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Table 1 Summary of included studies

From: Scoping out the literature on mobile needle and syringe programs—review of service delivery and client characteristics, operation, utilization, referrals, and impact

Author/year Study design Methods and recruitment Study description Outcomes/findings
Allen et al. 2015 (USA) Cross-sectional Analysis of data collected as part of a PWID population estimation study To examine differences in access to SEPs between current and former PWID seeking services at a mobile SEP in Washington, DC The independent samples t test showed that the difference in mean walking distance between active and former PWID was statistically significant (p < .05), with active PWID having a mean walking distance of 2.75 miles and former PWID having a mean walking distance of 1.80 miles.
The results of this study suggest that former PWID who are engaging with SEPs primarily for non-needle exchange services (e.g., medical or social services) may have decreased access to SEPs than their counterparts who are active injectors.
Altice et al. 2003 (USA) Cohort N = 13 A pilot project: HIV therapy was offered to 13 CHCV clients who met the following criteria: (1) confirmed HIV status; (2) active use of heroin; (3) eligibility for antiretroviral therapy A pilot project among out-of-drug treatment IDUs infected with human immunodeficiency virus (HIV); HIV therapy was successfully provided to active heroin injectors using the Community Health Care Van (CHCV) at sites of needle exchange The New Haven NEP provides clean syringes and paraphernalia to approximately 250–300 unique clients monthly.
This small pilot study suggests that health services based on needle exchange may enhance access to HAART among out-of-treatment HIV-infected IDUs. In addition, it demonstrates that this population can benefit from this therapy with the support of a nontraditional, community-based health intervention.
Bowser et al. 2010 (USA) Cross-sectional From January 2002 to May 2006, 487 unduplicated clients were recruited in year-long cohorts and offered services (n = 487) Examining the impact of MORE (mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-offenders who are active drug users) on reduction of drug use and re-incarceration for drug-related crimes By the 6 and 12-month follow-up interviews, active drug using clients reported significant reductions in their use of alcohol, cocaine/crack, heroin, and fewer sex partners and crimes. Program completers reported significantly reduced cocaine/crack and heroin use as well as fewer days in jail and crimes than non-completers (p < .01 to .001).
Courty 1999 (France) Case study   Describing the setting up of a mobile needle exchange bus, its functioning and the resulting coordination with the various partners The people attending the Bus are predominantly young people under the age of 18 years, who declare their limited information concerning the various health problems. They acknowledge that they do not attend the usual institutional structures, which fail to recognize them. The exchange-prevention bus therefore plays a role in access to information, care and various services as an intermediary between the young person’s demand and conventional institutions.
By providing a structure for exchange on drug addiction and AIDS, the Bus creates a first link between users and institutions, but also a link between users of the Bus, which is the first step towards a social link different from that usually generated by addictive behavior.
Deering et al. 2011 (Canada) Cross-sectional A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006–2008) to 242 FSWs in Vancouver, Canada Examining the determinants of using a peer-led mobile outreach program among a sample of street-based female sex workers (FSWs) who use drugs and evaluate a relationship between program exposure and utilizing addiction treatment services In 2006, an average of 1496 women accessed the MAP van per month, and 1432 condom packs and 3241 clean needles were distributed per month
Female sex workers at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.
Heimer 2008 (USA) Cross-sectional n = 1843 New Haven; n = 1022 Chicago; active drug injectors; Analysis of program tracking data Comparing two mobile syringe exchange programs operated with very different exchange policies Mobile van in New Haven—100,000 syringes distributed between November 1990 and October 1993. Data collected from two convenience samples of 1523 injectors between 1990 and 1993 and from 320 injectors between 1999 and 2001 found mean injections per month of 87 and 82, respectively.
Mobile van in Chicago—Data collected from two independent convenience samples of 733 injectors between 1997 and 2000 and from 289 injectors between 1998 and 2000 both found mean injections per month of 75.
Hyshka et al. 2012 (Canada) Review A review of 15 years of research on needle exchange in Vancouver’s DTES Demonstrating that: (1) NEP attendance is not causally associated with HIV infection, (2) frequent attendees of Vancouver’s NEP have higher risk profiles which explain their increased risk of HIV seroconversion, and (3) a number of policy concerns, as well as the high prevalence of cocaine injecting contributed to the failure of the NEP to prevent the outbreak NEP mobile vans would visit areas with a high prevalence of injection drug use during the evening hours to supplement the fixed site.
