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AIDS Education and Prevention, 15(3), 2 © 2003 The Guilford Press 268, 2003 A META-ANALYSIS OF NEEDLE SHARING, LENDING, AND BORROWING BEHAVIORS OF NEEDLE EXCHANGE PROGRAM ATTENDERS Kate Ksobiech This study used meta-analysis to examine cumulatively needle exchange pro- gram (NEP) change/comparison data from 47 studies between 1988 and 2001, based on data collected between 1986 and 1997. The research question posed was: Is NEP attendance associated with reductions in risky needle-related behav- iors? Results indicated that needle sharing (r= -.189), variations on the outcome measure of needle sharing (r = -.161), and needle lending/borrowing (r= -.194) consistently declined among NEP attenders, suggesting the NEPs are effective in reducing risky needle-related behaviors of IDUs. The meta-analytic results lend support to the harm-reduction philosophy often used as the rationale for the es- tablishment and maintenance of NEPS. Over the past two decades, one of the more controversial approaches to stemming the HIV/AIDS epidemic has been the creation of Needle Exchange Programs (NEPs), through which injection drug users (IDUs) are provided with sterile needles in ex- change for contaminated needles at little or no cost. Support for NEPs derived from a common philosophy, harm reduction, as first articulated by Newcome and Perry (1988), and theoretically supported via the mathematical formulae attributed to Kaplan and Heimer’s Circulation Theory (1994). Despite the ongoing debate regarding NEPs, there are now at least 131 such pro- grams operating in the United States, a significant number given that there were none at all until 1988 (“Update: Syringe Exchange Programs,” 2001). While there have been many individual studies conducted to describe and/or evaluate these NEPs, there is a need for a cumulative, statistical assessment of their impact on various risky, Kate Ksobiech is with the Center for AIDS Intervention Resi Medicine, Medical College of Wisconsin. Preparation of this manuscript was supported, in part, by center grant P30-MH52776 from the National Institute of Mental Health; NRSA postdoctoral training grant T32-MH19985; and Graduate School Dis- sertation Fellowship, University of Wisconsin-Milwaukee. ‘The author gratefully acknowledges the contribution of Mike Allen, Ph.D., Uni waukee, for his assistance in the coding of data for this study, and Anton Somlai, with editing this manuscript. Address correspondence to Kate Ksobiech, ment of Psychiatry and Behavioral Medicit Milwaukee, WI 5320. +h, Department of Psychiatry and Behavioral ity of Wisconsin-Mil D., for his assistance Ph.D., Center for AIDS Intervention Research (CAIR), Depart- -, Medical College of Wisconsin, 2071 North Summit Avenue, -mail: kksobiec@mew.edu 257 258 KSOBIECH drug-related behaviors, needle sharing in particular, ‘This study used the statistical technique of meta-analysis to initiate such an overview. By 1988 IDUs were recognized as a “reservoir for HIV infection” (Brown & Primm, 1988), and the President’s Commission on the Human Immunodeficiency Vi- rus Epidemic wrote, “Our nation’s ability to control the course of the HIV epidemic depends greatly on our ability to control the problem of intravenous drug abuse” (“President's Commission,” 1988, p. 94). It is estimated that over a million people in the United States inject drugs, at a cost to society of more than $50 billion a year (“Does HIV Needle Exchange Work?” 1998), These costs include health care, lost productivity, and crime. Beyond potentially sacrificing their own health, IDUs place others (e.g., sexual partners, needle-sharing partners, and offspring) at risk through their drug use (Des Jarlais, Friedman, & Ward, 1993). The HIV/AIDS epidemic in the United States and worldwide is a complicated, multi-layered problem, Injection drug use is but one of the risk behaviors, albeit an im- portant one, engaged in by those who are at high risk for HIV/AIDS. For a variety of reasons, such as differences in drug use patterns, different IDU demography, and dif ferent sociocultural factors, the international community (outside the United States) was reasonably quick to recognize and often legalize NEPs as a means to contain the spread of HIV/AIDS in the IDU community. Via changes in the law or working agree ments between public health officials and a variety of government officials, nations such as Switzerland, the Netherlands, the United Kingdom, Sweden, and Australia forged a public policy to support NEPs in the mid- to late-1980s (Stryker, 1989). Proponents of NEPs maintain that there are benefits to IDUs, community, and society in the form of: (1) reduced HIV seroconversion rates; (2) reduced harm to TDUs; (3) less needle sharing; and (4) fewer dirty/discarded needles in circulation (Geyser, 2000). They assert that the totality of the evidence from NEP-related, evaluative studies supports their effectiveness while not substantiating, to any signifi- cant degree, the concerns of critics with respect to encouraging drug