Objectives.Hepatitis C (HCV) has emerged as a major epidemic among injection drug users (IDUs), with observed prevalence exceeding 70% in many American and European cities. This article explores the potential of syringe exchange programs (SEPs) to reduce HCV incidence and prevalence.Design.A random-mixing epidemiological model is used to examine the potential impact of harm reduction interventions.Methods.Steady-state analysis is used to scrutinize the impact of SEP on HCV incidence and prevalence and to examine the accuracy of short-term incidence analysis in predicting long-run program effects.Results.SEP is predicted to have little impact on HCV incidence and prevalence within realistic populations of IDUs.Conclusions.Short-term incidence analysis substantially overstates SEP effectiveness and cost-effectiveness in preventing HCV. More comprehensive harm reduction models, coupled with referral of active IDUs to treatment, must complement syringe exchange to successfully contain highly infectious blood-borne diseases.
Choi K, Coates T.Prevention of HIV infection. AIDS. 1994;8:1371-1389.
2.
Kaplan EH. Economic analysis of needle exchange. AIDS. 1995; 9:1113-1119.
3.
Institute of Medicine. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington, DC: National Academy Press; 1995.
4.
Watters JK, Estilo MJ, Clark GL, Lorvick J.Syringe and needle exchange as HIV/AIDS prevention for injection drug users. JAMA. 1994;271:115-120.
5.
Zaric GS, Brandeau ML, Barnett PG. Methadone maintenance and HIV prevention: a cost-effectiveness analysis. Am J Public Health. 2000;90:1100-1111.
6.
Zaric GS, Brandeau ML, Barnett PG. HIV transmission and the cost-effectiveness of methadone maintenance. Management Sci. 2000;46:1013-1031.
7.
Ball J, Lange W, Myers C, Friedman S.Reducing the risk of AIDS through methadone maintenance treatment. J Health Social Behav. 1988;29:214-226.
8.
Ball JC, Ross A.The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome. New York: Springer-Verlag; 1991.
9.
Barnett P.The cost-effectiveness of methadone maintenance as a health care intervention. Addiction. 1999;94:479-488.
10.
Metzger D, Woody G, McLellan A, et al.Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr Hum Retrovirol. 1993;6:1049-1056.
11.
Pollack HA. Can we protect drug users from hepatitis C?J Policy Anal Manage. 2001;20:358-364.
12.
Des Jarlais D, Hagan H, Friedman S, et al.Maintaining low HIV prevalence in populations of injecting drug users. JAMA. 1995;274:1226-1231.
13.
Holmberg SD. The estimated prevalence and incidence of HIV in 96 large U. S. metropolitan areas. Am J Public Health. 1996;86:642-654.
14.
McCoy C, Metsch L, Chitwood D, Shapshak P, Comerford S.Parenteral transmission of HIV among injection drug users: assessing the frequency of multiperson use of needles, syringes, cookers, cotton, and water. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S25-S29.
15.
Battjes R, Pickens R, Brown L JR.HIV infection and AIDS risk behaviors among injection drug users entering methadone treatment: an update. J Acquir Immune Defic Syndr Hum Retrovirol. 1995;10(1):90-96.
16.
Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health. 1996;86:655-661.
17.
Alter M, Moyer L.The importance of preventing hepatitis C virus infection among injection drug users in the United States. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S6-S10.
18.
MacDonald M, Crofts N, Kaldor J.Transmission of hepatitis C virus among injecting drug users: rates, routes, and cofactors. Epidemiol Rev. 1996;18:137-148.
19.
Coutinho R.HIV and hepatitis C among injecting drug users: success in preventing HIV has not been mirrored for hepatitis C. BMJ. 1998;317:424-425.
20.
Crofts N, Hopper J, Milner R, Breschkin A, Bowden D, Locarnini S.Blood-borne virus infections among Australian injecting drug users: implications for spread of HIV. Eur J Epidemiol. 1994;10:687-694.
21.
Crofts N, Nigro L, Oman K, Stevenson E, Sherman J.Methadone maintenance and hepatitis C virus infection among injecting drug users. Addiction. 1997;92:999-1005.
22.
Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR. 1998;47(RR19):1-39.
23.
Garfein R, Doherty M, Monterroso E, Thomas D, Nelson K, Vlahov D.Prevalence and incidence of hepatitis C virus infection among young injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S11-S19.
24.
Mather D, Crofts N.A computer model of the spread of hepatitis C virus among injecting drug users. Eur J Epidemiol. 1999;15(1):5-10.
25.
Hagan H, Des Jarlais D, Friedman S, Purchase D, Alter M.Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma Syringe Exchange Program. Am J Public Health. 1995;85:1531-1537.
26.
Hagan H, McGough JP, Thiede H, Weiss NS, Hopkins S, Alexander ER. Syringe exchange and risk of infection from hepatitis B and C viruses. Am J Epidemiol. 1999;149:203-213.
27.
Moss A, Hahn J.Invited commentary: needle exchange—no help for hepatitis?Am J Epidemiol. 1999;149:214-216.