Demand for syringes increased significantly (when cocaine became the main drug) and the Vancouver NEP limits were doubled from 2 syringes to 4 syringes per day or 28 per week (3 per mobile van visit), and a second van was added in 1993. In response to rising HIV prevalence rates, public health officials increased the NEP budget significantly and by 1995 a third van had been added and the exchange limits were again doubled. Despite often being the only source for sterile syringes during the evening hours, many IDUs experienced trouble meeting up with the exchange van or spent their time in areas not covered by the fixed and mobile NEP sites.
Islam and Conigrave 2007 (Australia) Review A literature search revealed 40 papers/reports, of which 18 were on dispensing machines (including vending and exchange machines) and 22 on mobile vans The aim of this review is to examine, based upon the available international experience, the effectiveness of syringe vending machines and mobile van/bus based NSPs in making services more accessible to these hard-to-reach and high-risk groups of IDUs Services through dispensing machines and mobile vans have been reported to be responsive to a wider range of IDUs and most importantly to hidden and harder-to-reach IDUs in the community, who for several reasons do not or cannot attend conventional NSPs.
Unlike dispensing machines, mobile vans do not provide completely anonymous access to sterile injecting equipment, but peer staffed mobile vans can render a congenial environment that provides near anonymous access. Mobile vans can cover a greater geographic area and can more readily accommodate changes in local conditions. A van of this sort generally follows a relatively consistent route, and parks at a predictable location at a predictable time, although it can change in response to immediate neighborhoods conditions (e.g., increased police presence) or to incorporate additional populations of injecting drug users. One van may visit multiple sites in a single outing. It can provide the benefits of both a fixed and a mobile site. In addition, it can also provide shelter and some security for staff, some privacy for clients, and a consistent service while covering a large geographic area. A roving site also keeps staff members and clients relatively inconspicuous to neighbors, local business people, and police officers.
Mobile vans mostly provide a flexible outreach service and act as a bridge to fixed-site outlets. The mobile van can reduce the distance for users to travel to get needles and syringes. Carrying used syringes for long periods in order to exchange presents problems for IDUs in the presence of police pressure and can dissuade them from bringing used syringes back.
Janssen et al. 2009 (Canada) Cross-sectional Conducted surveys with 100 women sex workers who accessed MAP services and reviewed MAP logbooks to document use of services. The study assessed the impact of MAP through review of data from a concurrent cohort study of injection drug users and a survey of 97 women at a drop-in center in the Downtown Eastside Evaluating the impact of MAP (Mobile Access Point van) on safety and adoption of harm-reducing behaviors among sex workers The number of clean needles dispensed per month almost tripled during the MAP’s first 3 years of operations from 1240 in 2004 to 3241 in 2006.
A higher proportion of MAP users were injecting cocaine one or more times daily (31 vs. 19%), but rates of daily heroin injection at about 50% were similar. A higher proportion of MAP users were smoking crack (81 vs. 72%). Rates of borrowing used needles were similar (10%) but none of the MAP users, compared to 10.5% of the non-MAP users, had lent used needles.
Over 90% of MAP clients reported that the van made them feel safer on the street. Sixteen percent of surveyed MAP clients recalled a specific incident in which the van’s presence protected them from a physical assault and10% recalled an incident when its presence had prevented a sexual assault.
Kelsall et al. 2001 (Vietnam) Cross-sectional n = 200; interviews/questionnaires with heroin users who had injected/smoked heroin at least once in the past 6 months Examining the transitions between different routes of administration and, in particular, transitions between non-injecting—smoking/chasing or “burning”—and injecting routes of administration Needle/syringe programs (NSPs) were clearly the outlets most favored by the injectors in the sample (76%), including mobile/outreach NSPs (24%). Chemists were cited by injectors as a less common source (28%), as were friends (5%) and community health centers (5%).
