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Assessing the impact of nascent harm reduction efforts in Malaysia

Comparing injection risk behaviors among individuals with and without access to needle and syringe exchange. Alexander R. Bazazi Alexei zelenev Jeannia J. Fu Adeeba Kamarulzaman Frederick L. Altice. Assessing the impact of nascent harm reduction efforts in Malaysia.

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Assessing the impact of nascent harm reduction efforts in Malaysia

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  1. Comparing injection risk behaviors among individuals with and without access to needle and syringe exchange Alexander R. Bazazi Alexei zelenev Jeannia J. Fu Adeeba Kamarulzaman Frederick L. Altice Assessing the impact of nascent harm reduction efforts in Malaysia Yale school of medicine, Yale School of Public Health University of malayacentre of Excellence for research in AIDS

  2. Background • Numerous studies show that needle and syringe exchange programs (NSEPs) reduce injection risk behaviors and transmission of blood-borne viruses; not associated with increased injection frequency • Recommended as one of nine interventions in the WHO comprehensive package for people who inject drugs (PWIDs) • NSEP was first introduced in KL in 2006 after Malaysia did not meet Millennium Development Goal 6, and has since expanded nationwide Des Jarlais 2013; Watters 1994; Hartgers 1989; WHO 2012; Kamarulzaman 2009

  3. Challenges to evaluating NSEP • Selection bias in observational studies: • Individuals at higherrisk for HIV are more likely to use NSEPs. • Predictors of initial engagement in NSEPs: • Homelessness, high-risk injection practices • Predictors of retention in NSEPs: • Frequent injection, high-risk injection practices • Randomized trials rarely conducted due to logistical and ethical issues. Fisher 2002; Hagan 2000; Hahn 1997

  4. Specific Aim • To estimate the difference in HIV risk behaviors that can be attributed to NSEPs by matching similar individuals with and without access to NSEPs from a sample of PWIDs in Klang Valley, Malaysia.

  5. DATA description syringe • Cross-sectional sample of 460 PWIDs recruited using respondent-driven sampling in 2010 • Recruitment at 3 locations in Kuala Lumpur and surrounding areas in the Klang Valley • “Treatment” variable was defined as receiving most injection equipment from a NSEP • Outcomes: • Receptive sharing of injection equipment in prior 30 days • Binary (any sharing vs. no sharing) and count data (frequency) • Syringe barrel and needle reusein prior 30 days • Count data (frequency) needle

  6. Analytic methods • Parameter of interest: “Average effect of treatment on the treated” • What is the estimated effect of NSEPs on the HIV risk behaviors of people who accessed NSEPs? • First, each participant accessing NSEP was matched 1:4 to the most similar participants not accessing NSEPs. • Participants were matched on correlates of accessing NSEP that were not likely influenced by NSEP: • 1) recruitment site, 2) injections per day, 3) daily injection, and 4) unstable housing • Nearest neighbor matching used, Abadie & Imbens robust standard errors calculated. • Then, examined differences in HIV risk behaviors between each participant accessing NSEP and the average of their four matched participants (“controls”) Fisher 2002; Hagan 2000; Hahn 1997; Abadie & Imbens 2004

  7. Sample description (N=460) Sample is predominantly Malay (90%) men (96%) who had been injecting for >5 years (82%). All used opioids: (heroin) (94%); methadone (33%); buprenorphine (18%). Also, benzodiazepines(33%), methamphetamine (32%), and alcohol (18%).

  8. results

  9. Conclusions • There was a significant reduction (31%) in sharing of needles, but not syringe barrels, among PWIDs accessing NSEP services. • Syringe sharing is less common than needle sharing, and syringes are reused many more times than detachable needles. • NSEPs reduce reuse and therefore circulation time of both needles and syringes, potentially lowering the risk of transmission of blood-borne viruses. • Despite limitations in the study design and availability of measures related to accessing NSEPs, these data provide empirical support for expansion of NSEPs in Malaysia

  10. acknowledgments Research Assistants Clinic directors IshakKhafidz, M.D. MohdGhanni, M.D. L. Ting, M.D. • Ezra Akbar • NurAfiqahSalleh • MohdAzizi • HisyamuddinNawi • SyazwaniZakaria • AmranHashim • NurAinnaAmira • ElfaridzMohd. Radzi Other assistance • Theresa Anthony, CERiA • Rusdi Rashid, M.D. UMCAS • HussainHabil, M.D. UMCAS • Malaysian AIDS Council Needle Exchanges Funding • IKHLAS • PersuatanInsafMurni Malaysia • KAWAN • University Malay High Impact Research Grant • Yale Downs Fellowship • Yale OIMSE, OSR all the participants who gave generously of their time.

  11. Appendix (1): Crude and Adjusted Differences in outcomes

  12. Appendix (2): Matching Variables

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