programmes was associated with a lower incidence of HIV

Injecting Drug Use

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

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 people injecting drugs. Needle and syringe programmes incorporating additional harm reduction strategies have been highlighted as an approach that may influence HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of needle and syringe programmes 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 needle and syringe programmes settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger people who inject drugs and people who inject drugs with higher risk profiles. Two studies of interventions aimed at encouraging people who inject drugs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in needle and syringe programmes 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 people who inject drugs. Currently, it is difficult to draw conclusions on 'what works best' within the range of harm reduction services available to people who inject drugs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery needle and syringe programmes influence on effectiveness.

Editors’ note: This systematic review of existing studies found a paucity of evidence on the impact of organising needle-syringe programmes in different ways. The majority of evaluated programmes had combined needle-syringe distribution with other harm reduction strategies such as outreach, distribution of materials, and testing for blood borne viruses. The settings in which the services were offered varied. However, it was not possible to determine the effects of the additional components nor of different settings on drug injecting behaviours and the incidence and prevalence of blood borne viruses due to limitations in study design. The majority of studies were observational in nature and only four were randomised controlled trials. However, a variety of non-randomised designs for evaluation of public health interventions can be used to compare different service delivery models. It makes common sense that ‘one-stop shopping’ for HIV testing, needles/syringes, low threshold methadone, social support, and primary health care would best meet the needs of people who inject drugs. Key informant interviews, focus groups, and web surveys can be used to gather information on what service users think would most likely work for themselves and others. The principles of good participatory practice in biomedical HIV prevention trials of respect, transparency, integrity, and accountability are equally applicable to the design of services that will reduce risk and improve the health of people who inject drugs (cf UNAIDS/AVAC Good participatory practice guidelines in biomedical HIV