Knittel et al. 2010 (USA) Cross-sectional n = 88; interviews conducted with NEP participants between 2003 and 2006 Evaluating the HARC NEP (run exclusively from the outreach van), describing the operation of the NEP and its clients Injection-related risk behavior showed non-significant trends in the direction of risk reduction from baseline to follow-up. NEP users at follow-up were less likely to report sharing syringes (OR = 0.66), sharing equipment other than syringes (OR = 0.70), or reusing syringes (OR = 0.34). Follow-up users were also more likely to report exchanging syringes for another individual (OR = 2.77), though this also failed to reach statistical significance.
Compared to baseline measurements, NEP participants reused their syringes significantly fewer times before getting new ones (p = 0.012)
Lausevic et al. 2015 Cross-sectional Cross-sectional bio-behavioral survey among PWID Determining the prevalence of HIV, hepatitis C (HCV), hepatitis B surface antigen (HBsAg), and risk behaviors. HIV in people who use drugs (PWID) As sources of free-of-charge needles and syringes in the past 12 months, respondents mentioned mobile outreach teams (8.0%), primary health-care centers (17.9%), and drop-in centers (53.5%).
MacNeil and Pauly 2010 (Canada) Case study Interviews with clients and NEP staff This case study focuses on the consequences of the switch to mobile needle exchange services immediately after the closure of a fixed-site needle exchange The closure of fixed site needle exchange services and the switch to mobile delivery only has had a traumatic effect on clients, with reported increases in risk behavior such as needle reuse as well as a dramatic decrease in access to services. Contacts with vulnerable clients have been lost and thousands of needles are unaccounted for in the community.
Miller et al. 2001 (Norway) Cross-sectional n = 1260; three consecutive, anonymous cross-sectional surveys. 288, 449 and 523 SEP participants interviewed during comparable 1-week periods in 1992, 1994, and 1997, respectively Examining gender differences in syringe exchange program (SEP) use, particularly frequent SEP use, within and across survey years. SEP services in Oslo were provided exclusively through one mobile van During the study week in 1992, 765 recorded SEP visits; in 1994—1348 SEP visits; in 1997, 2175 recorded SEP visits. In 1992 and 1997, women were somewhat more likely to report weekly SEP use than men. During each survey period, just over half of SEP participants reported returning syringes. In 1992 and 1994, women were somewhat more likely to return syringes.
Women reported injecting more frequently than men, but neither reported more frequent SEP use nor acquiring more syringes during an exchange. Although syringe sharing decreased significantly over time, in 1997, 51% of SEP participants continued to share. HIV prevalence remained low (3–5%) over time. After controlling for gender, age, and HIV risk factors, frequent SEP use was significantly correlated with frequent injection for both women (OR 5 1.4) and men (OR 5 1.5). A lack of income or benefits independently increased the likelihood of being a frequent SEP user (OR5 3.0), while having shared a syringe at last injection independently decreased this likelihood (OR5 0.5)
Peter 2013 (Nigeria) Cross-sectional Two components: harm reduction outreach and a behavioral survey (n = 70). For 2 months in the year 2008—provision of mobile base harm reduction services in three neighborhoods Examining the feasibility and uptake of the night harm reduction services by a late night population of MSM Exchanged 1090 needles in 121 needle exchange visits, distributed 3200 condoms for both male, and provided 18 HIV tests and 8 opportunistic infections tests.
The study population of MSM was characterized by low levels of income, stigma, and discrimination.
Pollack et al. (2002) (USA) Cohort study n = 373 active IDUs; a pre-post comparison of ED utilization was performed using linked medical records from New Haven’s only two emergency departments Examining the impact of the New Haven Community Health Care Van (CHCV), a mobile needle exchange-based health care delivery system, in reducing emergency department (ED) use among out-of-treatment injection drug users (IDUs) CHCV clients included a broad range of extremely disadvantaged individuals. Seventy percent of CHCV clients are unemployed; 35% are current or recent injection drug users. IDUs who obtained CHCV services faced especially high medical and social risks. Twenty-seven percent reported a history of commercial sex work; 26% had been in jail or prison during the 6 months prior to CHCV service use. IDUs seeking services exhibited a mean of 2.9 medical encounters with CHCV staff over the survey period.
