2016 Syringe Exchange Program Evaluation Report

Transcription

1 2016 Syringe Exchange Program Evaluation Report Prepared by: Don C. Des Jarlais Ph.D, Stacy M. Lenze, Heather M. Lusk MSW, Joshua R. Holmes MPH For more information, contact: The CHOW Project 677 Ala Moana Blvd. #226 Honolulu, HI

2 Over Twenty Years of Syringe Exchange in Hawai'i The Hawai'i State Department of Health started a pilot syringe exchange project in 1989 in response to the growing Acquired Immunodeficiency Syndrome (AIDS) crisis. The project involved training ex-drug users and other individuals knowledgeable about the drug-using population to serve as peer educators for people who injected drugs and thus were at high risk for acquiring and/or transmitting Human Immunodeficiency Virus (HIV). In 1990, former Hawai'i Governor John Waihe e signed into law Act 280, enabling the Department of Health (DOH) to establish a two-year pilot Syringe Exchange Program (SEP). The first Hawai'i SEP site was operated out of the Rubber Room in Honolulu by members of the Life Foundation; the largest and oldest AIDS organization in the Pacific. Following the two-year pilot period, during which the SEP s safety and efficacy were assessed, the State Legislature created the Needle Exchange Program in Act 152 (1992), which was codified in chapter 325, Part VII, Hawai'i Revised Statutes (HRS). (See, Needle Exchange Program, section through , HRS). This legislation enabled the DOH to operate the SEP for as long as necessary to accomplish its intended purposes: preventing the transmission of HIV, hepatitis B (HBV), hepatitis C (HCV), and other blood-borne pathogens; and providing people who inject drugs (PWID) with referrals to appropriate health and social services. Section , HRS, requires the DOH to appoint an oversight committee to monitor the progress and effectiveness of the SEP and to examine available data compiled by the program. Section , HRS, requires the DOH to report annually to the oversight committee, including the number and demographics of participants, the impact of the program on HIV infection, an assessment of the cost-effectiveness of the program, the strengths and weaknesses of the program, the advisability of its continuation, and ways to improve the SEP. In 1993, the legislature named the Community Health Outreach Work Project (The CHOW Project) as the coordinating agency for the statewide SEP. By 1994, the CHOW Project extended the SEP services beyond O'ahu to the islands of Kaua'i, Maui, and Hawai'i island. The CHOW Project continues to operate the SEP and has expanded services to meet the growing needs of people who inject drugs in Hawai'i. In the SEP year 2016 (January 1 December 31) CHOW exchanged 1,020,286 syringes statewide, which is an almost 3,000% increase since 1993 when it exchanged only 35,365 syringes. The CHOW Project operates five mobile vans which cover each of Hawaii's counties and provides a variety of services beyond syringe exchange. Outreach workers attempt to establish contact and trust with the target population in an effort to encourage safer behaviors among PWID. Activities include conducting health education, offering HIV and HCV counseling, HIV and other testing, linkages to housing navigation and other services, as well as handing out harm reduction supplies including condoms, hygiene kits, health education materials, and pipe covers (used to prevent cuts and burns from smoking substances with a glass pipe). Currently, the Hawai'i statewide SEP is one of the larger programs in the United States and was the first program in the U.S. to be fully state-funded to offer coordinated services statewide, and to provide payment for drug treatment services for participants. SEP Operations Hawai'i's SEP began in a fixed location which provided the opportunity for the CHOW Project to offer comprehensive services to participants accessing the SEP. After the building was sold, CHOW relocated offices to a building that did not allow participants to access services onsite. The SEP is currently entirely run through mobile sites and Syringe Exchange Appointments (SEA) where outreach workers meet participants at locations convenient for the PWID. While this model provides flexibility, it limits the amount of services that may be provided on-site, including HIV and HCV counseling, testing The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 1

3 and referral (CTR), wound care, and other activities. The CHOW Project continues to seek a fixed site that would be appropriate for participants in Honolulu in order to provide more comprehensive services; Neighbor Island sites will continue to be run through the mobile vans. The downtown Honolulu mobile exchange has a regular schedule with the van parked in the same location five days a week, and most of the Neighbor Islands have a fixed schedule where the vans are parked at a location regularly in addition to SEA visits. During the research year the SEP began a collaborative relationship with the Hawai'i Island HIV/AIDS Foundation (HIHAF) in Kailua-Kona. HIHAF conducts syringe exchange out of their office on Palani Road. The SEP has seen a significant increase in the number of participants, especially youth participants, in Kona. Hawaiian Ocean View Estates (HOVE) continues to be served by the CHOW outreach worker from Hilo. From January 2016 to December 2016, the SEP operated from the following regular sites in addition to SEA: Island Exchange Site Area of Operation O'ahu Hawai'i CHOW O'ahu Mobile Exchange CHOW Downtown Mobile Exchange CHOW Hawai'i Mobile Exchange CHOW/HIHAF Kailua-Kona Fixed Site Island-wide Downtown Honolulu Island-wide Kailua-Kona Maui CHOW Maui Mobile Exchange Island-wide Kaua'i CHOW Kaua'i Mobile Exchange Island-wide As of May 2015, there were a total of 228 known SEPs operating in 35 states, the District of Columbia and Puerto Rico. 1 SEP sizes range from small (<10,000 syringes exchanged a year) to very large (>500,000 syringes exchanged per year) with only 21% falling in the category of very large. For SEP2016, the Hawai i SEP continued to be classified as a very large. Program Effectiveness The CHOW Project is dedicated to serving individuals, families, and communities adversely affected by drug use, especially PWID, through a participant-centered harm reduction approach. CHOW works to reduce drug-related harms such as, but not limited to, HIV, hepatitis B/C, and overdose. CHOW supports the optimal health and well-being of people affected by drug use throughout the State of Hawai'i. To ascertain the effectiveness of the SEP, it is important to look at cases of HIV and AIDS among PWID in Hawai'i and to compare this data with national HIV/AIDS surveillance. Historically, both national and local data has been available only for AIDS cases since HIV was not a reportable condition for the first two decades of the epidemic. This creates limitations because some individuals with HIV may take many years to progress to an AIDS diagnosis (if at all) especially in the age of The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 2

