OF THE
COWLITZ COUNTY HEALTH DEPARTMENT
NEEDLE EXCHANGE PROGRAM
An Analysis By
Chris Hale, PhD, MPH, Epidemiologist
for the
Cowlitz County Health Department
February 2001
FIRST ANNUAL EVALUATION OF THE COWLITZ COUNTY HEALTH DEPARTMENT’S NEEDLE EXCHANGE PROGRAM
Background
In early 1998, health department staff reported their concerns about increasing numbers of positive tests for HIV and for hepatitis A, B, and C to our epidemiologist, Dr. Chris Hale. With the help of the Washington State Department of Health, Office of HIV Surveillance, Dr. Hale compared HIV test results for Cowlitz County with those for all of Washington State and for the state, minus King, Pierce, and Cowlitz Counties. These analyses supported staff concerns.
In the summer of 1998, the Cowlitz County Health Department charged a community task force with developing a plan to control and prevent bloodborne diseases in the county. Six months later, the task force made seven preliminary recommendations to the Board of Health. One of the recommendations was to create a needle exchange program. The Board asked that a survey of community attitudes be completed. This survey, using a combination of modules from the Behavioral Risk Factor Surveillance System and a statewide questionnaire assessing HIV-related knowledge, attitudes, and practices, was done in March-April 1999. Results indicated 40% of the county’s adult population had been tested for HIV but not while donating blood, 95% would continue to see a friend with AIDS, and more than half supported specific HIV reduction efforts including a needle exchange program. During the summer of 1999, results of the survey and of the earlier HIV study were reviewed with the Board of Health. In early September 1999, the Board voted two-to-one to accept all recommendations of the task force. However, the vote was accompanied by a strongly worded mandate that the needle exchange component of this strategy be carefully evaluated. This report summarizes what we have learned in the first 12 months of the program’s operation.
Since January 2000, the Cowlitz County Health Department’s needle exchange program (NEP) has been operating out of a health department van two afternoons a week. After a relatively slow start, the number of needles exchanged seems to have stabilized at about 11,000-13,000 a month. (Based on around four hours a week, or 17 hours in the average month, that works out to about 650 to 765 needles per operating hour.)
Figure 1 shows number of clients per month. It rose from 14 in January to a peak of 110 in October, then fell to 66 in December. When clients come to the van, we ask them a number of evaluation questions. One is if they’re exchanging for others. If they are, we ask how many. The 707 visitors we had in 2000 represent a total of 2, 254 IV drug users, or an average of about three per person. These numbers are shown, broken out by month, in the Figure 1. It is possible that networks have formed to access the NEP. If that is the case, then those key exchangers can also be conduits for getting health and other important prevention information to others in the network.
Figure 2 shows the total number of syringes exchanged by month, the number of people exchanging, and the average syringes per exchanger. Although the number of people using the NEP actually fell after October, the number of needles being exchanged continues to grow. In October, the NEP had 110 clients who exchanged 13, 097 syringes; in November, 77 people exchanged 10,707 syringes; and, in December, 66 people exchanged 12,381 syringes. Although these numbers are different from each other, the average number of syringes per visitor continues to grow. We believe this pattern is additional evidence that networks of exchangers are developing here, as they have in other settings. Again, this possibility has important implications for future prevention efforts.
We also asked about repeat use of the NEP (not shown in Figure 2). For the past three months (that is, October through December 2000), about two-thirds of NEP clients were repeat visitors and a third were new. The same ratio characterizes the entire year. This stability suggests that the NEP is continuing to penetrate the drug-injecting residents of Cowlitz County and that growth in both clients and syringes exchanged should be expected for the coming year.
Demographic Characteristics of Exchangers
About 700 of the 707 exchange clients responded to our request for demo-graphic data. One caution: Data were collected for each client; we did not attempt to determine whether we had this individual in our existing database. Based on the experience of other NEPs, that screening will require unique identifiers for each client, a process that cannot begin until the NEP has been operating for several years. Figure 3 summarizes their characteristics. More than 97% were white, about 95% were non-Hispanic; 55% were male and 45% were female. Female clients were significantly younger than male clients (mean ages 34.1 and 37.5, respectively). Nearly 90% of female clients were in the childbearing ages of 15-44, and one-third of the male clients were 45 years old or older.
