A matter of convenience: factors influencing secondary syringe exchange in Baltimore, Maryland, USA

Distribution of sterile syringes to reduce the circulation of HIV-infection among injection drug user (IDU) communities is vital in curbing the spread of HIV among IDUs. In addition to other methods of distribution, syringe exchange programmes (SEPs) have been shown to be necessary in the dissemination of sterile syringes. Secondary syringe exchange (SSE) is an organic process by which IDUs distribute syringes to other IDUs and is an important complement to SEPs. This paper examines the motivations for people who provide SSE to other IDUs and the reasons why some IDUs do not use the Baltimore Needle Exchange Program (BNEP). Approximately 5000 individuals had obtained clean syringes from the BNEP between 1994 and 1997. In 1997, qualitative interviews were conducted in Baltimore with 20 providers of SSE and 10 SSE recipients who had never used the BNEP. Data from qualitative interviews were transcribed, coded and compiled. SSE providers reported economic gain and altruism as incentives. SSE recipients reported privacy, convenience of location and time, force of habit, and concern for carrying paraphernalia around as reasons influencing them to obtain syringes from secondary syringe exchangers rather than the needle exchange programme. Results from this study illuminate the social context in which SSE occurs and indicate the importance of SSE as a method for distributing sterile syringes.     

Sources of injecting equipment for drug users in Moscow, Russia

Syringe exchange programmes (SEPs) were approved in Moscow in 2002 and studies to evaluate access to sterile syringes are now needed. Clients of a non-governmental organisation (NGO) providing outreach to IDUs were interviewed concerning behaviours within the previous 30 days. Of 232 IDUs, 64% were male, mean age was 25 and mean duration of injection drug use was 5.8 years. Twelve percent reported injecting with used syringes and using prefilled syringes; 6% passed syringes to others and 91% shared paraphernalia. Seventy nine per cent admitted that they had never had a sterile syringe every time they needed it. Among women, 45% used pharmacies as their only source of injecting equipment. Out of 10 potential syringe sources, pharmacies were the major source, especially for women. The other two major sources were other drug users and drug dealers. NGOs offering syringe exchange were mentioned by 9%, whereas medical institutions were reported as the least popular source. Almost all (99%) reported that syringes are not expensive and their procurement is not difficult, but 83% mentioned that buying syringes at pharmacies often involves a risk of being examined by law enforcement staff. These results indicate that significant barriers for procurement and use of sterile syringes exist in Moscow.     

Topic-Focused Bibliography: Syringe Exchange: HIV Prevention,Key Findings,and Future Directions

HIV among injecting drug users (IDUs) has now been documented in over 60 countries in the world, and there are an additional 40 countries where injecting drug use has been reported including widespread epidemics in Southeast and southern Asia and in Latin America. At present HIV infection is almost always fatal, and there is no promise that a preventive vaccine will become available soon. Given the enormity of the HIV epidemic among IDUs and the critical need to reduce the spread of HIV transmission to and from IDUs, prevention efforts are essential. Syringe-exchange programs have become a major component of HIV prevention strategies in most developed countries and work within the philosophy of harm reduction. Increasing access to sterile syringes has been met with considerable controversy. Opponents of syringe exchange have generally argued that increasing access to sterile syringes would simultaneously increase the number of injecting drug users, increase the frequency of injection for already active IDUs, and appear to “condone” an illegal behavior. To date many research studies and four major reviews of syringe exchange literature have been conducted. All studies thus far have shown no increase in illicit drug injection associated with syringe exchanges, and significant decrease in drug risk behaviors.     

Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales

BackgroundInjecting drug users (IDUs) are at increased risk of acquiring and transmitting HIV and other bloodborne pathogens through the multi-person use of syringes. Although research has shown that increased access to syringes through syringe exchange programs (SEPs) is an effective strategy to reduce risky injection practices many areas of the United States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies over-the-counter sales of syringes has also been shown to reduce syringe sharing. The success of pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia laws, which in turn may contribute to fear among IDUs about being caught purchasing and carrying syringes.MethodsBetween 2003 and 2006, 851 out-of-treatment IDUs were recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were collected using audio-computer assisted interview (ACASI) technology. Multiple logistic regression analyses were performed to assess factors associated with purchasing syringes from pharmacies.ResultsIn our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes.ConclusionsGiven the absence of syringe exchange programs and the relatively high prevalence of HCV and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source of syringes among African-American IDUs in this study sample is problematic. The study findings support the need for effective multilevel interventions to increase access to clean needles in this population, as well as for policy interventions, such as legalization of SEPs and elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats posed by receptive syringe sharing.     

