美國必須解決注射藥癮者之間的種族差異並擴大針具服務計畫
資料來源：瑪麗亞·威爾伯格/2022 年 1 月 26 日/aidsmap/財團法人台灣紅絲帶基金會編譯
圖片來源：奈傑爾布倫斯登/nigelbrunsdon.com
發表在發病率和死亡率週報上的結果顯示，美國城市吸毒者在愛滋病毒流行和獲得服務方面存在驚人的種族差異。 2015 年至 2018 年期間，注射吸毒者的愛滋病毒感染總流行率穩定在 7%。 然而，儘管報告的 HIV 風險行為較少，但黑人的 HIV 感染率高於西班牙裔或白人。 同樣，在 2015 年至 2018 年期間，針具服務計畫的總體使用情況保持相對穩定。潛在的原因是種族差異，白人和西班牙裔人的使用情況有所改善，但黑人的使用情況大幅下降。 後一組也不太可能開處方藥來治療阿片類藥物使用障礙。
2014 年，美國因注射吸毒導致的 HIV 新增感染率一度下降，但從 2015 年開始，美國注射吸毒者中爆發了多起 HIV 疫情，包括目前在明尼蘇達州和西弗吉尼亞州爆發的疫情。這些增加和爆發在很大程度上歸因於美國處方和非處方阿片類藥物使用的增加。
針具服務計畫 (Syringe service programmes, SSPs) 是一種安全且具有成本效益的方法，可以在 PWID (People Who Inject Drugs) 中預防 HIV，但尚未證明會增加吸毒或犯罪。 SSP 可以幫助預防病毒性肝炎和其他細菌或真菌血源性感染的傳播，促進安全處置用過的針具，防止過量死亡，並作為與物質使用障礙治療、抗反轉錄病毒治療、暴露前預防、 以及其他針對 PWID 的服務。 另一篇文獻綜述研究了 SSP 的作用，並得出結論認為，如果不擴大 SSP，美國將無法結束 HIV 流行。 他們建議透過遵循最佳實踐來最大化 SSP 的影響，包括一種綜合方法，使 PWID 可以獲得藥物治療阿片類藥物使用障礙、PrEP 和 SSP 中的抗反轉錄病毒療法。
研究
美國疾病控制與預防中心 (CDC) 開展的 2018 年全國愛滋病毒行為監測調查收集了橫斷面數據，並在美國 23 個大都市統計區對 PWID 進行了愛滋病毒檢測。 研究人員使用受訪者驅動的抽樣方法，在每個地點選擇 28 名 PWID，並要求招募最多 5 名同伴，新推薦人也鼓勵招募最多 5 名同伴，依此類推。 參與者在每次成功招募以及完成面試和 HIV 檢測時都會獲得獎勵。 符合條件的參與者是在過去 12 個月內注射過非處方藥的人，他們居住在大都市統計區之一，年滿 18 歲，可以用英語或西班牙語完成訪談。 該研究共包括 11,348 名注射吸毒者。 67% 為男性，32% 為女性，1% 為變性人。 最大比例的受訪者 (42%) 是非西班牙裔白人，其次是非西班牙裔黑人 (32%)、任何種族的西班牙裔 (24%) 和其他 (2%)。 15% 的人年齡在 12-29 歲之間，23% 的人年齡在 30-39 歲之間，24% 的人年齡在 40-49 歲之間，38% 的人年齡在 50 歲或以上。 在男性受訪者中，10% 的人表示在過去 12 個月內有過男性伴侶。 研究人員能夠估計該群體的 HIV 總體流行率。 然而，這個數字太小，無法對男性之間的特定性行為做出可靠的估計。 大多數參與者 (80%) 已經注射毒品五年或更長時間，超過一半 (55%) 的人報告最常注射海洛因。 大多數受訪者 (82%) 當前擁有健康保險。
幾乎四分之三 (72%) 的人擁有高中文憑或更高學歷，但大多數 (75%) 的人生活在或低於聯邦貧困線。
考慮到美國的人口普查區域，36% 來自東北部，29% 來自南部，8% 來自中西部，26% 來自西部。 波多黎各聖胡安也有不到 500 名參與者，該地區未包括在任何人口普查地區。沒有包括農村地區。
結果
總體而言，7% 的參與者 HIV 檢測呈陽性，其中東北部為 10%，南部為 9%，中西部為 1%，西部為 4%。 總體流行率與 2015 年進行的上一次國家愛滋病毒監測研究相比沒有變化。加權愛滋病毒流行率在同性戀和雙性戀男性中最高，他們也報告注射吸毒 (25%) 和 40-49 歲的注射吸毒者 (12%)。 黑人參與者的 HIV 感染率 (12%) 高於白人 (5%) 和西班牙裔 (5%) 參與者。 總體而言，26% 的人報告使用過他人以前使用過的注射器。 與西班牙裔 (22%) 或黑人 (16%) 受訪者相比，這一比例在白人 (36%) 中最高。 在各個地點，近一半 (49%) 報告使用了以前使用過的注射設備（例如棉花、炊具、水）。
「白人和西班牙裔人獲得注射器服務的機會得到改善，但黑人的機會大大減少」
