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The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects

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Abstract

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16–0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22–0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

Resumen

Realizamos una revisión sistemática y un metanálisis del impacto de los programas de intercambio de agujas y jeringas (NSP, por sus siglas en inglés) de los comportamientos de uso compartido de agujas tanto a nivel individual como comunitario y otros resultados relacionados con el VIH en países de ingresos bajos y medianos (LMIC, por sus siglas en inglés). Realizamos búsquedas sistemáticas en cinco bases de datos hasta julio de 2021 en busca de ensayos revisados por pares o estudios cuasiexperimentales. En general, 42 intervenciones informadas en 35 estudios entre 56 751 participantes cumplieron los criterios de inclusión. El metanálisis de efectos aleatorios de ocho estudios a nivel individual y 12 a nivel comunitario con 11 075 participantes en total mostró una asociación protectora significativa entre la exposición a NSP y los comportamientos de compartir agujas (individual: OR 0,25, IC95%: 0,16–0,39; comunidad: OR 0,39, IC95%:0,22–0,69), aunque con una heterogeneidad importante. Cuando se estratificó por la direccionalidad del intercambio de agujas, la exposición a NSP permaneció asociada con un intercambio receptivo reducido, pero no con un intercambio distributivo. La exposición a NSP también se asoció con una incidencia reducida del VIH y un aumento de las pruebas del VIH, pero no hubo asociaciones consistentes para la prevalencia de infecciones transmitidas por la sangre. La evidencia actual sugiere impactos positivos de los NSP en los LMIC.

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Acknowledgements

The authors wish to thank Elizabeth Jere, Carolyn Pleisca, Sarah Mauch, Alison Groves, Rachel Hower, Devaki Nambiar, Jennifer Gonyea, Andrea Ippel, Kirk Fiereck, Prossy Namusisi, and Indira Prihartono for their coding work on this project, Lindsay Cooper for her assistance in checking the Spanish language abstract, and Elena Tuerk and Julie Denison for their contributions to study development and supervision.

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Funding

This work was supported by the US National Institute of Mental Health (Grant Numbers R01MH071204, R01MH090173, R01MH125798).

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Author notes

  1. Ping Teresa Yeh and Xuhao Yang are co-first authors.

Authors and Affiliations

  1. Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA

    Ping Teresa Yeh, Xuhao Yang, Caitlin E. Kennedy &  Sherryn

  2. Division of Global and Community Health, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA

    Kevin A. Armstrong, Virginia A. Fonner, Kevin R. O’Reilly & Michael D. Sweat

  3. FHI 360, Health Services Research Division, Durham, NC, 27701, USA

    Virginia A. Fonner

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Contributions

MDS and KRO conceptualized the study. MDS, KRO, PTY, CEK, and VAF were responsible for the methodology of the study. PTY and XY were responsible for data curation, though all authors were involved in literature search and screening, data collection, and data analysis to varying degrees. KAA and MDS conducted formal meta-analysis, while PTY, XY, S, and CEK performed qualitative synthesis. The original draft was written by PTY and XY, with support from S and CEK. All authors were involved in reviewing and editing the manuscript and gave their approval for submitting the final manuscript.

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Appendix: Search Strategy for All Databases, Last Searched on July 25, 2021

Appendix: Search Strategy for All Databases, Last Searched on July 25, 2021

PubMed

(“needle exchange” OR “needle distribution” OR “needle sales” OR “syringe sales” OR “syringe distribution” OR “syringe exchange” OR “syringe-exchange” OR “needle-exchange” OR “needle syringe programs” OR “needle syringe program” OR “needle syringe programme” OR “needle exchange programmes”) AND (HIV or AIDS).

PsycINFO

(“needle exchange” OR “needle distribution” OR “needle sales” OR “syringe sales” OR “syringe distribution” OR “syringe exchange” OR “syringe-exchange” OR “needle-exchange” OR “needle syringe programs” OR “needle syringe program” OR “needle syringe programme” OR “needle exchange programmes”) AND (HIV or AIDS).

CINAHL

(“needle exchange” OR “needle distribution” OR “needle sales” OR “syringe sales” OR “syringe distribution” OR “syringe exchange” OR “syringe-exchange” OR “needle-exchange” OR “needle syringe programs” OR “needle syringe program” OR “needle syringe programme” OR “needle exchange programmes”) AND (HIV or AIDS).

Sociological Abstracts

(“needle exchange” OR “needle distribution” OR “needle sales” OR “syringe sales” OR “syringe distribution” OR “syringe exchange” OR “syringe-exchange” OR “needle-exchange” OR “needle syringe programs” OR “needle syringe program” OR “needle syringe programme” OR “needle exchange programmes”) AND (HIV or AIDS).

Embase

(‘needle exchange’ OR ‘needle distribution’ OR ‘needle sales’ OR ‘syringe sales’ OR ‘syringe distribution’ OR ‘syringe exchange’ OR ‘syringe-exchange’ OR ‘needle-exchange’ OR ‘needle syringe programs’ OR ‘needle syringe program’ OR ‘needle syringe programme’ OR ‘needle exchange programmes’) AND (HIV or AIDS).

Hand search of the following journals:

AIDS

AIDS and Behavior

AIDS Care

AIDS Education and Preventionthe International Journal of Drug Policy

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Yeh, P.T., Yang, X., Kennedy, C.E. et al. The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects. AIDS Behav 27, 3306–3331 (2023). https://doi.org/10.1007/s10461-023-04051-x

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