Among 373 IDUs, 117 (31%) were CHCV clients, and 256 had not used CHCV services. At baseline, CHCV users were more frequent users of ED services ( ` .001). After full-scale implementation, mean ED utilization declined among CHCV clients and increased within the non-CHCV group. CHCV use is associated with statistically significant reductions in ED use. Full-scale implementation of the New Haven Community Health Care Van was associated with a more than 20% decline in emergency department visits
Robles et al. 1998 (Puerto Rico) Cross-sectional The data for this study were collected during the first months of the NEP from July 1995 to March 1996 in 13 communities of the San Juan metropolitan area. Subjects were the participants of two modalities of the NEP: a mobile team and a community-based drug treatment program Evaluating the effectiveness of the first needle exchange program (NEP) established in Puerto Rico The mobile unit reported 10,770 exchange contacts with 93,066 syringes exchanged; the on-site modality reported 8425 exchange contacts and 53,257 syringes exchanged.
More women participated in the on-site modality (22.8%) than the mobile modality (16.3%) (Pf0.01). There were no significant differences between the two modalities in years of injection (11.5 years in the mobile vs 12.1 years in the on-site modality; Pf0.27). However, participants in the on-site modality were more likely to inject more frequently than in the mobile modality (7.2 vs 5.9, Pf0.01).
Rose et al. 2006 (USA) Cross-sectional The study had two components: harm reduction outreach and a behavioral survey. For 4 months during 2004, we provided van-based harm reduction services in three neighborhoods in San Francisco from 1 to 5 a.m. for anyone out late at night. We also administered a behavioral risk and service utilization survey among MSM. n = 55 The purpose of the Late Night Breakfast Buffet (LNBB) (mobile service) was to determine the feasibility and uptake of harm reduction services by a late night population of MSM. The “buffet” of services included: needle exchange, harm reduction information, oral HIV testing, and urine-based sexually transmitted infection (STI) testing accompanied by counseling and consent procedures Exchanged 2000 needles in 233 needle exchange visits, and 200 packages containing 3 sterile syringes were provided to individuals who had no syringes to exchange, distributed 4500 condoms/ lubricants and provided 21 HIV tests and 12 STI tests.
Of the 36 MSM who reported ever injecting, 75% reported using a needle exchange service.
Van-based mobile outreach unit reached a disenfranchised population of MA-using MSM who are at risk for acquiring or transmitting HIV infection through multiple high-risk behaviors, and we established the feasibility and acceptability of late night harm reduction for MSM and MSM who inject drugs.
The LNBB corroborated earlier findings of a larger seroprevalence study among a similar population and established an effective methodology for reaching a high-risk population of MA-using MSM, half of whom were injection drug users (IDUs).
Schwartz 1993 (USA) Review Overview of the first large-scale syringe and needle exchange (SANE) programs   During the first 7.5 months of the program’s operation, 700 IVDU were enrolled (mean age 34, only 8% less than 25). 60% seropositive for HIV. Approximately equal numbers of white, black, and Hispanic clients. Approx. 25 new clients enrolled each week. In the first 7.5 months, 275 of clients were placed in treatment programs, mainly MMT and detoxification programs. The rate of return injection equipment was 52%.
Shannon et al. 2008 (Canada) Cross-sectional n = 198; interview-questionnaires, administered by trained peer researchers, with 198 women in street-level sex work in Vancouver, Canada Exploring how health service and syringe availability may be impacted at the geographic level by avoidance of physical settings due to violence and policing among women in street-level sex work Approximately half of current female IDUs (56%) had accessed syringes from a fixed site (56%) (including hotel exchange, pharmacy, and clinic) and the medically supervised injection facility (47%). In terms of mobile resources, 50 (43%) of women had accessed syringes from a mobile van in the core area, 20 (17%) from a mobile van in either of core or perimeter areas, and 13 (11%) from outreach workers, while 59 (29%) had accessed a mobile van for other harm reduction resources and referral in either of core or perimeter areas.
Somlai et al. 1999 (USA) Qualitative Ethnographic field observations and key informant and systems representative interviews Illustrating how social science and community assessment research can be used to guide the development of NEPs. Mobile van unit was found to be more acceptable alternative to a fixed site by the IDU’s and community members in one of Milwaukee’s neighborhoods.