總體而言，68% 的 HIV 陰性注射吸毒者報告沒有使用保險套進行陰道性交； 這在白人注射吸毒者中最高 (73%)，其次是西班牙裔和黑人參與者（均為 63%）。 總體而言，23% 的人報告說沒有保險套的異性肛交，在西班牙裔 (30%)、白人 (24%) 和黑人 (16%) 參與者中最高。 在檢測、預防和治療方面也存在種族差異。 57% 的 HIV 陰性受訪者在過去 12 個月內接受過 HIV 檢測，接受檢測的白人注射吸毒者 (53%) 少於西班牙裔注射吸毒者 (62%)。 超過一半 (56%) 報告在過去 12 個月內使用藥物治療阿片類藥物使用障礙 (MOUD)，其中黑人使用 MOUD 的可能性最低，為 47%，而白人和西班牙裔的這一比例分別為 58% 和 65% 人們。 有醫療保險的參與者比沒有醫療保險的參與者獲得更多服務，包括 HIV 檢測（分別為 59% 和 47%）、HIV 行為介入（35% 和 22%）、C型肝炎檢測（86% 和 71%） ，並接受 MOUD（61% 對 35%）。 總體而言，55% 的注射吸毒者在過去 12 個月內從 SSP 獲得了清潔針具，與 2015 年全國研究報告的 52% 相當。 然而，總體數字掩蓋了一個令人不安的現實：在這三年中，SSP 的使用因種族而異。 2015 年，SSP 在黑人、白人和西班牙裔人群中的使用率相當平均，分別為 51%、53% 和 54%。 到 2018 年，白人和西班牙裔人使用 SSP 的比例已增至 63%，而從 SSP 獲得針具的黑人 PWID 比例急劇下降至 40%。
本研究提供了 COVID-19 之前美國城市地區 PWID 的快照。 大流行已經中斷了 SSP 和相關服務的獲取，但要完全了解這些中斷對 PWID 健康的影響還為時過早。 此外，該研究僅包括居住在大都市地區的注射吸毒者。 據報導，居住在農村和非城市地區的注射吸毒者多次爆發愛滋病毒，這些環境帶來了不同的挑戰。 其中包括更少或不存在的 SSP、分散的服務、必須長途跋涉才能獲得服務、可能限制虛擬服務的寬帶接入挑戰，以及不同的社會和政治氣候。 儘管如此，總體停滯不前的結果和不斷惡化的種族差異顯示，現有的 SSP 未能為 PWID 取得有意義的進展。 最近的一篇文獻綜述得出結論，如果不擴大 SSP 和採用最佳實踐，美國將無法結束 HIV 流行。
改進針具服務計畫
CDC 的 Dita Broz 博士及其同事對 SSP 在美國終結 HIV 流行 (Ending the HIV Epidemic , EHE) 倡議中的作用進行了文獻綜述。 該審查涵蓋了 SSP 在 EHE 倡議的四大支柱中的作用的證據基礎：預防、診斷、治療和應對（愛滋病毒爆發）。 數十年來積累的證據顓顯示，SSP 可以在實現這些目標方面取得有意義和重大的進展。 然而，這些好處在很大程度上取決於 SSP 是否遵循服務交付的最佳實踐。 最佳實踐的一個關鍵要素是基於需求的針具分配，例如，不限制提供的針具數量。 對來自 24 個 SSP 的客戶進行的一項調查發現，61% 的客戶報告在基於需求的分配下每次注射都使用無菌針具，而在一對一針具交換下，這一比例為 26%。 任何限制針具的政策也會限制 SSP 最有效的工具之一：由同儕分發二次針具。 包括當前客戶在內的同儕已被證明可以接觸到更多樣化的注射吸毒者網絡，並接觸到在獲得服務方面面臨障礙的個人。 SSP 應培訓和支持同儕教育者，並積極促進二次針具的分發。 SSP 應響應當地 PWID 人口的需求。 吸毒者應該參與計畫設計和實施，這可能需要調整規劃過程以適應這種參與。 服務提供也應適應當地需求。 另一種最大化響應的方法是確保員工或志願者與客戶分享生活經驗。 鑑於黑人 PWID 對 SSP 的使用率較低，從黑人社區招募人員可能尤為重要。
「在針具服務處提供 PrEP 可以讓 PWID 在他們舒適的環境中獲得 PrEP」。
讓當地社區參與也可以為 SSP 創造一個支持性的社會和法律環境。 應該讓不同的合作夥伴參與進來，包括執法部門、衛生部門、當地企業和宗教組織。 有意識地讓黑人社區參與進來可能有助於解決現有的種族差異。 取得 SSP 應該是「低門檻」的：SSP 應該允許顧客匿名，避免大量的接收過程，只收集計畫評估所需的最少數據，並增加地點和可用時間。 此外，針具自動售貨機允許在藥店銷售針具，以及家庭和郵件遞送都是可以補充 SSP 的策略。 SSP 經常接觸 PWID，他們可能不會以其他方式參與醫療保健系統。 因此，他們提供了一個重要的機會，可以在他們所在的地方結識人們。 所有可用的證據都顯示，SSP 具有最大的影響力，它採用全面、綜合的方法來滿足 PWID 的其他需求。 至少，SSP 還應提供 HIV 和C型肝炎檢測以及與照護的聯繫、納洛酮分發以及物質使用障礙治療的提供或聯繫，包括治療阿片類藥物使用障礙的藥物 ( medications for opioid use disorder, MOUD)。 研究顯示，同地服務具有附加效應。 當 PWID 可以同時取得 SSP 和 MOUD 時，HIV 傳播的風險可以降低近 50%。 當 SSP 提供 MOUD 和 ART 時，會對 ART 依從性產生積極影響。 這種綜合方法也可能對 PrEP 的使用產生影響。 需要更多關於將 PrEP 整合到 SSP 中的研究，但研究顯示，注射吸毒者和提供者都報告了在 SSP 中獲取 PrEP 的偏好。 在 SSP 提供 PrEP 可以減少診所就診次數，並允許 PWID 在他們感到舒適且不太可能遇到恥辱的環境中獲得 PrEP。 遠程醫療是為 PWID 提供 MOUD、PrEP 和 ART 的一種方式。 其他可以增加整合的策略包括讓醫療保健提供者在 SSP 中看病人、直接管理 ART、常規 PrEP 訂單和現場藥物儲物櫃。 這種全面的服務最大限度地發揮了 SSP 對 PWID 健康和福祉的影響。