Public Health Interventionists,Penny Capitalists,or Sources of Risk?: Assessing Street Syringe Sellers in Hartford,Connecticut

Improved access to sterile syringes decreases risks related to blood-borne transmission of HIV and hepatitis among injection drug users (IDUs). While syringe exchange programs and pharmacy sales of over-the-counter syringes have received considerable attention from researchers and interventionists during the past decade, little is known about informal economy street syringe sellers. In Hartford, CT, as well as other regions throughout the United States a large percentage of IDUs utilize street sellers to facilitate their injection activities. A qualitative and ethnographic study was conducted in Hartford between 1999 and 2001 to help elucidate the public health risks and benefits of street syringe sellers.     

Distributive syringe sharing among young adult injection drug users in five U.S. cities

Blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are transmitted most commonly among injection drug users (IDUs) through the sharing of needles and syringes. Distributive syringe sharing (DSS) (i.e., passing on a used needle/syringe to another IDU) poses the potential risk of transmitting HIV and viral hepatitis to others. We studied the prevalence and correlates of DSS among IDUs enrolled in a randomized behavioral intervention trial designed to reduce behaviors associated with HIV and HCV transmission in five U.S. cities. Among 3129 IDUs ages 15-30 years who completed the baseline visit, 1432 (45.8%) engaged in DSS during the 3 months prior to baseline. Significant correlates of DSS were perception that peer norms condone needle sharing, frequent injection, not obtaining most syringes from needle exchange programs or pharmacies, injecting most frequently in shooting galleries and with sex partners, low perceived risk of HIV from sharing syringes, increased anxiety, low self-esteem, and having unprotected sex. Restricting to only those IDUs who reported not injecting with previously used syringes, similar independent correlates of DSS were found. These findings suggest that interventions to reduce ongoing transmission of blood-borne infections should focus on altering peer norms among networks of young IDUs.     

Syringe Disposal Options for Injection Drug Users: A Community-Based Perspective

This study was a qualitative exploration of syringe disposal interventions for injection drug users (IDUs). Data were collected through in-depth interviews with 26 community members who injected drugs and 32 noninjecting community members in Atlanta, Georgia. Both groups supported syringe exchange programs as syringe disposal interventions, while noninjecting community members favored a one-way drop box. IDUs identified fear of arrest for possession of syringes as the most salient barrier to safe syringe disposal, revealing the negative consequences of drug paraphernalia laws.     

Public health interventionists,penny capitalists,or sources of risk?: assessing street syringe sellers in Hartford,Connecticut

Improved access to sterile syringes decreases risks related to blood-borne transmission of HIV and hepatitis among injection drug users (IDUs). While syringe exchange programs and pharmacy sales of over-the-counter syringes have received considerable attention from researchers and interventionists during the past decade, little is known about informal economy street syringe sellers. In Hartford, CT. as well as other regions throughout the United States a large percentage of IDUs utilize street sellers to facilitate their injection activities. A qualitative and ethnographic study was conducted in Hartford between 1999 and 2001 to help elucidate the public health risks and benefits of street syringe sellers.     

Syringe disposal options for injection drug users: a community-based perspective.

This study was a qualitative exploration of syringe disposal interventions for injection drug users (IDUs). Data were collected through in-depth interviews with 26 community members who injected drugs and 32 noninjecting community members in Atlanta, Georgia. Both groups supported syringe exchange programs as syringe disposal interventions, while noninjecting community members favored a one-way drop box. IDUs identified fear of arrest for possession of syringes as the most salient barrier to safe syringe disposal, revealing the negative consequences of drug paraphernalia laws.     

