The Most Marginalized Population? Harm Reduction, Prevention and Care among Injection Drug Users in California

1. The Most Marginalized Population? Harm Reduction, Prevention and Care among Injection Drug Users in California Shanna Livermore, Alessandra Ross, Carol Crump Jesse Lopez, Larry Barker USCA–November 10, 2007, Palm Springs CDPH Office of AIDS

2. Overview • What does the HIV epidemic look like among IDUs in California? • Youth • Women • Gay men/MSM • OA’s response • Research • Prevention • Care

3. Overview • What are the gaps in research and service delivery? • Youth • Women • Gay men/MSM • How should we address those gaps? • Opportunities • Barriers • Solutions

4. HIV Prevention & Care for IDUs: California’s Policy and Program Response Alessandra Ross, California Department of Public Health, Office of AIDS

5. U.S. Public Health Service Recommendation • For those who are unable to stop injecting drugs, a new, sterile syringe should be used for each injection.

6. Syringe Sharing • IDUs don’t have access to new, sterile syringes. • IDUs fear arrest and detainment for infractions of paraphernalia possession laws.

7. Syringe Access • Numerous points of access • Syringe Exchange Programs • Pharmacy Access • Physician Prescription • Satellite syringe exchange • In other countries… • Safe injection rooms • Vending machines

8. Policy “Elephants” • Federal funding ban on syringe exchange • State paraphernalia law • In California, local authorization is required

9. Expanding syringe access: solutions authorized by the Governor and Legislature • Pharmacy Syringe Sales (SB 1159) • Syringe Exchange Programs (AB 547)

10. SB 1159 Pharmacy Sale of Syringes • Allows adults to purchase and possess up to 10 syringes without a prescription in counties (or cities) that opt in; • Requires pharmacists to provide info on HCV, HIV and addiction services in the area and to sell or provide disposal containers; • Opt-in oriented: counties/cities may opt in, pharmacies may opt in. • Sunsets in 2010

11. Research • HIV infection rates among IDUs were twice as high in cities that required a prescription (n=36) for syringe purchase as compared to cities that did not (n=60).Holmberg, SD. (1996). Am J Public Health 86:642-654. • Accidental needle-sticks decreased among law enforcement officers by 66% post pharmacy access legislation in Connecticut. Groseclose SL et al. (1995). Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting Drug Users and Police Officers – Connecticut, 1992-93. JAIDS 10:73-81.

12. Needle sightings by sanitation workers decreased post implementation in New York. • Lawitts, S. (2002). J Am Pharm Assoc. 42(Supplement 2): S92-S93. • Accidental needle-sticks decreased among law enforcement officers by 66% post pharmacy access legislation in Connecticut. • Groseclose SL et al. (1995). Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting Drug Users and Police Officers – Connecticut, 1992-93. JAIDS 10:73-81.

14. Commonalities • Approval linked to disposal • Resistance comes from law enforcement, or political response to law enforcement • Different levels of persuasion necessary, different levels of preparedness for persuasion and comfort with the role • Syringe exchange is being revisited

15. California Office of AIDS Response • Technical assistance to LHJs • Outreach to pharmacists • Evaluation of the project • Report due to the Legislature in 2010

16. SEPs in California • 44 SEPs operate in the state • First SEP established in 1990 • Authorized by the State in 2000 • 2005 legislation simplified the procedure for authorization

18. Research • A study of 81 cities around the world compared HIV infection rates among IDUs in cities that had SEPs to cities that did not. • In the cities with SEPs, HIV infection rates decreased by an average of 5.8% per year. In the cities without SEPs, HIV infection rates increased by 5.9% per year. • Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection . Lancet 1997;349:1797-1800.