結論
在阿片類藥物危機惡化和注射吸毒者在全國範圍內爆發 HIV 的背景下，很明顯，如果不擴大 SSP 和遵循最佳實踐，就無法在美國終結 HIV 的努力。 需求很大，美國城市地區 PWID 的最新快照顯示，超過一半的 PWID 在過去 12 個月內訪問過 SSP； 一張不完整的圖片，沒有說明居住在農村或偏遠地區的注射吸毒者。 黑人 PWID 在三年期間對 SSP 的使用急劇下降，儘管從事的 HIV 風險行為較少，但 HIV 的流行率較高，並且獲得 MOUD 的機會不平等。美國終止流行病倡議提供了一個機會，透過擴大 SSP 和相關服務來終止注射吸毒者中的愛滋病毒。這樣做的努力必須直接解決注射吸毒者在愛滋病毒流行和服務使用方面的種族差異。
參考文獻：
Handanagic, S et al. 注射吸毒者的 HIV 感染和 HIV 相關行為——美國 23 個大都市統計區，2018 年。發病率和死亡率週報。 70: 1459-1465， 2021年10月。 doi: 10.15585/mmwr.mm7042a1
Broz, D et al. 針具服務計畫在結束美國 HIV 流行方面的作用：為什麼我們不能沒有它們。 美國預防醫學雜誌，61：S118-S129，2021 年 11 月。 doi：10.1016/j.amepre.2021.05.044
The US must tackle racial disparities among people who inject drugs and expand syringe service programmes
Mariah Wilberg /26 January 2022/aidsmap
Nigel Brunsdon/nigelbrunsdon.com
Results published in the Morbidity and Mortality Weekly Report show alarming racial disparities in HIV prevalence and access to services among people who use drugs in US cities. Between 2015 and 2018, the overall prevalence of HIV infection among people who inject drugs held steady at 7%. However, Black people had higher rates of HIV than their Hispanic or White counterparts, despite reporting fewer HIV risk behaviours. Similarly, overall use of syringe service programmes held relatively steady between 2015 and 2018. Underlying that were concerning racial disparities, with access improving for White and Hispanic people but substantially declining for Black people. The latter group were also less likely to be prescribed medication to treat opioid use disorder.
Once on the decline in the US, new HIV infections attributed to injection drug started to increase in 2014. Since 2015, multiple HIV outbreaks have been reported among PWID in the US, including current outbreaks in Minnesota and West Virginia. These increases and outbreaks have largely been attributed to increases in both prescription and non-prescription opioid use in the US.