4 combination anti-retroviral therapy, and thus the picture created by looking at AIDS cases only may not reflect the current trends in HIV infection. Despite these limitations, AIDS data can help determine the epidemiology of HIV/AIDS especially when it comes to risk factors linked to acquisition of the disease. As of July 31, 2015, there have been 1,201,835 reported cases in the United States that met the AIDS diagnosis criteria established by the Centers for Disease Control and Prevention (CDC). 2 Since the identification of AIDS, 673,538 deaths have been attributed to this disease in the United States. These deaths represent 56% of all cases of AIDS. Approximately one third of all U.S. cases have been associated with injection drug use, either occurring among people who inject drugs (PWID), the sexual partners of PWID, or the children of PWID. In Hawai'i, only 15% of AIDS cases are related to solely injection drug use (IDU), with an additional 4% attributable to MSM/IDU. 3 This relatively low percentage, less than half the national average, can presumably be credited to the proactive efforts to implement early intervention HIV prevention programs, including the SEP, for PWID in Hawai'i. In alignment with the nationwide mandate, Hawai'i began reporting HIV cases by name in 2008, resulting in more accurate HIV data (including AIDS cases) and providing a more precise picture of those living with HIV in Hawai'i. Additionally, the data demonstrates CHOW s effectiveness in preventing new infections (incidence) of HIV among PWID. According to the Hawai'i Department of Health, the percentage of new HIV and AIDS diagnoses related to injection drug users is lower than the cumulative average mentioned above with four cases (8%) and five cases (7%) in 2014 and seven cases (15%) and six cases (6%) in 2015, respectively. New HIV cases in the MSM/IDU (men who have sex with men/injection drug user) population numbered five (7%) in 2014 and four (4%) in Another indication of the SEP s effectiveness in preventing HIV infection among PWID is detailed later in the report. Results of CHOW s HIV seroprevalence study in previous evaluations found a prevalence between 0.0% and 5.8% of HIV among CHOW s study cohort. These low numbers, coupled with the HIV/AIDS data above, is evidence that access to sterile syringes and other injectionrelated equipment is keeping the HIV prevalence low among PWID which also decreases the risk of HIV in their sexual partners and children. Not only has the HIV prevalence among PWID accessing the SEP continued to be low, having lower numbers of active PWID living with HIV decreases the risk for other PWID (and their partners) to become infected. Access to sterile syringes and other equipment decreases HIV-related risk behaviors, such as sharing used needles, but does not erase injection-related risk completely. Maintaining a low prevalence of HIV among PWID lowers their risk for HIV infection in the event they engage in high risk activities such as sharing equipment. 4 Secondary syringe exchange, also known as gatekeeping, is the practice of a participant exchanging syringes for someone other than themselves. With a large proportion of SEP s participants reporting gatekeeping for other individuals, this practice increases clean syringe access to PWID in Hawaii who may otherwise not have contact with the SEP, whether it be due to barriers around access or confidentiality, among other reasons. An unfortunate truth is that the effectiveness of syringe exchange services is often highlighted by the seroprevalence of populations who do not have access to clean syringes. In the spring of 2015, news sources reported an outbreak of HIV in a rural southeastern town in Indiana, with a majority of cases being linked to injection drug use and the sharing of injection drug equipment. As of May 2016, the Indiana State Department of Health has reported 217 confirmed HIV positives linked to this outbreak. 5 The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 3

