on Facebook
on Twitter
on YouTube
2004 Newsletter
What Makes Needle and Syringe Exchange Programs Effective in Preventing HIV Transmission?
Safe and certain access to sterile syringes is widely regarded as among the most effective methods for preventing the spread of HIV and hepatitis B and C viruses among injection drug users (IDUs) who are unwilling or unable to stop using drugs. In the absence of a national policy on this issue, state and local governments have been left to decide whether and how to provide access. This situation has resulted in a wide range of conditions under which IDUs might acquire sterile syringes. In many states, access is provided through syringe exchange programs (SEPs). However, the level of access provided through SEPs can be limited due to a program’s scope and geographical location as well as other obstacles, including laws and regulations that prohibit IDUs from possessing syringes, limit the number of syringes provided through SEPs, or forbid the purchase of syringes through pharmacies.
A new study led by DPRC researcher Ricky N. Bluthenthal compared SEPs in three U.S. cities to examine how variations in legal restrictions or program-related conditions might be associated with different outcomes for SEP users, such as different rates of syringe reuse or sharing. The study’s findings suggest that legal access to sterile syringes through SEPs may not be sufficient in itself to reduce syringe reuse if such programs operate under conditions that limit the number of syringes that can be exchanged, purchased, or possessed.
The study used HIV risk assessment data collected between 1998 and 2000 from IDUs in Chicago, Illinois; Hartford, Connecticut; and Oakland, California—all of which have SEPs. These cities offer a range of legal and program-related conditions, as shown in the table. While both Chicago and Hartford permit the legal possession of syringes under certain conditions, Oakland bans any possession of drug paraphernalia, including syringes. The Hartford SEP’s distribution policy coheres with legal mandates restricting the number of syringes that can be carried (10 through September 1999 and 30 thereafter), while both Chicago and Oakland have relatively permissive, large-volume syringe exchanges that augment one-for-one exchange of syringes with additional sterile syringes. Hartford allows IDUs to purchase up to 10 syringes at pharmacies, while the other cities do not permit pharmacy purchase.
Legal and Program Variations for Syringe Access - 1998 to 2000 |
|||
| Hartford, CT | Chicago, IL | Oakland, CA | |
| Legal restrictions on carrying syringes | Legal to carry a limited number of syringes (10 prior to 9/99; 30 after that) | Legal to carry syringes with client identification card from SEP | Illegal to carry syringes under any circumstances |
| SEP access conditions | Access to a small-volume SEP that conforms to legal mandates on the number of syringes that could be carried | Access to a very large, legal SEP providing syringes on a one-for-two basis | Access to a very large, legal SEP providing syringes on a one-for-one plus five syringes basis |
| Pharmacy access conditions | Ability to purchase up to 10 syringes per visit | No pharmacy access | No pharmacy access |
SEP Outcomes Varied Across Cities
The study found significant variation in the outcomes of the three programs.
- IDUs residing in the most legally restrictive locale (Oakland) had more police contact for possession of drug paraphernalia (37 percent) than their counterparts in Chicago (20 percent) or Hartford (17 percent).
- IDUs who participated in large-scale syringe exchange programs (Chicago and Oakland) were less likely to report syringe reuse than their Hartford counterparts, although not less likely to engage in receptive syringe sharing.
- After controlling for sociodemographics and other factors, the rate of syringe reuse in Hartford was not significantly lower than that in the other cities, despite the fact that all IDUs could purchase 10 syringes in pharmacies.
These findings indicate some of the ways in which the effectiveness of SEPs might vary according to the context in which they operate. For example, studies have shown that police contact for syringe possession is associated with injection-related HIV risk, suggesting that communities with strict drug paraphernalia laws, such as Oakland, should consider excluding syringes from these regulations in order to reduce the spread of infectious diseases among IDUs. The study’s findings also suggest that SEPs that do not have caps on the number of syringes exchanged, such as those in Chicago and Oakland, may be more likely to affect syringe reuse among IDUs than those with such caps, such as Hartford. Moreover, the lack of impact on syringe reuse seen from Hartford’s pharmacy access program provides further evidence of the potential counterproductiveness of capping the number of syringes provided to IDUs even when syringe access is provided through a variety of methods.
Better Understanding Is Needed of Community and Operational Factors Influencing SEPs’ Effectiveness
Taken together, these findings point to the need for better understanding of the impact of community context (e.g., legal restrictions on syringe possession and pharmacy access) and SEP operational factors (e.g., syringe distribution policies and limits on access) on the effectiveness of syringe access programs. Examples of other community factors that might affect SEP effectiveness include the prevalence of HIV and its incidence among IDUs in the local community, the drug being injected, and the sexual mixing patterns between IDUs and other groups with high HIV prevalence (e.g., men who have sex with men). Other important opera- tional characteristics include the loca- tion of SEP services (e.g., health clinic, van, shooting gallery, staff on foot), number of hours and days of the week that services are available, ancillary services provided, and the cultural appropriateness of the staff to the population served.
Now that there is little question of the effectiveness of SEPs in the broad sense, new research efforts are needed to help guide public health care pro-viders and policymakers in deciding where and what type of SEPs to implement in their communities.
For more information, please see
Bluthenthal, R. N., M. Rehan Malik, L. E. Grau, M. Singer, P. Marshall, and R. Heimer for the Diffusion of Benefit through Syringe Exchange Study Team, “Sterile Syringe Access Conditions and Variations in HIV Risk Among Drug Injectors in Three Cities,” Addiction, Vol. 99, No. 9, 2004, pp. 1136–1146.
Kral, A. H., and R. N. Bluthenthal, “What Is It About Needle and Syringe Programmes That Make Them Effective for Preventing HIV Transmission?” International Journal of Drug Policy, Vol. 14, 2003, pp. 361–363.
Top