Syringe service programmes (SSPs) are a safe and cost-effective way to prevent HIV among PWID that have not been shown to increase drug use or crime. SSPs can help prevent transmission of viral hepatitis and other bacterial or fungal blood-borne infections, facilitate safe disposal of used syringes, prevent overdose deaths, and serve as a conduit for linkage to substance use disorder treatment, antiretroviral therapy, pre-exposure prophylaxis, and other services for PWID. A separate literature review looked at the role of SSPs and concluded that the US will not end the HIV epidemic without scaling up SSPs. They recommend maximising the impact of SSPs by following best practices, including a comprehensive approach where PWID can access medications to treat opioid use disorder, PrEP, and antiretroviral therapy within SSPs.
The study
The 2018 National HIV Behavioral Surveillance survey conducted by the Centers for Disease Control and Prevention (CDC) collected cross-sectional data and conducted HIV testing with PWID in 23 US metropolitan statistical areas. Researchers used respondent-driven sampling, where 28 PWID were selected at each site and asked to recruit up to five peers, with the new referrals also encouraged to recruit up to five peers, and so on. Participants received incentives for every successful recruitment, as well as for completing interviews and HIV tests. Eligible participants were people who had injected non-prescribed drugs in the previous 12 months, who resided in one of the metropolitan statistical areas, who were 18 or older and could complete the interview in English or Spanish. A total of 11,348 PWID were included in the study. Sixty-seven per cent were male, 32% female, and 1% transgender. The largest proportion of respondents (42%) were White, non-Hispanic, followed by Black, non-Hispanic (32%), Hispanic people of any race (24%), and other (2%). Fifteen per cent were aged 12-29, 23% were 30-39, 24% were 40-49, and 38% were 50 or older. Among male respondents, 10% reported a male partner within the previous twelve months. Researchers were able to estimate the overall prevalence of HIV for this group. However, the number was too small to produce reliable estimates of specific sexual practices between men. Most participants (80%) had been injecting drugs for five or more years and over half (55%) reported most frequently injecting only heroin. Most respondents (82%) had current health insurance.