The association of syringe type and syringe cleaning with HCV infection among IDUs in Budapest,Hungary

We assessed whether syringe type, syringe cleaning and distributive syringe sharing were associated with self-reported and laboratory-confirmed HCV infection among Hungarian IDUs. Injecting drug users (N = 215) were recruited from non-treatment settings in Budapest, Hungary between October 2005 and December 2006. Multivariate logistic regression models identified correlates of self-report of being HCV infected and testing positive for HCV. While 37% tested positive for HCV, 14% of the total (39% of those who tested positive) self-reported being HCV infected. Using any two-piece syringes was significantly associated with self-reported HCV infection, while distributive syringe sharing was not associated with self-report of being HCV infected. Engaging in receptive sharing of only one-piece syringes but always cleaning before reuse was not associated with testing HCV positive, while any receptive sharing of only one-piece syringes and not always cleaning before reuse was significantly associated with testing HCV positive. Sharing cookers and squirting drugs from one syringe into another syringe were not associated with testing HCV positive. The high percent of those HCV infected who did not know they were infected highlights the need to provide better access to confidential testing and counseling services. Counseling should emphasize secondary prevention of HCV among HCV infected IDUs. Our findings also indicate that syringe type and syringe cleaning practices may play a role in HCV transmission. Ethnographic research should identify the reasons why IDUs may use two-piece syringes and suggest means to reduce their use. Thorough cleaning of one-piece syringes when sterile syringes are unavailable may be an efficient way to reduce the risk of HCV infection.     

Comparison of injection drug users accessing syringes from pharmacies,syringe exchange programs,and other syringe sources to inform targeted HIV prevention and intervention strategies

ObjectiveTo describe injection drug users (IDUs) who access syringes through different outlets to help inform the prevention needs of IDUs who underuse safe syringe sources in New York City (NYC), where syringe availability is high compared with other U.S. cities.DesignCross sectional.SettingNYC, 2005–2007.Participants285 IDUs.InterventionParticipants were recruited using random street-intercept sampling in 36 socioeconomically disadvantaged neighborhoods.Main outcome measuresIDUs using syringe exchange programs (SEPs), pharmacies, or other outlets as a primary syringe source were compared based on sociodemographic characteristics, injection practices, and medical service use.ResultsChi-square tests and polytomous logistic regression were used to compare IDUs with different self-reported primary syringe sources used in the 6 months preceding study entry. Compared with IDUs using other syringe sources, those primarily using SEPs were less likely to be black (adjusted odds ratio 0.26 [95% CI 0.11–0.57]), more likely to inject daily (3.32 [1.58–6.98]), and more likely to inject with a new syringe (2.68 [1.30–5.54]). Compared with IDUs using other syringe sources, those primarily using pharmacies were less likely to be black (0.39 [0.17–0.90]).ConclusionThese data suggest that pharmacies and SEPs may be reaching different populations of IDUs and highlight a subpopulation of highly marginalized IDUs (i.e., black race, infrequent injectors) who are underusing safe syringe sources in NYC. Targeted interventions are needed to reduce racial disparities and increase use of safe syringe outlets.     

Assessing Needle Exchange Operations in a Poor Brazilian Community

This article assesses the operations of Porto Alegre, State of Rio Grande do Sul, (southern Brazil) needle exchange program (NEP), a setting where HIV infection rates have been on the rise among injection drug users (IDUs) in recent years, contrasting with substantial declines observed in this population, in major Brazilian cities (located in the southeast and southernmost part of Brazilian northeast). We explored local syringe dynamics, with the exclusive delivery in the local NEP of tagged syringes, and the subsequent monitoring of returned tagged/untagged used syringes from January to September 2002. We further assessed local NEP operations using focus groups and field observation, trying to expose the underlying reasons for the substantial delay in the return of tagged syringes and the continuous and relevant return of untagged syringes throughout the study period. We found that local IDUs reuse, divert, and create caches of syringes at their discretion. All efforts should be made to increase the availability of clean syringes and to fully integrate syringe exchange with comprehensive health education and health screening to effectively curb HIV spread.     