5 National and local data on the prevalence of hepatitis C was not available for comparison but CHOW s hepatitis C seroprevalence data will be detailed later in this report. Injection Drug Use Behaviors Nationally the prevalence of injection drug usage among youth has remained steady over the last several years with 1.8%, or 1 in 50, public high school youth reporting that they have ever injected an illegal drug at least one time in Locally in Hawaii, 3.3% of public high school students reporting ever injecting illegal drugs in 2015, a statistically significant increase compared to national rates. 7 Certain sub-populations, such as sexual minorities, disproportionately report injection drug usage. Recent data from Hawai i State Department of Health s Sexual and Gender Minority Health Report show that almost 1 in 10 (8.9%) of LGB youth in public high school report having ever injected an illicit drug at least one time. 8 Limited data sources exist for adult prevalence of injection drug usage in Hawai i. State level surveillance, as well as monitoring at SEP, are important for identifying populations at risk and dveloping culturally appropriate and tailored services and interventions. Methods and Data Sources The timeframe for the evaluation report (the SEP year) is January 1, 2016 through December 31, 2016, which from here forward will be referred to as SEP2016. The CHOW Project collects data through a variety of sources and maintains four databases: the Daily Log database which captures CHOW services and participant demographics; the Survey database which compiles data from the annual survey results; the Participant Card database which collects basic demographic data about participants who have received a participant card; and the Seroprevalence databases which include HIV and HCV counseling and testing data. Data from these four sources are combined to create a picture of CHOW s services and the participants that access them. Daily Logs Data from the daily logs includes operational and demographic information collected by CHOW staff each time a participant exchanges syringes or accesses harm reduction supplies. This includes the number and type of syringes exchanged, the gender and ethnicity of the participant, and outreach activities such as condoms distribution. This database is the foundation for the data reported in the section on Syringe Exchange Program activity for the SEP year. Participant Card Log Every person who exchanges syringes with the SEP is offered a participant card which identifies that person as a participant with the program. Participants remain anonymous. A member of the outreach team creates a unique identifier for the participant and collects basic demographic data about the participant. The card has been well received as it also summarizes the law allowing participants to carry syringes to and from the exchange printed on the back ( The person bearing this card has registered with the CHOW Project, a statewide syringe exchange program funded by the Hawai'i Department of Health. This participant is carrying syringes to and from the exchange because it has been proven to prevent the transmission of HIV, hepatitis, and other blood-borne pathogens. Hawai'i Revised Statutes provides that exchanges under this program shall not constitute an offense for the participant. ). The The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 4

6 participant card has been reported to offer participants limited amnesty when they are stopped by police and allows them to keep syringes that they have in their possession. At the end of 2015 the outreach team also began collecting the participant card number of the people who exchange on the daily log (see above). This information allows the SEP to have an idea of how many unique individuals exchange in any given year. SEP2016 saw 1,085 unique participant cards. While this number does not include participants who refused a card, this is the first time that the SEP has been able to measure the number of individual participants served. Any time Participant Card data is listed below this refers specifically to these 1,085 individuals who exchanged in In-depth Participant Interviews Given the limitations of this data, and in order to obtain more detailed information regarding participants using the SEP, 100 research interviews were conducted in SEP2016 with a randomly selected group of participants. A sampling scheme was developed to choose participants at random at every site at various times of the day. These interviews included specific demographic, drug use, sexual behaviors and HIV/HCV risk data. The participants were paid a modest incentive for participating in these interviews which were conducted in all four counties. While names were not collected, unique identifiers were generated so that initial and follow-up interviews from the same participant could be linked. The data on demographic characteristics, drug use, and HIV/HCV risk behaviors in this 2016 report are based on survey interviews conducted during this SEP year. In order to obtain a better estimate of HIV and HCV prevalence among PWID accessing the SEP, CHOW included HIV and HCV antibody testing as a part of the annual evaluation. The HIV/HCV seroprevalences component of this study was incorporated and included in the SEP2016 survey. In SEP2016 the same 100 participants who were randomly selected to complete the survey were included in the HIV/HCV study. Participants were asked to contribute a small blood sample for the Clearview Complete HIV ½ Rapid HIV Antibody Test (Alere, Waltham, MA) to test for HIV antibodies and the Oraquick HCV Rapid Antibody Test (OraSure Technologies, Bethlehem, PA) to test for HCV antibodies. Participants were given the option to obtain their HIV/HCV status. To ensure confidentiality, results were coded with the same client ID used on the interview, and no names were linked with the result. Test results were recorded and stored with no identifying information. Participation was voluntary and participants were free to decline learning their HIV/HCV status at the time of testing. No participants declined to learn their status. Participants were also free to decline HIV/HCV testing as part of the research. No participants declined to participate in the research testing portion of the interview. Results The number of syringes exchanged statewide by the Hawai'i SEP in SEP2016 exceeded its program high by exchanging a total of 1,020,286 syringes, maintaining its status as a very large SEP for the seventh year in a row. The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 5

