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FIELD ACTION REPORT |
At the time of the study, all authors were with the British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, British Columbia. Evan Wood, Mark W. Tyndall, Julio S. G. Montaner, and Thomas Kerr are also with the Department of Medicine at the University of British Columbia, Vancouver.
Correspondence: Requests for reprints should be sent to Evan Wood, PhD, Division of Epidemiology and Population Health, British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada (e-mail: ewood{at}cfenet.ubc.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONVANCOUVER SAFER INJECTING...DISCUSSION AND EVALUATIONNEXT STEPSReferences |
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In 2003, the city of Vancouver, British Columbia, opened North America’s first government-sanctioned safer injecting facility, where injection drug users (IDUs) can inject preobtained illicit drugs under the supervision of nurses. Use of the service by IDUs was followed by measurable reductions in public drug use and syringe sharing. IDUs who are frequently using the program tend to be high-intensity cocaine and heroin injectors and homeless individuals.
The facility has provided high-risk IDUs a hygienic space where syringe sharing can be eliminated and the risk of fatal overdose reduced. Ongoing evaluation will be required to assess its impact on overdose rates and HIV infection levels, as well as its ability to improve IDU contact with medical care and addiction treatment
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONVANCOUVER SAFER INJECTING...DISCUSSION AND EVALUATIONNEXT STEPSReferences |
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). The SIF, known as Insite, is funded by Vancouver Coastal Health (the local health authority). We report on service uptake and client characteristics.
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VANCOUVER SAFER INJECTING FACILITY |
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TOPABSTRACTINTRODUCTIONVANCOUVER SAFER INJECTING...DISCUSSION AND EVALUATIONNEXT STEPSReferences |
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The methodology for evaluating the SIF—through the recruitment of a representative cohort of SIF users, known as the Scientific Evaluation of Supervised Injecting (SEOSI) cohort—has recently been described in detail.10 We present cohort baseline characteristics and our examination of factors associated with reporting daily SIF use at the time of participant’s baseline interview. Variables of interest are listed in Tables 1 and 2, and variable definitions were identical to those used in previous studies of Vancouver IDUs.3,5,11–15 Variables potentially associated with daily SIF use were examined in bivariate analyses.
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DISCUSSION AND EVALUATION |
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TOPABSTRACTINTRODUCTIONVANCOUVER SAFER INJECTING...DISCUSSION AND EVALUATIONNEXT STEPSReferences |
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Between December 1, 2003, and July 30, 2004, 904 SIF users were randomly invited to enroll in the SEOSI study, among whom 735 (81.3%) attended the external research site to learn about participation in the SIF evaluation. Overall, 5 were deemed by research staff unfit to provide informed consent and were not enrolled, and 15 decided not to enroll after learning what cohort participation would require. Overall, among the 713 participants who consented to enroll in the SEOSI cohort, 308 (43.2%) reported using the SIF daily at the time of their baseline interview.
Among the SEOSI cohort, 30% were women, and 19% self-identified as Aboriginal. Interestingly, although venous blood samples indicated that the hepatitis C virus prevalence was high at 88%, the HIV prevalence among SIF users was 16%, which is lower than HIV levels reported previously among the neighborhood’s IDUs.3,16 Overall, daily In-site users tended to be younger than nondaily users (38 years vs 40 years; P<.001). A detailed presentation of client characteristics stratified by daily SIF use is shown in Tables 1
and 2.