28.
Kaplan EH. Needles that kill: modeling human immunodeficiency virus transmission via shared needle injection equipment in shooting galleries. Rev Infect Dis. 1989;11:289-298.
29.
Anderson RM, May RM. Infectious Diseases of Humans. Oxford, UK: Oxford University Press; 1991.
30.
Pollack HA. Cost-effectiveness of methadone as HIV prevention. In: National HIV Prevention Conference, 1999. Atlanta (GA): Centers for Disease Control and Prevention; 1999.
31.
Vlahov D, Khabbaz RSC, Cohn S, Galai N, Taylor E, Kaplan J.Incidence and risk factors for human T-lymphotropic virus type II seroconversion among injecting drug users in Baltimore, Maryland, USA. J Acquir Immune Defic Syndr Hum Retrovirol. 1995;9(1):89-96.
32.
Brookmeyer R, Gail MH. AIDS Epidemiology. Oxford, UK: Oxford University Press; 1994.
33.
Des Jarlais D, Friedman S.Shooting galleries and AIDS: infection probabilities and “tough” policies. Am J Public Health. 1990;80:142-144.
Osmond D, Padian N, Sheppard H, Glass S, Shiboski S, Reingold A.Risk factors for hepatitis C virus seropositivity in heterosexual couples. JAMA. 1993;269:361-365.
36.
Kaplan E, Heimer R.A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr Hum Retrovirol. 1992;5:1116-1118.
37.
Jacquez J, Koopman J, Simon C, Longini I.Role of the primary infection in epidemics of HIV infection in gay cohorts. J Acquir Immune Defic Syndr Hum Retrovirol. 1994;7:1169-1184.
38.
Kaplan E, Heimer R.A circulation theory of needle exchange. AIDS. 1994;8:567-574.
39.
Lurie P, Reingold AL, Browser B, et al.The Public Health Impact of Needle Exchange Programs in the United States and Abroad. San Francisco: Institute for Health Policy Studies, University of California, San Francisco; 1993.
40.
Holtgrave DR, editor. Handbook of Economic Evaluation of HIV Prevention Programs. New York: Plenum Press; 1998.
41.
Tengs T, Adams M, Pliskin J, Safran D, et al.Five-hundred life-saving interventions and their cost-effectiveness. Risk Anal. 1995; 15:369-390.
42.
Kretzschmar M, Wiessing L.Modelling the spread of HIV in social networks of injecting drug users. AIDS. 1998;12:801-811.
43.
Morris M.Social networks and HIV. AIDS. 1997;11(Suppl A): S209-S216.
44.
Kaplan E, Cramton P, Paltiel A.Nonrandom mixing models of HIV transmission. In: Castillo-Chavez C, editor. Lecture Notes in Biomathematics. New York: Springer-Verlag; 1989. p. 218-241.
45.
Watts D.Small Worlds: The Dynamics of Networks Between Order and Randomness. Princeton (NJ): Princeton University Press; 1999.
46.
Koopman J, Jacquez J, Welch G, et al.The role of early HIV infection in the spread of HIV through populations. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;14:249-258.
47.
Wong JB, Bennett WG, Koff RS, Pauker SG. Pretreatment evaluation of chronic hepatitis C: risks, benefits, and costs. JAMA. 1998; 280:2088-2093.
48.
Younossi Z, Singer M, McHutchison J, Shermock K.Cost effectiveness of interferon 2b combined with ribavirin for the treatment of chronic hepatitis C. Hepatology. 1999;30:1318-1324.
Brown K, Crofts N.Health care costs of a continuing epidemic of hepatitis C virus infection among injecting drug users. Aust N Z J Public Health. 1998;22(Suppl 3):384-388.
51.
Kaplan EH, Pollack HA. Allocating HIV prevention resources. Socio-Economic Plann Sci. 1998;32:257-263.
52.
Institute of Medicine. No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Press; 2000.
53.
Des Jarlais D, Friedman S, Ward T.Harm reduction: a public health response to the AIDS epidemic among injecting drug users. Annu Rev Public Health. 1993;14:413-450.
54.
Heimer R.Can syringe exchange serve as a conduit to substance abuse treatment?J Subst Abuse Treatment. 1998;15:183-191.
55.
Hammett TM, Gaiter JL, Crawford C.Reaching seriously at-risk populations: health interventions in criminal justice settings. Health Educ Behav. 1998;25:99-120.
56.
Pollack H, Khoshnood K, Altice F.Health care delivery strategies for criminal offenders. J Health Care Finance. 1999;26(1):63-77.
57.
Hammett T, Rhodes W, Harmon P.HIV/AIDS and other infectious diseases among correctional inmates: a public health problem and opportunity. In: 1999 National HIV Prevention Conference, 1999. Atlanta (GA): Centers for Disease Control and Prevention; 1999. Abstract 571.
58.
Thompson A, Blankenship K, Selwyn P, et al.Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. J Comm Health. 1998;23:419-440.
