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Syringe sharing among people who inject drugs in Tijuana: before and after the Global Fund. Daniela Abramovitz 1. Javier Cepeda 1. Gudelia Rangel 2 3. Natasha K. Martin 1. Steffanie A. Strathdee 1. However, their effectiveness relies on sufficient individual and population level coverage. Subsequently, we found a significant decline in NSP access -. Coordinated efforts with local authorities are needed to sustain major coverage NSP in settings receiving GF or external aid to guarantee continuity of harm reduction services and prevent reinside in risk behaviors associated with HIV transmission. Sin embargo, su efectividad depende de una cobertura suficiente a nivel individual y poblacional. Needle and syringe programs NSP have been shown to effectively reduce syringe sharing among people who inject drugs PWID in a range of settings Fernandes et al. Regarding this, a recent meta-analysis Aspinall et al. Effectiveness of NSP varies between settings, partly as a result of heterogeneity in coverage. In addition, the number of syringes received by PWID should be sufficient to cover at least each one of their daily injections to reduce the risk of syringe sharing. Tijuana is a border city in Baja California, Mexico, situated on a major illicit drug trafficking route towards the United States. As a result, it has a high prevalence of illicit drug use. However, due to the launch of a new GF funding model in , based on calculations of country income and national disease burden Bridge et al. As the cohort is ongoing, we have monitored temporal trends biannually before, during, and after the GF funding period, thereby providing an opportunity to investigate the impact of GF investment and withdrawal on NSP access on receptive syringe sharing. Using data from this cohort, Cepeda et al. We also investigated changes in the number and cost of syringes distributed by one of the main NSPs in Tijuana before and after GF withdrawal. We expanded the study period to include the pre-GF period to characterize the impact of GF initiation on these outcomes. We hypothesised that 1. GF support initiation resulted in significant increases in NSP access and in significant reductions in receptive syringe sharing, which were sustained over the funding period and that 2. Eligibility criteria included injecting drugs within the past month, being at least 18 years old, being able to speak Spanish or English, and currently living in Tijuana with no plans to move away in the following two years. Participants completed a baseline survey and bi-annual follow up surveys in Spanish or English administered by trained interviewers using computer assisted personal interviewing technology in a private setting. Written informed consent was obtained prior to completing any study procedures. Study interviews captured information on drug use, including information on harm reduction service utilization and syringe sharing. We carried out descriptive analyses of the baseline data to characterize PWID participating in the cohort in terms of socio-demographics, injecting behaviors, and access to harm reduction. Chi-square tests and Wilcoxon rank sum tests were conducted to assess differences between men and women for binary and continuous variables, respectively. In particular, we were interested in assessing differences by gender in our three variables of interest to determine whether we needed to control for gender in our primary analysis. To assess how GF support which officially started October 15, and GF withdrawal which officially started December 31, may have impacted NSP clean syringe provision and syringe sharing among PWID, we analysed data collected between March and September Following Cepeda et al. Although officially the GF support started and ended on the dates mentioned above, we assumed that the GF implementation and its winding down, respectively, took about three months, and as a result, we adjusted the starting dates for the during GF and post-GF periods accordingly. Furthermore, since the surveys assessed the outcome for the previous six-months, responses from surveys that took place three months or less into one of the global funding periods were classified as part of the previous period e. Mixed effects logistic regression models with random intercepts and an unstructured covariance matrix to control for within subject correlations and period as a fixed effect, was used to estimate the probability of each outcome at each of the 18 three-month time periods. Gender was used as a covariate in models in which the outcome was found to significantly differ by gender. Then, the probabilities for each period estimated by the mixed effects logistic regression models were used as the outcome variable in a segmented regression analysis Lopez Bernal et al. The segmented regression models were tested for autocorrelation by using the Durbin-Watson test, and auto-regressive terms were added to the models to adjust for auto-correlation. The auto-regressive error models were estimated using the maximum likelihood ML method with the Yule-Walker estimates being used as starting values for the iterative computation of the ML estimates. All analyses were conducted in SAS v9. Mean age was Also over a quarter reported experiencing homelessness in the past six months, with this being higher among women compared to men The average duration of injection was The vast majority Over half However, no significant