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NEXT STEPS |
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TOPABSTRACTINTRODUCTIONVANCOUVER SAFER INJECTING...DISCUSSION AND EVALUATIONNEXT STEPSReferences |
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IDUs requiring help with injections was negatively associated with SIF use, which is concerning because we have previously found that this risk behavior is associated with elevated rates of syringe sharing and HIV infection among Vancouver IDUs.18 Feasibility studies indicated that IDUs who required help with injections would be less willing to use the facility if rules prohibited assisted injection, and it appears that this rule is reducing uptake among this high-risk population.19 Efforts to accommodate those who require help with injections, through education or other interventions, should also be undertaken.18 It is also noteworthy that use of methadone was negatively associated with daily SIF use. However, this association is likely explained by the fact that methadone has been associated with reduced demand for injection drugs rather than methadone use being a barrier to SIF use.20 This finding indicates that efforts to expand methadone use among opiate users in the community should be increased, and future studies must examine the impact of the SIF on referrals to addiction treatment programs.9
KEY FINDINGS
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Conversely, it is encouraging that daily use of the SIF was associated with several high-risk behaviors including cocaine injection and homelessness. The fact that the daily SIF use was associated with homelessness is perhaps not surprising given that previous studies have indicated that SIF use may be associated with not having a safe place to inject.19 Given that homeless persons may be more likely to inject in public, the association between homelessness and frequent SIF use may partially explain why the opening of the SIF was linked to substantial reductions in public drug use.21
Our study was limited by its cross-sectional study design and the evaluation is limited by its observational nature. Unfortunately, this cohort will have to be followed longitudinally for several years before an examination of blood-borne infection incidence will be possible, and it is likely that ethical concerns will prevent interventional studies that randomize participants to SIF use vs nonuse.22 Another limitation is that the evaluation largely relies on self-report; therefore, it is likely that we have underestimated socially undesirable behaviors, such as syringe sharing.23 Finally, frequent use of the SIF was on the basis of self-report and was measured cross-sectionally at the time of recruitment into the study. Future studies examining exposure to the SIF will require prospective examination of SIF use through the use of the SIF database.
This report is the first presentation of the sociodemographic and risk characteristics of a representative sample of SIF users in the public health literature. Our study indicates that the SIF was well accepted by high-risk IDUs in the community and that frequent use is characterized by homelessness and high-intensity drug use, including cocaine injection. The site’s opening was recently associated with improved public order and reduced syringe sharing,17,21 and it is noteworthy that frequent use was associated with homelessness in the present study because homeless drug users may be particularly prone to public drug use.24 Although these preliminary findings are encouraging, prospective evaluation of SIF users will be required to examine the impact of SIF use on a number of outcomes, such as rates of blood-borne infections. In addition, program rules that may create barriers to uptake must be further examined.
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Acknowledgments |
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The authors wish to thank the staff of the Insite safer injecting facility and Vancouver Coastal Health (Chris Buchner and Heather Hay). We also thank Deborah Graham, Bonnie Devlin, Aaron Eddie, Suzy Coulter, Megan Oleson, Peter Vann, Dave Isham, Daniel Kane, Steve Gaspar, Carl Bognar, and Evelyn King for their research and administrative assistance.
Note. The views expressed herein do not represent the official policies of Health Canada.
Human Participant Protection
This study was approved by the University of British Columbia’s research ethics board at St Paul’s Hospital.
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Footnotes |
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Contributors
E. Wood designed the study and prepared the first draft of the article. E. Wood, R. Zhang, and Z. Qui conducted the data analyses. All authors contributed to the design of the study, as well as to the drafting and revision of the article.
Accepted for publication April 15, 2005.
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References |
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TOPABSTRACTINTRODUCTIONVANCOUVER SAFER INJECTING...DISCUSSION AND EVALUATIONNEXT STEPSReferences |
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2. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users. JAMA. 1995;274:1226–1231.[Abstract]
3. Tyndall MW, Currie S, Spittal P, et al. Intensive injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS. 2003;17:887–893.[CrossRef][ISI][Medline]
4. Garfield J, Drucker E. Fatal overdose trends in major US cities: 1990–1997. Addictions Research and Theory. 2001;9:425–436.
5. Wood E, Tyndall MW, Spittal PM, et al. Unsafe injection practices in a cohort of injection drug users in Vancouver: could safer injecting rooms help? CMAJ. 2001;165:405–410.
6. Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K. Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990–98. Addiction. 2003; 98:739–747.[CrossRef][ISI][Medline]
7. Dolan K, Kimber J, Fry C, Fitzgerald J, McDonald D, Frautmann F. Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia. Drug Alcohol Rev. 2000;19:337–346.
8. Kimber J, Dolan K, van Beek I, Hedrich D, Zurhold H. Drug consumption facilities: an update since 2000. Drug Alcohol Rev. 2003;22:227–233.[CrossRef][ISI][Medline]
9. Wood E, Kerr T, Montaner JS, et al. Rationale for evaluating North America’s first medically supervised safer-injecting facility. Lancet Infect Dis. 2004; 4:301–306.[CrossRef][ISI][Medline]
10. Wood E, Kerr T, Lloyd-Smith E, et al. Methodology for evaluating Insite: Canada’s first medically supervised safer injection facility for injection drug users. Harm Reduct J. 2004;1:9.[CrossRef][Medline]
11. Spittal PM, Craib KJ, Wood E, et al. Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. CMAJ. 2002; 166:894–899.
12. Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. J Acquir Immune Defic Syndr. 2002;30:335–341.[ISI][Medline]
13. Wood E, Tyndall MW, Spittal PM, et al. Factors associated with persistent high-risk syringe sharing in the presence of an established needle exchange programme. AIDS. 2002;16:941–943.[CrossRef][ISI][Medline]
14. Corneil TA, Kuyper LM, Shovellor J, et al. Unstable housing, associated risk behaviour, and increased risk for HIV infection among injection drug users. Health Place. 2006;12:79–85.[Medline]
15. Tyndall MW, Craib KJ, Currie S, Li K, O’Shaughnessy MV, Schechter MT. Impact of HIV infection on mortality in a cohort of injection drug users. J Acquir Immune Defic Syndr. 2001;28:351–357.[ISI][Medline]
16. Strathdee SA, Patrick DM, Currie SL, et al. Needle exchange is not enough: lessons from the Vancouver injecting drug use study. AIDS. 1997; 11:F59–F65.[CrossRef][ISI][Medline]
17. Kerr T, Tyndall M, Li K, Montaner JS, Wood E. Safer injection facility use and syringe sharing in injection drug users. Lancet. 2005;40:1153–1167.
18. Wood E, Spittal PM, Kerr T, et al. Requiring help injecting as a risk factor for HIV infection in the Vancouver epidemic: implications for HIV prevention. Can J Public Health. 2003;94:355–359.[Medline]
19. Kerr T, Wood E, Small D, Palepu A, Tyndall MW. Potential use of safer injecting facilities among injection drug users in Vancouver’s Downtown East-side. CMAJ. 2003;169:759–763.
20. Gibson DR, Flynn NM, McCarthy JJ. Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users. AIDS. 1999;13:1807–1818.[Medline]
21. Wood E, Kerr T, Small W, et al. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ. 2004;171:731–734.
22. Christie T, Wood E, Schechter MT, O’Shaughnessy MV. A comparison of the new Federal Guidelines regulating supervised injection site research in Canada and the Tri-Council Policy Statement on Ethical Conduct for Research Involving Human Subjects. Int J Drug Policy. 2003;15:66–73.[CrossRef]
23. Des Jarlais DC, Paone D, Milliken J, et al. Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial. Lancet. 1999;353:1657–1661.[CrossRef][ISI][Medline]
24. Broadhead RS, Kerr TH, Grund JPC, Altice FL. Safer injection facilities in North America: their place in public policy and health initiatives. J Drug Issues. 2002;32:329–355.
This article has been cited by other articles:
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  L. Beletsky, C. S. Davis, E. Anderson, and S. Burris The Law (and Politics) of Safe Injection Facilities in the United States Am J Public Health, February 1, 2008; 98(2): 231 - 237. [Abstract] [Full Text] [PDF]
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 E. Wood, M. W. Tyndall, J. S. Montaner, and T. Kerr Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Can. Med. Assoc. J., November 21, 2006; 175(11): 1399 - 1404. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