7 # of syringes Figure 1.Total Number of Syringes Exchanged Statewide, ,000, , , , , Year During SEP2016 there were a total of 11,120 participant visits; a 12% increase from the 9,960 visits observed in SEP2015. About half of these were seen in Kona, which saw an increase from 198 visits in 2015 to 836 visits in 2016, which is a 322% increase. This change is due to HIHAF participating with the SEP. Previously, participants in West Hawai i only had access to a SEP worker two days a month. The average number of syringes exchanged per visit on O'ahu decreased for the second year in a row, down from 85.8 syringes per visit in 2014 and 62.5 syringes per visit in 2015, to 53.0 syringes a visit in This may, in part, be explained by the increase in the number of visits to the O'ahu exchange. In the SEP2016, 68 out of the 100 participants interviewed reported gatekeeping. Comparatively, 1,840 of the 11,120 participants who visited the SEP in 2016 reported participating in secondary syringe exchange. These participants exchanged 516,925 syringes and provided clean syringes and injection drug equipment to an additional 6,671 people. Table 1. Number of participant exchange visits, first exchange visits, syringes exchanged, and average number of syringes exchanged by site during SEP2015 and SEP2016. Percents reflect column percentages. Exchange Site Visits/percent of total visits N (%) First visits/ percent of total visits N (%) Syringes exchanged N (%) Average # of syringes exchanged per visit N O'ahu 7,689 (77%) 8,591 (77%) 51 (<1%) 41 (<1%) 480,882 (51%) 455,422 (45%) The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 6

8 East Hawai i 1,027 (11%) 636 (6%) 23 (2%) 8 (1%) 176,329 (18%) 220,220 (22%) West Hawai i 198 (2%) 836 (8%) 48 (24%) 34 (4%) 99,842 (5%) 113,266 (11%) Maui 831 (8%) 690 (6%) 58 (7%) 31 (5%) 137,433 (14%) 159,114 (16%) Kaua'i 215 (2%) 367 (3%) 9 (5%) 19 (5%) 64,751 (12%) 72,264 (7%) Statewide 9,960 11, (1.9%) 133 (1.2%) 959,237 1,020, Participant Demographics Traditionally the SEP has been an aging population. Until 2008 the average age had increased yearly, then from 2009 through 2014 the average age decreased incrementally each year, due in part to the over sampling of youth participants. Then in 2015 the average age began to increase, with the average age of participants being 43.4 years. This trend continued in 2016 when the average age of the SEP participants was 44.1 years. Based on participant card data, 25% of all the participants who exchanged in 2016 were youth (defined as 30 years of age and under). Participants in this age cohort tend to be new to our community and may account for fluctuations in the overall age of SEP participants over time. In SEP2016, approximately three in five participants (59%) were male, which is similar to previous years. Similarly, participant card data indicates that 58% of the people who exchanged with the SEP in 2016 were male. In SEP2016, three transgender participants were interviewed. Eighteen transgender participants exchanged with the SEP in While this community makes up less than one percent of the SEP s overall population they report disproportionate risk. Further study is needed to assess for needs and gaps in the continuum of care specific to this community. SEP2016 participants come from diverse racial and ethnic backgrounds with the majority of participants identifying as Caucasian (38%) and almost a quarter (23%) identifying as Native Hawaiian/part Native Hawaiian. Participants who identified as Native Hawaiian/Part Native Hawaiians and Native Americans/Part Native American were categorized as Native Hawaiian or Native American regardless of other ethnic identification. This is in line with participant card data from 2016 where the majority of participants identified as Caucasian (48%) and Hawaiian (22%). The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 7

9 Figure 2 - SEP2016 Ethnicity Figure 3 SEP2016 Participant Card Ethnicity Hispanic, 3% African American, 3% Native American, 8% Pacific Islander, 0% Multiracial, 18% Hispanic, 2% African American, 1% Asian, 7% Native American, 5% Pacific Islander, 2% Multiracial, 13% Asian, 7% Hawaiian, 23% Caucasian, 38% Hawaiian, 22% Caucasian, 48% Housing continues to be problematic for many SEP participants. In SEP2016, only one in three (33%) participants reported living in houses or apartments that they rent or own (Figure 4). Of the remaining SEP participants, 22% reported being temporarily/unstably housed, meaning they were staying in shelters or in another person s home. While 45% of respondents reported living on the streets, 60% of respondents reported being homeless, even if they had some kind of shelter or housing. Figure 5 shows similar data based on the participant card database. Anecdotally, homeless participants are less likely to decline participation in the research due in part to the monetary incentive, which appears to be less of a draw to housed participants. Figure 4 SEP2016 Housing Figure 5 SEP2016 Participant Card Housing Temp/Unstable 22% Permanent 33% Temp/Unstable 21% Permanent 42% Homeless 45% Homeless 37% A disproportionate number of participants report being out of work or disabled and not able to work. In SEP2016, 37% of participants reported being out of work, a significant increase from 26% in SEP2015. Additionally, 41% of respondents reported being disabled in SEP2016. Psychological Conditions and Mental Health Services Utilizations Another challenge that many SEP participants face is mental illness (Figure 6). In SEP2016, three-fourths (75%) of participants reported having at least one psychological diagnosis in their life time. However, only 36% of these respondents were engaged in mental health treatment. The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 8