differences by gender were found in terms of their reported difficulty in finding sterile syringes and in receptive syringe sharing. Table 1. A comparison of the participants lost to follow-up with those who completed the follow-up showed that there were no significant differences between the two with respect to socio-demographic characteristics data not shown. Figure 1 shows the mean predicted probability of reporting obtaining syringes from NSP Panel A , finding it hard to get sterile syringes Panel B and receptive syringe sharing Panel C at each of the 18 time periods spanning the pre-, during- and post-GF periods. Level changes immediately after the GF started and immediately after it ended i. Figure 1. Probability of A receipt of syringes from NSP in the past 6 months, B finding it hard to get new syringes in the past 6 months and C receptive syringe sharing in the past 6 months based on self-reports pre, during and post Global Fund support among PWID in Tijuana. For the three estimates within the pre-GF period, the number of observations range was observations; for the nine estimates during the GF period there were observations; and for the six estimates within the post-GF period, there were Table 2. Estimates of level of change comparing the pre-, during, and post-Global Fund support periods and trend change in pre-, during, and post-Global Fund support periods for the probability of getting syringes from NSP, finding it hard to get sterile syringes and receptive syringe sharing in the past 6 months. The probability of reporting difficulty in obtaining sterile syringes was highest during the pre-GF period and this trend was maintained over the entire period. We found significant changes in the trends of receptive syringe sharing in each of these three periods consistent with our hypothesis of lower probability of syringe sharing during GF support as a result of higher NSP coverage and increased syringe sharing following GF withdrawal. We also investigated whether changes in syringe sharing were consistent with trends in the probability of obtaining syringes from NSP and of reported difficulty in finding sterile syringes. During the pre-GF period, the frequency of receptive syringe sharing increased and so did NSP access. While this result is counterintuitive, the effect size for receptive syringe sharing 12 percentage points was much larger than the effect size for access to NSP 1 percentage point. In turn, we found a much larger and significant increase in NSP access immediately following initiation of GF support, which was consistent with a very large decrease in receptive syringe sharing. This finding is supported by significant declines in reported difficulty in finding sterile syringes. The significant decrease in NSP access immediately post-GF withdrawal and thereafter was also consistent with observed increases in syringe sharing and in reported difficulty in finding sterile syringes, suggesting a strong relationship between GF support and NSP access. The magnitude of the decrease in syringe sharing during the GF support appears large compared to that of the increase in NSP access. Indeed, the kits distributed over this period by at least one of the NSP in Tijuana contained 60 syringes each Cepeda et al. It is also likely that the increase in NSP access translated into greater reductions in syringe sharing by reducing overall opportunities for sharing i. Interestingly, the changes in NSP access and syringe sharing post-GF support were of much closer magnitude, suggesting that PWID might have found alternative ways of obtaining sterile syringes following reductions in NSP coverage. Our study suggests that while the GF support likely translated into higher NSP access and drastic reductions in syringe sharing, its abrupt withdrawal appears to have had immediate and long-lasting repercussions on both outcomes. Importantly, sudden large-scale increases in syringe sharing at the population level can drive outbreaks of HIV and other bloodborne infections. The GF has been the global leading donor for harm reduction services for over a decade making huge contributions towards the scale up of NSP and opioid substitution therapy OST Bridge et al. However, the proportion of GF resources allocated to harm reduction services hugely decreased following their transitional funding mechanism in from USD million in to USD million in and it is unclear how the new funding model has impacted this distribution Bridge et al. Restricting funding based on income status ignores the profound health inequalities pervasive in many middle- and high-income countries, which predispose vulnerable communities such as PWID to increased hardship Bridge et al. Under the current funding situation, local governments must make additional financial commitments to cover harm reduction needs to prevent the progress achieved so far from being eroded. In addition to investigating the impact of changes in GF support on NSP access and syringe sharing, our study contributes additional evidence on the association between NSP coverage and syringe sharing available from numerous settings. A consensus study Wiessing et al. We investigated changes in trends of NSP access, ease of syringe access, and receptive syringe sharing over different GF periods. However, given the ecological nature of this analysis, we cannot directly attribute these to either GF support or lack of such Cepeda et al. Similarly, our analyses do not demonstrate a direct