Commentary
Optimal provision of needle and syringe programmes for injecting drug users: A systematic review

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Abstract

The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among injecting drug users (IDUs). NSPs incorporating additional harm reduction strategies have been highlighted as an approach that may impact on HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of NSPs are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different NSP settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger IDUs and IDUs with higher risk profiles. Two studies of interventions aimed at encouraging IDUs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in NSPs was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among IDUs. Currently, it is difficult to draw conclusions on ‘what works best’ within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery NSPs impact on effectiveness.

Introduction

The emergence of HIV among drug using populations in the early 1980s prompted the introduction of programmes for distributing sterile injecting equipment, first in the Netherlands (van den Hoek, van Haastrecht, & Coutinho, 1989) and later in the United Kingdom (Advisory Council on the Misuse of Drugs, 1998) and Australia (Wodak, 1995). Since then, provision of these services has grown rapidly and needle and syringe programmes (NSPs) have become a central component of harm reduction strategies aimed at injecting drug users (IDUs) in many developed and developing countries (Bastos & Strathdee, 2000). The rapid introduction of NSPs has been credited with averting HIV epidemics in the UK (Stimson, 1995, Stimson, 1996) and Australia (Wodak & Lurie, 1997), where HIV infection among IDUs has remained relatively uncommon (HPACI, 2007, National Centre in HIV, 2008). However, the same cannot be said for the prevalence of hepatitis C (HCV) (Crofts et al., 1997, Health Protection Agency, 2007).

There is good evidence that NSPs reduce injection risk behaviours among IDUs (Committee on the Prevention of HIV, 2006, Gibson et al., 2001, Wodak and Cooney, 2004), however questions remain about the impact of NSPs on HIV and HCV incidence (Committee on the Prevention of HIV Infection among Injecting Drug Users in High-Risk Countries, 2006). In developed countries where NSPs have been widely established, such as the UK and Australia, varying models of service provision have been implemented and further research is needed to identify the most effective combination of programmes (Committee on the Prevention of HIV Infection among Injecting Drug Users in High-Risk Countries, 2006). In addition, in the UK for example, there is great variation in the extent and types of services provided (Huntington et al., 2006, NTASM, 2007) and information on the effectiveness of different approaches to the organisation and delivery of NSPs is required for evidence-based decision making.

Considering the need to develop guidance on the optimal provision of NSPs from the perspective of the UK National Health Service (NHS) a systematic review was undertaken to inform the development of evidence-based policy recommendations in England by the National Institute for Health and Clinical Excellence (NICE). The data presented here are drawn from an extensive review of the effectiveness and cost-effectiveness of NSPs for IDUs (Jones, Pickering, Sumnall, McVeigh, & Bellis, 2008).

The review sought to determine which approaches to the organisation and delivery of NSPs for IDUs are effective by addressing three research questions: (1) What types of NSPs are effective? (2) Which additional harm reduction services offered by NSPs are effective? and (3) Are NSPs delivered in parallel with, or alongside, opiate substitution therapy (OST) effective? In examining which types of NSPs were effective, the following organisational characteristics of services were considered: provider, site and setting of services; availability and accessibility; geographical setting; type of injecting equipment supplied; and return policies on used equipment.

Section snippets

Study selection and characteristics

Studies that addressed the research questions were eligible for inclusion if they examined the distribution of needles, syringes and other injecting equipment to populations of currently injecting drug users, including injectors of opiates, stimulants, and non-prescribed anabolic steroids and other performance and image enhancing drugs (PIEDs). Studies that examined the role of needle exchange in prisons were included in the original review (Jones et al., 2008) but are not reported on here.

Summary of studies identified

A total of 406 full text articles were screened for inclusion and of these, 16 studies were judged to be eligible for inclusion. The process of study selection is shown in Fig. 1 and a summary of the studies identified for inclusion is presented in Table 1. Eleven studies examined different types of NSPs, and based on the literature identified we were able to examine the effectiveness of different types of NSPs by site and setting (Fisher et al., 2003, Khoshnood et al., 2000, Masson et al., 2007

Discussion

This review examined the optimal provision of NSPs for IDUs in terms of different types of NSPs, and the additional harm reduction services that may be delivered alongside the distribution of injecting equipment, including the combination with OST. Sixteen studies were identified that addressed the research questions of interest. Eight studies, including two RCTs, examined the effects of setting on injection risk behaviours, and three cross-sectional studies examined the impact of different

Conclusions

This review has identified that there is a paucity of evidence with regards to different approaches to organisation and delivery of NSPs. Further studies are required which have a stated aim of evaluating how setting and the additional services provided at NSPs impact on effectiveness. These studies should consider how the diversity of populations attending NSPs and the influence of social, organisational and political context impact on effectiveness.

Currently, it is difficult to draw

Conflict of interest statement

None to declare.

Acknowledgements

This review was funded by the UK National Institute for Health and Clinical Excellence (NICE) for the purposes of informing public health guidance. The interpretation, analysis and views expressed are those of the authors and not necessarily those of NICE. We would like to thank the information staff at the Support Unit for Research Evidence at the University of Cardiff for developing and executing the search strategies for the review.

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