Social Context of Needle Selling in Baltimore,Maryland

Although much of the debate surrounding the distribution of sterile syringes to injection drug users (IDUs) has focused on needle exchange programs (NEPs), IDUs acquire their syringes from three major sources: NEPs, pharmacies, and secondary exchangers or needle sellers. The purpose of the present study is to examine types and frequencies of social interactions among drug injectors who sell needles, most of which come from NEPs, compared with individuals who do not sell needles. Specifically, we compared engagement in drug-related behaviors, roles in the drug economy, and social network membership. Data were collected as part of the SHIELD study, an HIV prevention intervention targeted at drug users and their social networks (n = 910) from February 2001 through September 2003 in Baltimore, Maryland (USA). In this sample, 56 participants reported selling needles. Needle sellers had higher levels of engagement in drug-related social interactions, including using drugs with others, giving or receiving drugs from others, and buying drugs with other users. Participants who sold needles had a significantly higher number of roles in the drug economy. Also, they had more social network members who were injectors, with whom they talked about risky drug behaviors, gave needles to, and shared cookers and bleach with. Compared with nonselling injectors, needle sellers engage in HIV risk-related behaviors, such as injecting daily and sharing injection equipment, more frequently. The study's findings may be useful to determine whether secondary exchangers should be targeted for HIV prevention activities both to reduce their own risk and to diffuse risk reduction information throughout the drug using community.     

Social context of needle selling in Baltimore, Maryland

Although much of the debate surrounding the distribution of sterile syringes to injection drug users (IDUs) has focused on needle exchange programs (NEPs), IDUs acquire their syringes from three major sources: NEPs, pharmacies, and secondary exchangers or needle sellers. The purpose of the present study is to examine types and frequencies of social interactions among drug injectors who sell needles, most of which come from NEPs, compared with individuals who do not sell needles. Specifically, we compared engagement in drug-related behaviors, roles in the drug economy, and social network membership. Data were collected as part of the SHIELD study, an HIV prevention intervention targeted at drug users and their social networks (n=910) from February 2001 through September 2003 in Baltimore, Maryland (USA). In this sample, 56 participants reported selling needles. Needle sellers had higher levels of engagement in drug-related social interactions, including using drugs with others, giving or receiving drugs from others, and buying drugs with other users. Participants who sold needles had a significantly higher number of roles in the drug economy. Also, they had more social network members who were injectors, with whom they talked about risky drug behaviors, gave needles to, and shared cookers and bleach with. Compared with nonselling injectors, needle sellers engage in HIV risk-related behaviors, such as injecting daily and sharing injection equipment, more frequently. The study's findings may be useful to determine whether secondary exchangers should be targeted for HIV prevention activities both to reduce their own risk and to diffuse risk reduction information throughout the drug using community.     

A randomized trial of contingency management for adolescent marijuana abuse and dependence

We assessed whether syringe type, syringe cleaning and distributive syringe sharing were associated with self-reported and laboratory-confirmed HCV infection among Hungarian IDUs. Injecting drug users (N = 215) were recruited from non-treatment settings in Budapest, Hungary between October 2005 and December 2006. Multivariate logistic regression models identified correlates of self-report of being HCV infected and testing positive for HCV. While 37% tested positive for HCV, 14% of the total (39% of those who tested positive) self-reported being HCV infected. Using any two-piece syringes was significantly associated with self-reported HCV infection, while distributive syringe sharing was not associated with self-report of being HCV infected. Engaging in receptive sharing of only one-piece syringes but always cleaning before reuse was not associated with testing HCV positive, while any receptive sharing of only one-piece syringes and not always cleaning before reuse was significantly associated with testing HCV positive. Sharing cookers and squirting drugs from one syringe into another syringe were not associated with testing HCV positive. The high percent of those HCV infected who did not know they were infected highlights the need to provide better access to confidential testing and counseling services. Counseling should emphasize secondary prevention of HCV among HCV infected IDUs. Our findings also indicate that syringe type and syringe cleaning practices may play a role in HCV transmission. Ethnographic research should identify the reasons why IDUs may use two-piece syringes and suggest means to reduce their use. Thorough cleaning of one-piece syringes when sterile syringes are unavailable may be an efficient way to reduce the risk of HCV infection.