Data on drug use have been collected only since July (Figure 4). Heroin was the drug of choice for over half the NEP clients, followed closely by methamphetamines. But looked at month by month, the use of heroin was relatively stable at 50-60%, while the use of methamphetamines rose steadily until by December almost two-thirds of those exchanging used methamphetamines. Cocaine was the only other drug cited by more than a few NEP clients, and its use was steady at between 20% and 25%. Many clients injected more than one drug.
Health-related Behavior and Information
Those using the needle exchange need what we’re offering. Figure 5 shows a significant change in reported syringe reuse. In the early months of the NEP, between half and two thirds of program clients said they had reused needles. But in the second half of the year, that fraction fell to between one-third and one-fifth. In Clark County by the second year of their NEP, they were reporting statistically lower re-use rates among clients who were repeat exchangers compared to new ones. We will be conducting a similar analysis of our data in 2001.
In addition to providing clean needles, the NEP also offers health education materials and condoms. About 2,100 pamphlets and over 6,300 condoms were distributed in the first year of the NEP operation (Figure 6). There has been some decrease in the consumption of both items in the past few months. The decline in pamphlet distribution is understandable if we are beginning to saturate the audience for them. However, condom distribution should be more stable. In the coming year, we will be making a renewed effort to ensure that all clients are taking advantage of the condoms availability.
We have seen continued demand for kits that clean needles (Figure 7), another pattern consistent with the possibility that (1) networks of exchangers are emerging and (2) there is potential for NEP expansion in our community. On the other hand, there is less demand for either works education or sex education.
Finally, referrals for both HIV testing and drug and alcohol treatment have fallen off in the past quarter (Figure 8), although about half of NEP clients continue to seek HIV testing. The reasons for the decline may be related to unexpected changes in staffing of the NEP, to the possibility that repeat use has increased, or to some other factor we have not yet detected. We will be exploring the reasons for this shift with clients as part of the second year’s evaluation of this program.
In its first year of operation, the Cowlitz County Health Department’s Needle Exchange Program served 707 persons (not unduplicated) and exchanged over 69,000 needles. Based on the most recent three-month period, we expect to exchange at least 11,000-13,000 needles a month or 132,000 to 156,000 a year. To put our numbers in perspective, compare that experience with that of Clark County, where the population is about three to four times ours. By the end of two years of operation, they were exchanging more than 20,000 syringes a month. One possible interpretation of these figures is that level of IV drug use here is several times higher than it is in Clark County, and that greater intensity accounts for our numbers.
We can assess that possibility by comparing our numbers with those for the Seattle-King County five-site NEP network. This program has been in operation for about 10 years now and exchanges about 1,000,000 syringes a year, or about 1 syringe for every 1.6 people in the county. In its first year of operation, the Cowlitz County Health Department’s NEP has exchanged an average of 1 needle for every 0.7 resident. But if we look at the numbers for the last three months of 2000, when about 11,000-13,000 syringes were exchanged each month, and project those numbers for a year, that projection indicates an exchange of 1 syringe for every 1.3-1.6 residents, about the same as in the Seattle-King County program. Those numbers suggest that the drug problem in Cowlitz County is at least as significant as it is in King County.
The Health Department has been responding to these numbers. Knowing that almost half our exchange clients are women of childbearing age, we have applied for a March of Dimes grant to use the NEP, jail, and drug court to gain access to these high-risk women and to assure they receive prenatal care, family planning, and other health services. (In this regard, it is notable how many more NEP clients here fall into that women of child bearing age category than is true for either King or Clark County.) The Veterans Administration will be opening an office in Longview offering health and behavioral health services to eligible individuals. The Health Department will encourage NEP clients to use VA services, including drug treatment. Finally, the Cowlitz County Health Department will be expanding its assessment of the NEP to answer the questions raised in this analysis, as well as to continue to monitor program utilization.
At the end of the first year, despite some unanswered questions, one thing would seem to be clear. This community needs its needle exchange program.
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