Preventing Medical Preventing Medical Complications Complications

of Injection Drug Useof Injection Drug Use

Keith Heinzerling, MD, MPH

UCLA Seminars in Addiction Psychiatry Course

August 11, 2005

Public Heath Burden of Public Heath Burden of Blood-borne Viral InfectionsBlood-borne Viral Infections

• Human immunodeficiency virus (HIV):– 850,000 to 950,000 Americans infected– 180,000 to 280,000 unaware of infection

• Hepatitis C virus (HCV):– 4 million Americans infected– Leading reason for liver transplant– HIV-HCV co-infection: higher mortality

Injection Drug Use: Important Injection Drug Use: Important Source of TransmissionSource of Transmission

• Sharing of contaminated drug injection equipment by injection drug users (IDUs) has resulted in:– 25% of cumulative AIDS cases before

2000 (CDC, 2003) – 20% of new HIV/AIDS diagnoses in 2000

(CDC, 2004)– 68% of HCV infections (Alter, 2002)

Prevalence of HIV and HCV Prevalence of HIV and HCV Among IDUs is HighAmong IDUs is High

• HIV seroprevalence among IDUs: – 2% to 30% (Monterroso, 2000)

• HCV seroprevalence among IDUs:– 66% to 93% in methadone patients– 27% to 41% in IDUs under age 30

• Average time to HCV seroconversion for IDUs is 3.4 years (Hagan, 2004)

Soft Tissue Infections (STIs): Soft Tissue Infections (STIs): Common Among IDUsCommon Among IDUs

• Prevalence (Binswanger, 2000):– 68% (lifetime), 32% (current)

• Risk factors (Murphy, 2001):– Syringe reuse, Skin popping, Speedball

• San Francisco General (CDC, 2001):– $10 million for inpatient and ER care

• California, 2000 (Heinzerling, 2005):– 4,152 hospital discharges for STIs

Preventing Complications WithPreventing Complications WithGood Injection Hygiene: Good Injection Hygiene:

www.cleanneedlesnow.orgwww.cleanneedlesnow.org

Courtesy of Kristen OchoaCourtesy of Kristen Ochoa

Use Sterile Water and a Clean Use Sterile Water and a Clean “Cooker” to Dissolve Drugs“Cooker” to Dissolve Drugs

Use Sterile “Cottons” to Use Sterile “Cottons” to Filter DrugsFilter Drugs

Find a Good VeinFind a Good Vein

Find a SAFE VeinFind a SAFE Vein

Missing or “Booting” Can Cause Missing or “Booting” Can Cause Abscesses or CellulitisAbscesses or Cellulitis

Sharing Cookers, Cottons, Water Sharing Cookers, Cottons, Water is More Common than Syringe is More Common than Syringe

Sharing (Source of HCV?)Sharing (Source of HCV?)

Increased HIV/HCV Risk: Increased HIV/HCV Risk: “Backloading”“Backloading”

Being Injected by Others: Being Injected by Others: Frequent Syringe Sharing and Frequent Syringe Sharing and

Exposure to BloodExposure to Blood

Syringe Exchange Programs: Syringe Exchange Programs: Sterile Syringes, Injection Equipment, and Sterile Syringes, Injection Equipment, and

Health Services for IDUsHealth Services for IDUs

History of Syringe Exchange History of Syringe Exchange Programs (SEP):Programs (SEP):

• 1984: First SEP in Amsterdam• 1988: First US SEP in Tacoma, WA• 1999: Surgeon General’s SEP Report• 2000: SEPs “legal” in California• 2002: 148 SEPs in 32 states exchanged 25

million syringes; “Bridge to Services for IDUs”- HIV testing at 72%, HCV testing at 43%, HBV vaccination at 36%

• 2005: 30 SEPs in California, 7 SEPs in Los Angeles- services available 6 days a week

SEPs: Reduced Risk Behaviors for HIV SEPs: Reduced Risk Behaviors for HIV and Abscesses but Maybe Not for HCVand Abscesses but Maybe Not for HCV• HIV: Meta-analysis (Ksobiech, 2003)– 47 studies from 1988-2001– SEP use significantly associated with lower

syringe sharing, lending, and borrowing

• STIs (Bluthenthal, 2004)– Syringe reuse lower for SEPs without caps on

number of syringes exchanged

• Effectiveness for HCV Unclear (Thorpe, 2005)– SEP use associated with reductions in syringe

sharing but not sharing of cookers

•Comprehensive Comprehensive approach is needed:approach is needed:

•Sterile syringes and condoms

•Injection and sexual risk reduction counseling

•Screening for HIV, HBV, HCV, STDs

•Substance abuse treatment

Unmet Need for Recommended Unmet Need for Recommended Preventive Health Services Preventive Health Services

Among Among Syringe Exchange Program Syringe Exchange Program

Clients in CaliforniaClients in CaliforniaKG Heinzerling, NM Flynn, AH Kral, RL Anderson, ML Gilbert, A Scott,

SM Asch, RN Bluthenthal

CDC R06/CCR918667UCLA / VA RWJ Clinical Scholars Program

Research QuestionsResearch Questions

• Are SEP clients receiving recommended preventive services from any source?

• What percent of preventive services are received from SEPs?

• What is the availability of HIV and HCV testing on-site at SEPs?

Research QuestionsResearch Questions

• What factors are associated with receipt of HIV and HCV testing by SEP clients?

– SEP on-site testing, use of primary care or drug treatment?