Almost three-quarters (72%) had a high school diploma or greater, but most (75%) lived at or below the federal poverty guidelines.
Considering US census regions, 36% were from the Northeast, 29% from the South, 8% from the Midwest, and 26% from the West. There were also just under 500 participants in San Juan, Puerto Rico, which is not included in any of the Census regions. No rural areas were included.
Results
Overall, 7% of participants tested positive for HIV, including 10% prevalence in the Northeast, 9% in the South, 1% in the Midwest, and 4% in the West. Overall prevalence was unchanged from the previous National HIV Surveillance study conducted in 2015. Weighted HIV prevalence was highest among gay and bisexual men who also reported injection drugs use (25%) and PWID aged 40-49 (12%). Black participants had a higher HIV prevalence (12%) than White (5%) and Hispanic (5%) participants. Overall, 26% reported using syringes previously used by another person. This was highest among White people (36%) compared to Hispanic (22%) or Black (16%) interviewees. Across sites, nearly half (49%) reported using injection equipment (e.g., cottons, cookers, water) that had previously been used.
“Access to syringe services improved for White and Hispanic people but substantially declined for Black people”
Overall, 68% of HIV-negative PWID reported vaginal sex without a condom; this was highest among White PWID (73%), followed by Hispanic and Black participants (both 63%). Overall, 23% reported heterosexual anal sex without a condom, highest among Hispanic (30%), White (24%), and Black (16%) participants. Racial disparities were also present in testing, prevention and treatment. Fifty-seven per cent of HIV-negative interviewees had received an HIV test in the previous twelve months, with fewer White PWID receiving a test (53%) than Hispanic PWID (62%). Over half (56%) reported using medication to treat opioid use disorder (MOUD) in the preceding twelve months, with Black people being the least likely to be using MOUD at 47%, compared to 58% of White people and 65% of Hispanic people. Participants who had health insurance accessed more services than those who didn’t, including HIV testing (59% vs 47% respectively), HIV behavioural interventions (35% vs 22%), ever testing for hepatitis C (86% vs 71%), and receiving MOUD (61% vs 35%). Overall, 55% of PWID received syringes from an SSP in the previous twelve months, comparable to the 52% reported in the 2015 national study. However, the overall figures mask a troubling reality: SSP use diverged along racial lines in those three years. In 2015, SSP use was fairly even among Black, White, and Hispanic people at 51%, 53%, and 54%, respectively. By 2018, SSP use had increased to 63% for both White and Hispanic people, while the proportion of Black PWID receiving syringes from an SSP dropped sharply to 40% .
This study offers a pre-COVID-19 snapshot of PWID in urban areas of the US. The pandemic has disrupted access to SSPs and related services, but it is too soon to fully understand the implications of these disruptions on the health of PWID. Further, the study only included PWID who live in metropolitan areas. Multiple HIV outbreaks have been reported among PWID living in rural and non-urban areas, and these settings present different challenges. These include fewer or non-existent SSPs, fragmented services, having to travel far to access services, challenges with broadband access that can limit virtual services, and different social and political climates. Nonetheless, the overall stagnant outcomes and worsening racial disparities suggest that existing SSPs are failing to make meaningful progress for PWID. A recent literature review concluded that the US will not end the HIV epidemic without scaling up SSPs and adopting best practices.