use and facilitat- ing undesirable behaviors (Stryker & Smith, 1993). Further, NEP advocates argue that this approach has been more effective than other alternatives, such as bleach ster- ilization in limiting the availability and use of contaminated needles (Geyser, 2000), while also creating a bridge to entice IDUs into treatment programs (Ferguson, Perez, & Burris 1998). STATEMENT OF PROBLEM Researchers focusing specifically on NEPs have conducted numerous studies, both quantitative and qualitative, using a wide variety of techniques to measure dependent variables, such as rate of HIV infection, number of needles exchanged, amount of nee- dle sharing, number of referrals for medical or psychological treatment, and other risky IDU-related behaviors. To summarize these studies and derive collective conclusions from these isolated investigations, there have been at least eight narrative reviews of the NEP evaluative literature (Drucker, Lurie, Wodak, & Alcabes, 1998; “The Effectiveness of AIDS Pre- vention Efforts,” 1995; General Accounting Office, 1993; Lurie et al., 1993; Normand, Vlahov, & Moses, 1995; “Proceedings of the National Institutes of Health Consensus Conference,” 1997; “Report to the Committee on Appropriations for the Department of Labor, Health and Human Services and Related Agencies,” 1998; and" The Twin Epidemics of Substance Use and HIV," 1991). All of these narrative NEPs AND RISKY IDU DRUG BEHAVIORS META-ANALYSIS 259 overviews conclude that NEPs are a useful rool for public health officials in their ef forts to control the spread of HIV/AIDS. More recently, Cross, Saunders, and Bartelli (1998) performed a meta-analysis on needle sharing behavior, with data from ten NEP studies published between 1984 and 1995, From a combined total of 1,675 subjects, there was a weighted mean effect of .279, using the Glass, MeGaw, & Smith (1981) probit transformation table, sug- gesting that NEP use was associated with reductions in high risk drug behaviors. The researchers cautioned that the effect might be the result of differences between nations and their ability to enforce drug-related laws, relative acceptance of NEPs, or the abil- ity of program staff to conduct other harm-reduction activities, ‘The present paper reports on the results of three meta-analyses, focused on vari- ous categories of needle sharing behavior. It extended the work of Cross et al. (1998) by gathering and recoding the data from studies that measure NEP efficacy in the ar- cas of needle sharing, borrowing, and lending. This study differs from prior efforts in two important respects. First, it included data from NEP-related studies conducted between 1988 and 2001, thereby updating the Cross et al. study’s timeframe by six years. Second, it coded data with respect to a larger number of needle sharing vari- ables. This was done in the hope of bringing together, within broader meta-analyses, data froma variety of variables, each of which appeared related to risky needle behav iors. Thus, it might be possible to formulate a more generalized response to the ques- tion of NEP efficacy on decreasing risky needle behaviors. METHODOLOGY THE TECHNIQUE OF META-ANALYSIS Given many different NEPs, operating in many different places, utilizing differ ent methods of evaluation, it has been difficult to compare and evaluate overall NEP success (Des Jarlais, 1995). To achieve this purpose, and answer specifically the ques- tion of how needle sharing behaviors are influenced by participation in an NEP, the re- searcher used the technique of meta-analysis. Because the scientific method assumes that single study will notand cannot gen- erate the answer to a major research question, meta-analysis has been more and more frequently used to advance cumulative knowledge (Hunter, Schmidt, & Jackson, 1982; Hunter & Schmidt, 1990). In meta-analysis, findings from a group of studies focused on a particular topic are converted to a common metric (Glass, McGaw, & Smith, 1981). Because each study’s outcome measures are treated as “cases” for anal- ysis, statistical interpretation of the whole becomes possible, and the magnitude of an effect across a body of research can be assessed (Allen & Preiss, 1990). Note that meta-analysis combines evidence across studies quantitatively rather than in an inter- pretive, qualitative fashion (Hedges & Olkin, 1986). As such, it is not a reanalysis of data; it is not a narrative summary providing a subjective overview of research; it is nota “vote-counting” technique which reports the number of studies that have shown positive or negative results regarding a particular research question or hypothesis (Glass et al., 1981). LOCATING PERTINENT RESEARCH STUDIES ‘The search techniques employed in the present study were: (1) computerized da- tabase searches; (2) hand searches of key journals; (3) reviews of references listed in scholarly works; and (4) attempts to contact via email researchers whose work was not published and/or available through conventional means.

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