10 Figure 6. Psychological conditions of SEP Participants 60% 50% 40% 30% 20% 10% 0% Depression Anxiety/Panic Disorder PTSD Schizophrenia Bipolar Disorder ADHD Other Use of Emergency Services While 85% of SEP participants reported having some kind of health insurance, they utilized emergency services at much higher rates than the general public. According to a report put out by the CDC, roughly 1 in 5 (19.5%) adults between the ages of will visit an emergency room in a given year. 9 Among SEP participants, 4 out of 5 participants (80%) report visiting the emergency room in a given year. Moreover they will average 4.5 visits over a two year period. Eight participants reported visiting the emergency room more than ten times in the last two years. Of the eighty participants who reported accessing emergency room services in the two years prior to interview, only three of those participants reported visiting the ER for dope sickness/med-seeking. Infections, open wounds, and severe trauma (broken bones and vehicular accidents) were the most common reason for visiting the emergency room. Participants reported not having insurance at the time, unable to access primary care physician, and emergency circumstance as the primary reason that they accessed healthcare through the emergency room instead of through primary care services. Wound Care In January 2016, CHOW begin to offer acute wound care services in response to the growing and alarming number of clients that reported visiting the emergency department (ED) for wounds in the annual evaluation interviews. In SEP2016, thirty-eight percent of participants reported having one or more wounds (or open sores) that did not heal within a month. Sixty-six percent (66%) of these participants went to the emergency room to seek medical care for these wounds, and more than half of those were admitted to the hospital. For the calendar year 2016, 117 persons were seen at CHOW s wound care program for a total of 230 visits, averaging approximately two visits per patient. The estimated cost per patient was on average $92, which includes the nurse practitioner s (NP) time. An evaluation of the wound care pilot found that every nickel spent on wound care at CHOW was equivalent to one dollar spent at the emergency department. 10 CHOW s wound care program continues to treat clients with the aim to reduce ED usage, and increase client efficacy in self-care. The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 9

11 Hundreds Drug Use On average, SEP2016 participants reported engaging in injection drug use for 17.5 years and reported an average age of 26.6 years for their first time injecting drugs. This is up from SEP2015 in which participants reporting injecting for an average of 16.5 years. The SEP participants inject drugs very frequently. In SEP2016 they reported injecting on an average of 5.6 days per week (three participants reported injecting less than 4 times in a month), a decrease from 6.1 days a week in SEP2015. While the number of days participants inject has gone down, the number of injections per day when they do inject has remained the same. In SEP2016 participants reported an average of 2.9 injections a day, while in SEP2015 participants reported an average of 3.0 injections a day. The SEP participants would be at high risk for HIV infection if they did not have stabile access to sterile injection equipment given the frequency of their reported HIV risk behaviors. SEP2016 saw the continued decrease in heroin use, while maintaining the increase in uppers alone (Figure 7). This is consistent with the decrease in heroin use that the SEP has witnessed over the last several years. The increase in uppers alone (predominantly methamphetamine) is seen in both injection and non-injection use. Figure 7. SEP Participants Injection Drug Use Heroin 59% Uppers Alone 56% Other Narcotics 28% Uppers Mix 23% Heroin Other Narcotics Uppers Alone Uppers Mix SEP2016 participants reported being engaged in drug use outside of injection use at high rates (Figures 8 and 9). The most common non-injection drugs used were marijuana and uppers alone. The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 10

12 Method of administration was not asked. For many years SEP participants were mono-drug users, meaning they typically only used a single type of drug, rarely using anything else. More recent trends find that nearly all (94%) of SEP participants are now poly-drug users, meaning that participants are more likely to use any type of drug available. And, more importantly, SEP participants are using contraindicated drug combinations, which may have led to an increase in overdoses in our community. (See section on Overdose). Figure 8. SEP Participants Alcohol and Marijuana Use % % Alcohol Marijuana Figure 9. SEP Participants Non-injection Use % % 28% 9% Crack Cocaine Uppers Alone Downers Other Narcotics Drug-related Risk Behaviors of SEP Participants Despite exchanging 1,020,286 syringes and distributing nearly 25,000 cookers and 10 pounds of cotton pellets, the SEP2016 saw a startling increase in the number of participants who reported receptive and distributive sharing of syringes and injection equipment (see Table 2). Receptive sharing is The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 11

13 defined as having injected with a syringe or other injection equipment that had been used by someone else. Distributive sharing is defined as passing on used syringes or other injection equipment to other drug injectors. The sharing of cookers (used to heat and dissolve the drug before injecting) and cottons (used to filter the drug solution before injecting), is similar to the direct sharing of syringes. Sharing of cookers and cottons has not been proven to be an efficient method of transmitting HIV, but studies suggest that sharing cookers and cottons may also be instrumental in transmitting HCV. 11 Table 2. Receptive and Distributive Sharing of Injection Drug Equipment in 2015 and 2016 Receptive Syringe Receptive Cooker Receptive Cotton Distributive Syringe Distributive Cooker Distributive Cotton Total Female Under 30 (youth) HCV Positive *1 *2 *0 *1 *0 * *New HCV Positive at time of research test SEP participants have always reported a moderate amount of sharing behaviors, but 2016 saw the highest rates in evaluation history. Participants who reported receptive and distributive sharing were disproportionately homeless (70%) and were using a combination of highly contraindicated drugs (methamphetamine 69% and downers 50%). In SEP2016, 51% of participants who reported sharing syringes, indicated that this had occurred due to a lack of access to clean equipment. Anecdotally, most of these participants reported that their belongings had been stolen. Given the relatively low prevalence of HIV among the SEP participants, this moderate rate of distributive sharing is not likely to lead to new HIV infections. However, this distributive sharing is likely to generate new HCV infections among SEP participants (see Table 3 for HCV infections and risk factors). This is especially true that among the 26 participants that reported distributing their used syringe(s), 69% screened positive for HCV. Current available data suggest that a relatively high percentage of participants are infected with and capable of transmitting HCV. Overdose SEP2016 is the fifth year to incorporate questions about drug overdose, with overdose being defined as loss of consciousness. Recent research by the Hawai'i Department of Health 12 states that accidental drug overdose is the leading cause of accidental death both in Hawai'i and nationally. The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 12