Spittal et al. 2004 (USA) Qualitative Ethnographic interviews and observations conducted with fixed site and mobile van “exchange agents” Examining the access to sterile syringes by IDUs in Vancouver between May 2000 and March 2001 Interviews and observations suggest that on any given van route, the “loaners” make up roughly 5–10% of the syringes distributed to clients. The demand for “loaners” was greatest along the mobile routes, especially at particular stops within the Downtown Eastside where numerous clients appeared with nothing to exchange. Clients visiting the mobile exchanges are often low-volume, high-frequency traders. These clients may not have other avenues through which to access needles, especially through the evening and into the night.
Stark et al. 1995 (Germany) Cross-sectional Participants (n = 557) were recruited from drug-free long-term treatment centers, a storefront agency and a syringe exchange bus Investigating differences in prevalence and determinants of HIV infection, and in recent risk behavior (previous 6 months) among injecting drug users (IDUs) who are in contact with different types of services for IDUs in Berlin Participants entering long-term treatment were most likely, and IDUs at the syringe exchange bus were least likely to have borrowed and passed on syringes in the previous 6 months.
Of the individuals examined at the storefront agency and at the syringe exchange bus, 20.7 and 14.6% were HlV-infected, respectively, HBV and HCV seroprevalence rates were significantly lower among IDUs entering treatment (n = 157) than among IDUs at the storefront agency (n = 203) (anti-HBc 48.4 vs 63.5%, p < 0,005; anti-HCV 73.1 vs 89.8%, p < 0.0001). IDUs entering treatment had injected for a significantly shorter time: their median time since first injection was 6 years (interquartile range 3–11), compared to 11 (5–16) years (storefront agency), and 9 (5–15) years (syringe exchange bus) (p < 0.0001)
Strathdee et al. 2006 (USA) RCT n = 245 IDUs; a randomized trial of a case management (intervention) versus passive referral (control) among NEP attenders requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs Evaluating a case management intervention to increase treatment entry among injecting drug users referred from 2 mobile needle exchange programs (NEP) Those who were randomized to case management were more likely to enter treatment within 7 days. Additional “as treated” analyses revealed that participants who received 30 min or more of case management within 7 days were 33% more likely to enter treatment and the active ingredient of case management activities was provision of transportation.
Strike et al. 2002 (Canada) Qualitative Using a modified ethnographic approach (i.e., interviews and observations), NEP staff and managers at all Ontario NEPs and government officials involved with the Ontario provincial needle exchange program participated in semi structured, audio-taped interviews (11/98 to 04/99) Examining the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts Mobile service is believed to increase accessibility for clients who prefer to exchange during evening hours, do not have a vehicle, money for transportation, and/or may be too impaired to drive to the fixed site. While mobile service is believed to meet the needs of clients in terms of basic services, it is viewed as insufficient for lengthy counseling sessions, arranging referrals, HIV, and other disease testing
Tinsman et al. 2001 (USA) Cross-sectional N = 9296; clients were recruited through 12 HIV Outreach Project sites Describing 12 HIV Outreach Demonstration Project and summarizing the findings of multivariate statistical analyses aimed at identifying important project and client characteristics that influenced project success Projects used multiple outreach strategies to attract the “hard-to-reach” population. The projects that used mobile testing units to reach their clients were vastly more successful than other projects in their HIV testing efforts: all else being equal, outreach clients at projects with mobile units were 86 times more likely to obtain an HIV test than those at other outreach projects.
Mobile units or vans provided a movable center for outreach services such as counseling and testing as well as transport for outreach workers to target neighborhoods. Advantages to mobile units included high community recognition of the outreach project, safer place for worker/contact interaction, and relative privacy for outreach contacts and service provision. They also served as a focal point to initiate conversations.
Wood et al. 2002 (Canada) Cohort N = 761: persons who returned for follow-up during the period June 1, 2000/May 31, 2001; active drug injectors Providing possible explanations for persistent needle sharing through an evaluation of the Vancouver Injection Drug Users Study (VIDUS), an ongoing cohort study of IDU that began in 1996 351 (46.1%) of participants acquired most of their needles from the fixed site exchanges, 109 (14.3%) from the exchange vans, 60 (7.9%) from pharmacies, and 241 (31.7%) acquired needles from multiple sources and did not identify a primary source. The present study suggests that difficulty meeting the exchange van poses problems and shows that exchange vans may be an effective means of providing services to IDUs in areas of low injection drug use prevalence and not being served by a fixed-site.