causal relationship between each of the three outcomes. Rather, these show consistency between observed trends, which support our hypothesis. It is worth mentioning that not all participants contributed equally to all the periods, but the loss to follow up was low. Finally, our analyses rely on self-reported behaviors and are subject to social desirability and imprecision due to recall. Despite this, study interviewers were highly experienced in interviewing PWID in Tijuana and created a trusting and non-judgmental environment, suggesting that social desirability may have been limited. Similarly, several studies have shown that the combination of NSP and OST results in synergistic reductions in syringe sharing and bloodborne infection incidence. Examining these questions in the context of Tijuana will be important next steps to estimate and improve the effectiveness of NSP. Our study provides strong evidence at the ecological level of a relationship between GF support, access to NSP, and receptive syringe sharing. To be effective, harm reduction efforts require appropriate scale-up and sustainability and therefore coordinated efforts with local, state, and federal authorities are needed to ensure the continuity of harm reduction coverage following donor aid withdrawal. The authors wish to thank the study participants for sharing their detailed histories, without which this research would not have been possible. We also wish to thank the Tijuana and San Diego research staff members for their dedication to the research study. Aspinall, E. Hutchinson, S. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: A systematic review and meta-analysis. International Journal of Epidemiology , 43 1 , Bridge, J. Wolfe, D. International Journal of Drug Policy , 27 , Cepeda, J. Martin, N. Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: A costing analysis. BMJ Open , 9 1 , e Csete, J. Beyrer, C. Public health and international drug policy. The Lancet , , Fernandes, R. Carneiro, A. Effectiveness of needle and syringe Programmes in people who inject drugs—An overview of systematic reviews. BMC Public Health , 17 1 , Kelley, M. A cultural impact of needle exchange: The role of safer-injection mentors. Contemporary Drug Problems , 28 3 , Lopez Bernal, J. Interrupted time series regression for the evaluation of public health interventions: A tutorial. International Journal of Epidemiology , 46 1 , PI: Steffanie Strathdee. Platt, L. Hickman, M. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Robertson, A. Strathdee, S. Harm Reduction Journal , 11 1 , 4. Sawangjit, R. Addiction , 2 , Shaw, S. Determinants of injection drug user IDU syringe sharing: The relationship between availability of syringes and risk network member characteristics in Winnipeg, Canada. Addiction , 10 , Snead, J. Secondary syringe exchange among injection drug users. Journal of Urban Health , 80 2 , Patterson, T. Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region. PLoS One , 6 4 , e Differential effects of migration and deportation on HIV infection among male and female injection drug users in Tijuana, Mexico. PloS One , 3 7 , e Individual, social, and environmental influences associated with HIV infection among injection drug users in Tijuana, Mexico. Journal of Acquired Immune Deficiency Syndromes , 47 3 , Vickerman, P. Model projections on the required coverage of syringe distribution to prevent HIV epidemics among injecting drug users. Wagner, A. Segmented regression analysis of interrupted time series studies in medication use research. Journal of Clinical Pharmacy and Therapeutics , 27 4 , White, E. Wiessing, L. Griffiths, P. Monitoring quality and coverage of harm reduction services for people who use drugs: A consensus study. Harm Reduction Journal , 14 1 , Email: aborquez ucsd. Conflicts of interest The authors declare they have no conflicts of interest. This is an open-access article distributed under the terms of the Creative Commons Attribution License. Servicios Personalizados Revista. Similares en SciELO. Original articles Syringe sharing among people who inject drugs in Tijuana: before and after the Global Fund. Discussion and conclusion We demonstrated significant temporal changes in NSP access and receptive syringe sharing among PWID in Tijuana after GF initiation and withdrawal consistent with our hypothesis. Introduction Needle and syringe programs NSP have been shown to effectively reduce syringe sharing among people who inject drugs PWID in a range of settings Fernandes et al. Measures Study interviews captured information on drug use, including information on harm reduction service utilization and syringe sharing. Statistical analyses We carried out descriptive analyses of the baseline data to characterize PWID participating in the cohort in terms of socio-demographics, injecting behaviors, and access to harm reduction. Acknowledgments The authors wish to thank the study participants for sharing their detailed histories, without which this research would not have been possible. Received: February 23, ; Accepted: August 01, Duration years of injection Y. Number of times overdosed ever Y. Ever received professional help for drug or alcohol use. Level change after global funding begins change between pre-global and during-global funding periods. Level change after global funding ends change between during-global and post-global funding. Trend change after global funding.

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