14 Figure 10. SEP2016 Experienced overdose in the 2 years prior to interview Experienced an Overdose 11% Three or more times Figure 11. SEP2016 Witnessed overdoses in the 2 years prior to interview Witnessed an Overdose 10% Two times 9% One time 70% Did not experience overdose 29% Three or more times 8% Two times 12% One time 51% Did not witness overdose Overall, 30% of respondents reported having ever experienced an overdose within the past two years (Figure 10). Among those who have reported experiencing an overdose, more than 1 in 3 have experienced three or more. Additionally, 49% of respondents reported having witnessed an overdose, with over half (59.2%) of those respondents reporting witnessing three or more overdoses (Figure 11). More than two in three (67%) respondents in SEP2016 who had reported having experienced an overdose also reported having spent some time in prison in the last five years. Spending time in prison, and presumably being drug free, is a known risk factor for future overdose as a person s tolerance for their drug of choice may be greatly reduced. 13 Additionally, 68% of SEP2016 participants reported injecting alone. Injecting alone does not increase the likelihood of overdose; however, it increases the likelihood that an overdose may be fatal because there is no one to provide assistance. Calling 911 and doing rescue breathing were the most common responses to witnessing an overdose. Only 14% of participants who reported witnessing an overdose reported that Naloxone was administered by themselves or by Emergency Services. It is not surprisingly with the low administration of Naloxone that 8.2% of participants who reported witnessing an overdose in SEP2016 also reported that the last person they witnessed overdosing died due to the overdose. In July 2016, Act 68 (SB2392) was passed which provides immunity for health care professionals and pharmacists, who prescribe, dispense, distribute, or administer overdose reversal medications such as Naloxone and authorizes first responders, as well as friends and family to administer such a medication to anyone experiencing an opioid related drug overdose. Since the inception of the SEP s overdose protocol in September 2016, the SEP has distributed nearly 600 doses of Naloxone. As of May 2017, participants have reported 25 overdose reversals involving Naloxone obtained from the SEP. Sexual Risk Behaviors of SEP Participants The survey respondents reported moderate levels of sexual risk behaviors. In SEP2016, 41% of respondents reported having a sexual relationship with a primary partner. Of these respondents, 78% reported not always using a condom with their primary partner. In SEP2016, 13% of participants The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 13

15 reported having a sexual relationship with a casual partner. Of these respondents, 54% reported not always using a condom with their casual partners. Participants also reported engaging in trading sex for money or drugs. In SEP2016, 10% of participants surveyed reported this behavior, and 25% of these did not always use a condom when trading sex for money or drugs. Participants who reported not using protection cited being paid more as the primary reason for not always using protection. While the HIV prevalence among PWID is low, this high level of sexual risk-taking is worrisome because of the risk of sexually-acquired HIV as well as the risk for other sexually transmitted diseases. CHOW will continue to distribute condoms and provide safer sex education to participants to address sexual risk-taking among SEP participants. CHOW distributed 19,286 condoms to at-risk individuals in SEP2016. HIV Infection No participants screened positive for HIV in SEP2016. Overall number of known HIV positive participants in the SEP population remains low. The data from the HIV testing study is consistent with all other HIV testing data in the state. 3 The HIV testing component of the study provides direct evidence that both prevalence and incidence of HIV infection are quite low among PWID participating in the SEP. CHOW offers HIV testing for participants as an ongoing service and encourages participants to know their HIV status and to link HIV positive persons to medical care. HCV Infection In SEP % of respondents screened positive for HCV antibodies. Over 1 in 5 (20.6%) of these participants reported never having been previously screened positive for HCV. Table 3. Demographics and Risk Profile of SEP HCV Positives HCV (n=65) Gender AGE HOUSING HCV Testing HCV NEW* (n=18) HCV (n=65) HCV NEW* (n=7) HCV (n=68) HCV NEW* (n=14) Male Female Transgendered and under (Youth) Over Permanently Housed Marginally Housed Homeless Previous Test Yes No 2 n/a The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 14