• What is the frequency of health care linkages among SEPs with different availability of on-site HIV/HCV testing?

Methods- SampleMethods- Sample

• Programs:– 23 SEPs throughout California– Two-thirds of California SEPs in 2003

• Clients:– Approximately 25 clients per SEP

recruited by SEP staff from March to September 2003

– 560 current injection drug users with at least one SEP visit in the last 30 days

Methods- Data CollectionMethods- Data Collection

• SEP Directors were interviewed about:– Availability of on-site HIV and HCV

testing– SEP structural and organizational

characteristics

• SEP Clients were interviewed about:– Demographics, medical history, risk

behavior– Receipt of preventive services- past 6

months

Results: SEPs in SampleResults: SEPs in Sample

SEP Client CharacteristicsSEP Client CharacteristicsDemographics

Age 43 years

Male 68%

White 51%

Homeless 51%

Heath Care

Uninsured 56%

Primary Care Visit 44%

Drug Treatment 25%

SEP Visits- 30 days 4.42

Risk Behavior

Unprotected Sex 57%

Syringe Sharing 27%

Percent of Eligible Clients Who Received Percent of Eligible Clients Who Received Each Service and Source of CareEach Service and Source of Care

0% 5% 10% 15% 20% 25% 30% 35%

Safer Sex Ed.

Drug Counseling

Overdose Prevent.

Safer Injection Ed.

STD test

HBV test

HCV test

HIV test

From SEP From Non-SEP

Percent of Eligible Clients Who Received Service

Availability of SEP On-site Availability of SEP On-site Testing ServicesTesting Services

Testing Services Available

SEPs (%)

None 4 (17%)

HIV Testing 4 (17%)

HIV + HCV Testing 15 (66%)

0% 5% 10% 15% 20% 25% 30% 35% 40%

HCV Testing

HIV Testing

HIV+HCV Test Avail. HIV Test Avail. None Available

HCV Test p=0.008

Percent of Eligible Clients Who Received Testing

HIV Test p=0.002

Percent of Clients Who Received HIV and Percent of Clients Who Received HIV and HCV Testing by Availability of SEP On-Site HCV Testing by Availability of SEP On-Site

Testing ServicesTesting Services

0% 5% 10% 15% 20% 25% 30% 35%

HCV Testing

HIV Testing

Primary Care NO Primary Care

HCV Test p=0.12

Percent of Eligible Clients Who Received Testing

HIV Test p=0.84

Percent of Clients Who Received HIV and Percent of Clients Who Received HIV and HCV Testing by Use of Primary CareHCV Testing by Use of Primary Care

0% 5% 10% 15% 20% 25% 30% 35% 40%

HCV Testing

HIV Testing

Drug Treatment NO Drug Treatment

HCV Test p=0.72

Percent of Eligible Clients Who Received Testing

HIV Test p=0.10

Percent of Clients Who Received HIV and Percent of Clients Who Received HIV and HCV Testing by Use of Drug TreatmentHCV Testing by Use of Drug Treatment

Logistic Regression Model Logistic Regression Model Predicting Receipt of HIV TestingPredicting Receipt of HIV Testing

Testing Available

OR 95% CI P Value

None Ref Ref Ref

HIV 1.73 0.39-7.72 0.475

HIV + HCV 3.74 1.02-13.77

0.047

Controlling for age, region, SEP visits, unprotected sex, and use of drug treatment.

Logistic Regression Model Logistic Regression Model Predicting Receipt of HCV TestingPredicting Receipt of HCV Testing

Testing Available

OR 95% CI P Value

None Ref Ref Ref

HIV 1.10 0.15-7.88 0.928

HIV + HCV 6.50 1.25-33.68

0.026

Controlling for age, race/ethnicity, homelessness, region, SEP visits, and use of primary care.

SEP-Health Care Linkages and SEP-Health Care Linkages and On-site Testing AvailabilityOn-site Testing Availability

Organization Type

None HIV HIV+HCV

Independent SEP

100% (4) 50%(2) 33% (5)

AIDS Service Organization

0% (0) 50%(2) 27% (4)

Drug Treatment Program

0% (0) 0% (0) 20% (3)

Clinic/Health Department

0% (0) 0% (0) 20% (3)

LimitationsLimitations

• Convenience sample limited to IDUs using SEPs

• Self-reports of utilization

• Observational design

ConclusionsConclusions• SEPs are often the only source

of preventive care for their IDU clients

• Primary care providers and drug treatment programs miss opportunities to test SEP clients for HIV and HCV

ConclusionsConclusions• Availability of on-site HIV and

HCV testing may be increased by formation of structural or organizational links between SEPs and health care providers

–Should drug treatment programs provide needle exchange?

Other Available InterventionsOther Available Interventions• Pharmacy syringe sales:

– Purchase up to 10 syringes without a prescription, disposal and prevention info available from pharmacist

– Approved by Los Angeles County Supervisors June 2005, implementation by October 2005

• Supervised Injection facilities:

– First in North America: Vancouver in 2003

– Decreases in injecting in public and publicly discarded syringes 12 weeks after facility opened (Wood E, 2004)

– Pilot supervised smoking facility underway

AcknowledgementsAcknowledgements

• Staff and Clients of California Syringe Exchange Programs

• UCLA / VA RWJ Clinical Scholars Program• CDC R06/CCR918667• RAND, UC San Francisco, UC Davis• Urban Health Study