groups statistically equivalent based on age, place of residence, education and income, and groups were compared regarding the proportion of borrowing or lending of syringes/cookers, reusing syringes and recent HIV testing.

Results

Overall, 76% of participants reported any NSP service use during the two months prior to interview. Only 23% (95%CI: 17–27) reported outreach NSP as their main source of syringes. Using facility-based NSP significantly decreased recent syringe borrowing (OR: 0.27, 95%CI: 0.10–0.70), recent syringe reuse (OR: 0.38, 95%CI: 0.23–0.68) and increased recent HIV testing (OR: 2.60, 95%CI: 1.48–4.56). Similar effects were observed among outreach NSP users; in addition, the outreach NSP model significantly reduced the chance of lending syringes (OR: 0.31, 95%CI: 0.15–0.60), compared to facility-based NSP (OR: 1.25, 95%CI: 0.74–2.17).

Conclusion

These findings suggest that the outreach NSP model is as effective as facility-based NSP in reducing injection risk behaviours and increasing the rate of HIV testing. Outreach NSP was even more effective than facility-based in reducing the lending of syringes to others. Scaling up outreach NSP is an effective intervention to further reduce transmission of HIV via needle sharing.

Introduction

UNAIDS/WHO has reported that about 270,000 people are living with HIV in the Middle East and North Africa (United Nations Office on Drugs and Crime, 2012). In Iran, HIV prevalence is low in the general population (less than 1%), while concentrated among people who inject drugs (PWID) (Haghdoost et al., 2011, Supreme Council of Nationwide Planning of HIV/AIDS Infection Prevention and Control, 2014). There are approximately 170,000–230,000 PWID in Iran, of whom, 15% are infected with HIV (Khajehkazemi et al., 2013, Nasirian et al., 2012). Over two-thirds of all newly identified HIV cases have been attributed to unsafe injection (Haghdoost et al., 2011, Mirahmadizadeh et al., 2009, Zamani et al., 2010). In 2002, in order to reduce the risk and harms associated with injection, needle and syringe programs (NSPs) were implemented in Iran. These services are delivered through drop-in centres (DIC) and by outreach teams to those PWID who may have difficulties accessing DIC (Eshrati et al., 2008, Mirahmadizadeh et al., 2009, Nissaramanesh et al., 2005) and are the main sources of needles and syrnges in Iran (Noroozi et al., 2015, Supreme Council of Nationwide Planning of HIV/AIDS Infection Prevention and Control, 2014).

NSP outreach is a community-based intervention, reaching PWID where they live, socialize, buy or inject drugs (Needle et al., 2005). The DICs and outreach NSP provide sterile needle and syringes, deliver training on safe injecting practices and overdose prevention and provide condoms and safe sex education (Mathers et al., 2010, Needle and Coyle, 1997). Safe injection kits distributed at each visit to an NSP, either at a DIC or via outreach, consist of 3–4 syringes, 3–4 extra needles, sterile water vials, and alcohol pads (Vazirian et al., 2005).

The effectiveness of the two models of NSP has yet to be evaluated in Iran. The costs of establishing and maintaining a new NSP site are much higher than adding-on an outreach-based NSP to an existing DIC or health facility. Some NSP sites are focused on on-site service delivery and are much less interested in providing outreach NSP. In part this is because of a lack of knowledge or belief in the effectiveness of outreach activities delivered in the community. The objective of this study was to evaluate and compare the effectiveness of the two NSP models  on-site services at DICs and outreach-based NSP  by examining the injecting risk behaviors of PWID in Kermanshah, an urban setting in southwestern part of Iran. Kermanshah was where the HIV epidemic first emerged in Iran and triggered the national response to HIV.

Section snippets

Methods

A cross-sectional study design was used. Participants were recruited from the community and NSP sites between September and December 2014. PWID from NSP sites were recruited by convenience sampling, and in the community through outreach and peer-referral. The outreach team regularly attended venues where PWID congregated and they also encouraged respondents to refer their peers to the study by distributing referral coupons. Study inclusion criteria were males aged over 18 years of age, who

Characteristics of study participants

A total of 455 men who injected drugs participated in the study. The characteristics of participants in pooled (unmatched) and matched sub-sample are presented in Table 1. The matched sample (n = 278) had a mean age ± standard deviation (SD) of 34.5 ± 8.6 (range 19–58) years. The majority of respondents were under 30 years old (54.6%). Also, 61.8% of participants had less than a high school education, 77.3% were single, 52.5% lived with their families, and 87.3% had a monthly income of less than

Discussion

We found that outreach NSP is as effective as facility-based outreach in decreasing the use of borrowed syringes, reusing one's own used syringes and increasing the likelihood of being tested for HIV. Based on the behaviour of service users, outreach NSP shows a more promising effect on reducing the lending of syringes than the facility-based NSP.

Effectiveness of needle/syringe programs in reducing equipment sharing among PWID has been shown in previous studies (Islam et al., 2008, Kral et al.,

Conflict of interests

AN and AH participated in the planning and implementation of harm reduction programs in Ministry of Health. All other authors had no conflicts of interest to be declared.

Funding source

This study was a PhD thesis at Shahid Beheshti University of Medical Sciences (SBMU) and funded by Substance Abuse Prevention and Treatment Office (SAPTO) of Mental Health, Social Health and Addiction Department (MeHSHAD) of Ministry of Health and Medical Education, Islamic Republic of Iran.

Authors’ contributions

HS and AM helped in study concept and design. MN and SH helped in analysis and interpretation of data. MN and AM drafted the manuscript. AN, PH, HS, SH, AH, AM helped in critical revision of the manuscript.

Acknowledgements

We gratefully thank all staff in the drop-in centre in Kermanshah who contributed in recruiting (Ms. Barkhordar) and data collection/interview (Mr. Azad and Mr. Amini). We profoundly thank people who were generous for their time and participated in the study. We also want to appreciate Mostafa Shokohi and other experts from Regional Knowledge Hub for HIV Surveillance who provided valuable inputs to the study protocol and the questionnaire.

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