16 INJECTION RISK BEHAVIOR Known positive - RNA test 26 n/a 33 n/a 34 n/a Length of time injecting 22.4 years 13.3 years 18.3 years 13.3 years 22 years 10.8 years Days a week Inject Number of injections a day Length of time accessing 10 years 4.2 years 6.9 years 6 years 9.1 years 4.5 years SEP Receptive sharing syringes 6/14** 1 10/13** 3 15/17** 2 Receptive sharing cookers 4/6** 1 11/12** 0 17/19** 1 Receptive sharing cottons 2/4** 0 10/10** 3 12/16** 0 Distributive sharing 10/17** 3 10/16** 2 18/26** 3 syringes Distributive sharing cookers 4/5** 1 7/11** 0 18/26** 2 Distributive sharing cottons 4/5** 1 5/8** 1 17/20** 2 *These participants reported having previously tested negative for HCV antibodies ** The denominator indicates total number of participants who reported this activity While previously the overall prevalence of HCV has slowly been decreasing amongst SEP participants since the HCV antibody test was added to the Evaluation in 2008, 2016 saw the first increase in HCV positives. The fluctuation in the number of new HCV antibody positive participants interviewed has many corollaries. Of significant importance is the number of participants who tested positive for HCV antibodies who also reported distributive and receptive sharing of injection drug equipment. This increase in sharing behavior (see Table 2) puts participants at significantly higher risk if they are receptively sharing injection drug equipment, especially as HCV is approximately 10 times more infectious than HIV and can live outside the body (unlike HIV) for up to four days. 14 Sexual/Physical Abuse One of the issues that many SEP participants face is dealing with past, and ongoing, physical and sexual abuse. SEP2016 is the sixth year participants were asked about physical and sexual abuse in childhood (before the age of 18) and in adulthood (after the age of 18). Physical abuse is defined as any act resulting in a non-accidental physical injury. Sexual abuse is defined as any unwanted sexual contact, including being molested, sodomized, or raped. Table 4. SEP2016 Physical and Sexual Abuse Childhood Sexual Abuse Adult Sexual Abuse Childhood Physical Abuse Adult Physical Abuse Total Male SEX Female Transgendered Under 30 (Youth) The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 15

17 AGE Over Permanently housed HOUSING MENTAL HEALTH Marginally housed Homeless Psych diagnosis PTSD ADHD Treatment In SEP2016 a vast majority of all respondents who reported being physically and/or sexually abused in adulthood were female. These respondents where disproportionately abused by primary partners. According to national statistics, 1 in 5 women will experience sexual assault in her lifetime. 15 Women who have experienced sexual assault are diagnosed with PTSD at higher rates than any other group of people in the United States, including combat veterans. 16,17 Moreover, physical and sexual abuse in childhood often leads to re-victimization in adulthood, which can be illustrated in our own community. In SEP2016, 56% of all respondents who reported being sexually abused in childhood also reported experiencing sexual abuse in adulthood. Additionally, 70% of participants who reported experiencing childhood physical abuse also reported experiencing physical abuse as adults. Adverse Childhood Experiences (ACEs) This is the first year that the Adverse Childhood Experiences (ACEs) was included in the evaluation. It consists of ten questions that evaluate for childhood trauma and stressors, including physical and mental child abuse, neglect, and the mental health and substance use of caregivers. Answering yes to a question is one point added to a composite score with a maximum score of ten. A high score on the ACEs puts people at higher risk for a plethora of mental and physical health concerns, as well as future high risk behaviors. A person with a score of five or greater is seven to 10 times more likely to use illegal drugs, report addiction, and to inject illegal drugs. 18 he average score for participants of the SEP2016 evaluation was a five. Among the 96 respondents that answered all questions, 35% of all respondents scored a seven or higher, with 6% reporting the maximum score of ten. Female participants scored higher on average (6) than their male counterparts (4). Participants that scored four or higher were marginally significantly more likely to test positive for HCV (73.8% vs. 57.1%; p=0.045) and be diagnosed with depression (63.9% vs. 42.9%; p=0.056) compared to those that scored less than four. A similar trend was seen with receptive syringe behaviors, with 21.3% of those respondents reporting using a syringe after someone else had used it compared to 5.7% of respondents with a score of three or less (p=0.047). A similar trend was seen with distributive behaviors, with 31.2% of respondents with scores of 4 or higher reporting using a syringe and passing it on to another person to use compared to 14.3% of those with lower scores, although this was not statistically significant. Alarmingly, 39.3% of respondents with scores of four or more had experienced an overdose in the past three years, which is over twice the proportion of those with scores of three or less (17.1%; p=0.038). A larger proportion of respondents with a score of three or less (34.3%) reported injecting for less than five years compared to those with a score of four or more (25.0%), although this was not statistically significant (p=0.35). In the future, several more years of data analysis may provide The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 16