Improving syringe service programmes
Dr Dita Broz and colleagues from the CDC conducted a literature review about the role of SSPs in the US Ending the HIV Epidemic (EHE) initiative. The review covered the evidence base for the role of SSPs in the four pillars of the EHE initiative: prevent, diagnose, treat, and respond (to HIV outbreaks). The evidence, which has been accumulating for decades, showed that SSPs can make meaningful and significant progress towards these goals. However, these benefits are largely dependent on whether the SSPs follow best practices for service delivery. One key element of best practice is needs-based syringe distribution, e.g., not limiting the number of syringes provided. A survey of clients from 24 SSPs found that 61% reported using a sterile syringe for each injection under needs-based distribution, compared to 26% under a one-for-one syringe exchange. Any policy that limits syringes can also limit one of the most effective tools of an SSP: secondary syringe distribution by peers. Peers, including current clients, have been shown to reach more diverse networks of PWID and reach individuals who are facing barriers to accessing services. SSPs should train and support peer educators and actively promote secondary syringe distribution. SSPs should be responsive to the needs of the local PWID population. People who use drugs should be engaged in programme design and implementation, which may require adapting the planning process to accommodate such participation. Service delivery should also be adapted to local needs. Another way to maximise responsiveness it to ensure that staff or volunteers share lived experience with clients. Given the low rates of SSP utilisation by Black PWID, recruitment from Black communities may be particularly important.
“Offering PrEP at syringe services can allow PWID to access PrEP in a setting where they are comfortable.”
Engaging the local community can also create a supportive social and legal environment for SSPs. Diverse partners should be engaged, including law enforcement, health departments, local businesses, and faith-based organisations. Deliberately engaging the Black community may help address the existing racial disparities. Access to SSPs should be ‘low-threshold’: SSPs should allow clients to be anonymous, avoid extensive intake processes, only collect the minimum data necessary for programme evaluation, and increase locations and available hours. Further, syringe vending machines, allowing sales of syringes at pharmacies, and home and mail delivery are all strategies that can complement SSPs. SSPs often reach PWID who may not otherwise engage in the healthcare system. As such they offer an important opportunity meet people where they are at. All the available evidence show that SSPs have the greatest impact with a comprehensive, integrated approach that addresses other needs of PWID. At a minimum, SSPs should also offer HIV and hepatitis C testing and linkage to care, naloxone distribution, and provision of or linkage to substance use disorder treatment, including medication to treat opioid use disorder (MOUD). Studies have shown an additive effect of co-located services. The risk for HIV transmission can drop by nearly 50% when PWID can access both SSPs and MOUD. When both MOUD and ART are available at SSPs, there is a positive impact on ART adherence. This integrated approach may have implications for PrEP use as well. More research on integrating PrEP in SSPs is needed, but studies have shown that both PWID and providers report a preference for PrEP access at SSPs. Offering PrEP at SSPs can reduce the number clinic visits and allow PWID to access PrEP in a setting where they are comfortable and less likely to encounter stigma. Telehealth is one way to offer MOUD, PrEP, and ART for PWID. Other strategies that can increase integration include having healthcare providers see patients in SSPs, directly administered ART, standing PrEP orders, and on-site medication lockers. Such comprehensive services maximise the impact of SSPs on the health and wellbeing of PWID.
Conclusion
In the context of a worsening opioid crisis and nationwide HIV outbreaks among people who inject drugs, it is clear that efforts end HIV in the United States will not be achieved without scaling up SSPs and following best practices. The need is great. The most recent snapshot of PWID in urban areas of the US showed that just over half of PWID had accessed an SSP in the preceding twelve months; an incomplete picture that doesn’t account for PWID living in rural or remote locations. Black PWID experienced a drastic decline in use of SSPs over three-year period, had a higher prevalence of HIV despite engaging in fewer HIV risk behaviours, and had inequitable access to MOUD. The US Ending the Epidemic initiative offers an opportunity to end HIV among PWID through expansion of SSPs and related services. Efforts to do so must directly address racial disparities in HIV prevalence and service use among PWID.
References
Handanagic, S et al. HIV infection and HIV-associated behaviors among persons who inject drugs — 23 metropolitan statistical areas, United States, 2018. Morbidity and Mortality Weekly Report, 70: 1459-1465, October 2021. doi: 10.15585/mmwr.mm7042a1
Broz, D et al. Syringe service programs’ role in ending the HIV epidemic in the U.S.: why we cannot do it without them. American Journal of Preventive Medicine, 61: S118-S129, November 2021. doi: 10.1016/j.amepre.2021.05.044