19. Results of Federal Studies on SEPs • No increase in drug use • No increase in new drug users • No evidence of increase in youth drug use • No change in frequency of illegal drug injection • No increase in crime • Arrest patterns not significantly different in areas served by SEP than in other areas of a jurisdiction • No magnet effect: SEP’s do not attract IDUs from other communities • No increase in syringe litter

20. Proven Effectiveness of SEPs “An impressive body of evidence suggests powerful effects from needle exchange programs... Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs." –National Institutes of Health

21. California Office of AIDS Response • Technical assistance to LHJs • Technical assistance to SEPs • Harm Reduction Coalition has a contract with OA • Funding for Syringe Exchange Programs • 2.25 million over 3 years

22. California Office of AIDS Response • For many IDUs, the SEP is their only contact with the public health system (Bluthenthal et al) • 76% of all of the basic screening and counseling services for SEP participants were provided by the SEPs • OA funds 10 programs to expand services

23. California Office of AIDS Response • The CALSEP study found that legally sanctioned SEPs are open an average of 18 hours per week. • Only 9% of the SEPs were found to provide sufficient access to syringes to maximize disease prevention (Bluthenthal et al., 2003). • OA funds programs to expand their reach

24. Satellite Syringe Exchange • Program funds 5 CBOs to provide SSEs with training and supplies to do their volunteer work more effectively.

25. Research • 75% of IDUs surveyed in CalSEP study reported participating in SE in previous six months (Lorvick et al., 2006) • Disease risk more common among SSEs (Lorvick, 2006) • Building SE into SEP structures can facilitate provision of HR supplies and information to IDUs who do not access SEPs (Snead et al., 2003) • Need for training of SSEs and IDUs (Anderson et al., 2003)

26. Demographic Findings • No real differences between SSEs and the IDUs they serve. • SSEs recruited were slightly more likely to be in the older age groups (50+)

27. Findings on Risks • SSEs may be more experienced IDUs • Began injecting at similar age, but appear to be little older (longer injecting life) • More likely to inject daily • More likely to inject others • Have used more drugs (“ever”) • Have injected more drugs • More report “ever” having an abscess • SSEs are more likely to use heroin while recipients are more likely to use speed/meth • SSEs engage in fewer risky practices • Except more report a history of abscesses

28. Big Future Question • Can we predict what pockets of high risk under-served IDUs will be reached by knowing the characteristics of SSEs? • Examples: • Do AA SSEs serve primarily AA IDUs? • Do meth-using SSEs serve primarily meth-using IDUs? • Do migrant or immigrant IDU serve same IDU population? • Do SSEs recruit same demographic clients? • Can’t answer yet because need more recipients (link SSE with each recipient)

29. Local Interventions

30. Evaluating Local Interventions (ELI) • Over 1000 interventions per year • Over 300 agencies reporting • Priority populations include IDU and several subcategories of IDU • IDU All • MSM/IDU • IDU MSF • IDU Female • IDU TG • Sex partners of IDU

31. Hepatitis C/HIV Testing Integration • Started as a pilot program in 2003 • As of January 1st, all CA counties funded to provide HCV testing and/or education and referrals

32. Care Branch Activities

33. Care Branch Activities • Positive Changes – harm reduction model integrated within HIV care setting • Bridge Project – peer outreach to HIV+ persons never in care or lost to care • Providing assistance to care sites in developing IDU-friendly policies and procedures

34. Care Site Staff Involvement • Active participation in local SEPs • Assistance to IDUs in overcoming barriers to entering/remaining in care • Training for medical staff on supporting active users in care • Outreach to care appropriate to specific user populations (e.g. heroin vs. meth users)

35. What it’s like… Working with IDUs in Care Settings

36. Discussion • What are the gaps in research and service delivery? • Youth • Women • Gay men/MSM • How should we address those gaps? • Opportunities • Barriers • Solutions

37. For More Information Contact: Alessandra Ross, Injection Drug Use Policy & Program Coordinator alessandra.ross@cdph.ca.gov Shanna Livermore HIV Prevention Research and Evaluation Section Shanna.livermore@cdph.ca.gov Carol Crump, Care Branch Carol.crump@cdph.ca.gov CDPH Office of AIDS