18 adequate power to look at all indicators and potential associations between ACEs score. Additionally, since the mean score of five for this evaluation is already elevated, a higher threshold could be explored which may provide additional information on differences among SEP participants. Table 5. SEP2016 and ACES <4 ACES Score N (%) 4 ACES Score N (%) Total (36.5%) 61 (63.5%) % % Female 22.9% 45.9% HCV Positive 57.1% 73.8% Diagnosed Depression 42.9% 63.9% Receptive Syringe Behaviors 5.7% 21.3% Distributive Syringe Behaviors 14.3% 31.2% Experienced Overdose Past 3 Years 17.1% 39.3% Injecting < 5 Years 34.3% 25.0% *Percentages reflect column percentages Significant at P<0.05 Cost/Benefit Analysis of Hawai'i SEP While there are many difficulties in conducting a cost/benefit analysis of any HIV prevention program, it is clear that it is very expensive to treat HIV infection, and the cost has increased with the advent of highly active anti-retroviral treatment (HAART). According to a 2010 analysis 19 the average lifetime cost of treating someone living with HIV is $379,668. Additionally, a very close linkage exists between HIV infection among PWID and heterosexual transmission of HIV in the United States. 20 Based on the national data, preventing an average of three HIV infections per year among PWID would then prevent an average of 1.2 additional HIV infections among non-drug injecting heterosexual partners of PWID for a total of slightly more than four infections prevented per year. The combined SEP/CHOW Project would provide a cost savings to the State of Hawai'i if it prevented as few as two HIV infections per year. Conclusions The annual survey has a modest sample size (100 subjects) and there is frequently year-to-year variation in many operational characteristics of the program. Consequently, the evaluation should be viewed as a snapshot of the PWID in Hawai'i and the epidemiological value of the study is found both in the annual survey as well as in the trends in the data over time. In addition, the survey offers the opportunity for CHOW participants to give feedback about the services they are receiving. The CHOW participants who participated in the survey rated the SEP at a 9.7 on a 10-point scale when asked how satisfied they were with CHOW services. These comments and the survey results will direct any programmatic changes that are necessary to ensure services reflect the study s outcomes and recommendations. HIV/AIDS among PWID is a major public health problem in many countries throughout the world. It is a particular problem in the United States, where approximately one third of all reported AIDS cases have been related to injection drug use. Hawai'i acted early to establish HIV prevention programs for PWID which has kept the AIDS cases related to injection drug use at about half the national average. The CHOW HIV testing study conducted over the past ten years found both a low The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 17

19 prevalence (3%) and a low incidence (likely to be less than 1% per year) among PWID participating in the SEP. Given that the program is relatively large, it probably reaches a high percentage of PWID in the state, and it is unlikely that prevalence or incidence are very different among PWID not participating in the SEP. The continuing success in limiting HIV transmission among injecting drug users in Hawai'i is notable given indications of a resurgence of HIV infections among some high-risk populations in Hawai'i and in other parts of the United States. 2,3 The CHOW HCV testing study conducted for the first time in 2007 showed a high prevalence of 88.7% and the prevalence for SEP2016 was 68%. These findings fall within the world-wide range of 60% to 80% among PWID. 21 Because the average duration of injecting among the syringe exchange participants is approximately 17.5 years, with a range from less than a month to more than 46 years, many of the participants may have been infected with HCV before the syringe exchange became fully established. Nonetheless, the notable trend of high HCV+ seropositivity rates among SEP participants supports the importance of syringe exchange services in combatting the rise of other prevalent bloodborne pathogens. Also of note is the steady increase in methamphetamine use in the SEP community (Figures 7 and 9). Data from Hawaii s Youth Risk Behavior Survey (YRBS) shows that 3.8% of public high school students in 2015 have ever used methamphetamine at least one time. 8 It is widely acknowledged that the use of methamphetamine, alone or in conjunction with other substances, significantly interferes with activities of daily living. The rise in the use of methamphetamine also coincides with the increase in homelessness in the SEP community. This decrease in stability has had far reaching implications, including increased interpersonal violence and a decrease in personal care. Moving forward with this subset of SEP participants will be challenging, but the SEP will continue to seek guidance from other harm reduction organizations and the participants themselves on the needs of this part of our community. While the present data systems do not permit an exact count of the number of PWID who use the Hawai'i SEP, the participant card data is able to give a broad estimate. As of May 2017, the SEP had generated 1,991 participant cards for individual SEP participants. The program is one of the larger programs in the United States based on the annual numbers of syringes exchanged with SEP2016 having the largest number of syringes exchanged since the program s inception. Given the upwards trend in number of syringes exchanged, it seems unlikely that the annual number of syringes exchanged has stabilized and monitoring of the numbers of syringes exchanged should be continued. Participants in the SEP report moderate rates of injection risk behavior; and based on their drug injection frequencies, participants in the SEP would be at very high risk for HIV infection if they did not have a legal source of sterile injection equipment and other needed educational and support services. Given the considerable costs of medical treatment for HIV infection and the consistent evidence for low rates of HIV infection among PWID in Hawai'i, there is great certainty that the investment in the integrated SEP/CHOW Project produces a substantial cost savings for the State of Hawai'i. Recommendations The Hawai'i SEP has become an effective statewide program and has contributed to the low prevalence of HIV among PWID in Hawai'i. The highest priority must be given to maintaining quality and quantity of the services provided, in particular to preventing transmission of HIV and HCV by The CHOW Project 2016 Syringe Exchange Program Evaluation -DRAFT Page 18