Structural level interventions to increase needle/syringe access for preventing HIV and hepatitis C among people who inject drugs in low and middle income countries: An international systematic review

Background: Persons who inject drugs (PWID) are at elevated risk for HIV and hepatitis C (HCV) infection. In many high-income countries, structural level needle-syringe exchange programs (NSP) have been associated with large reductions in blood-borne infections. However, we do not have a good understanding of NSP effectiveness in low/middle income countries. Methods: Systematic literature searches, following PRISMA guidelines, were utilized to collect primary data on NSP program coverage and changes in HIV and HCV prevalence/incidence among PWID in low/middle income countries. Inclusion criteria were laboratory measures of HIV or HCV over time and structural level NSP, defined as at least 50% coverage of the local injecting population. Results: Data were obtained from: Bangladesh, Brazil, China, Estonia, Iran, Lithuania, Taiwan, Thailand and Vietnam. Decreases in HIV prevalence ranged from 3% to 42% in six studies and increased in two studies by 6% and 15%. Decreases in HCV prevalence ranged from 4.2% to 10% in three studies and HCV incidence remained stable in one study. In four national reports, three showed decreases in newly reported HIV cases among PWID during/after NSP expansion, ranging from 30% to 93%, while one documented a 38% increase. Conclusion: The data generally support the effectiveness of structural NSP in reducing HIV and HCV prevalence/incidence in low/middle income countries. There is, however, great variation in the effectiveness of programs as measured in HIV and HCV data. Future research should utilize an implementation science framework to identify and address factors limiting the effectiveness of NSPs in low/middle income countries.