Secondary Syringe Exchange Among Users of 23 California Syringe Exchange Programs

This article describes the secondary syringe exchange (SSE) practices of injection drug users (IDUs) attending 23 syringe exchange programs (SEPs) in the state of California during 2002 (n = 539). The sample was primarily heroin injecting, about two thirds male, half White and half other racial/ethnic groups. Participants were interviewed with a structured questionnaire that included items on sociodemographic factors, drug use practices, sexual practices, use of SEP and other social services, and satisfaction with SEP services. Interviews lasted about 30 minutes. SSE was highly prevalent: 75% of IDUs reported participating in SSE in the 6 months before interview. Program characteristics, such as legal status, SSE policy, and exchange policy, did not affect the prevalence of SSE among SEP clients. Infectious disease risk behaviors were significantly more common among SSE participants than nonparticipants. SSE participants were more likely to share syringes (p <. 001) and cookers (p <. 001) in the previous 6 months. SSE was significantly associated with being stuck with another person's syringe (needle-stick), a little-discussed “occupational hazard” of this practice. In multivariate analysis, the adjusted odds ratio of needle-stick among SSE participants was 2.8 (95% confidence interval, 1.3, 6.0). The high prevalence of SSE and the infectious disease risk associated with it warrant additional research to determine the causality of these associations. In the interim, SEPs should consider reinforcing HIV prevention education messages and training IDUs who engage in SSE in safe handling of biohazardous materials.     

Practices surrounding syringe acquisition and disposal: effects of Syringe Exchange Programmes from different Brazilian regions—the AjUDE-Brasil II Project

The study describes practices relating to syringe acquisition and disposal by Syringe Exchange Programme (SEP) participants. A cross-sectional multi-city study enrolled 857 injection drug users (IDUs) from six SEPs in different Brazilian regions, and assessed self-reported acquisition and disposal behaviours. Seven hundred and nine males (82.9%) and 146 females (17.1%) were recruited through outreach and interviewed, most from the streets or their neighbourhoods (54.1%). The average age was 28.5 years; 76.4% reported injecting cocaine in the past 6 months. Sources for acquiring new syringes differed significantly between time of injection drug use debut and the 6 months prior to interview. Fifty-three percent of IDUs reported acquiring their syringes in pharmacies when they initiated injection drug use, whereas most reported acquiring new syringes in the 6 months before interview from several simultaneous sources: 69% through SEPs; 58% through pharmacies; 36% from friends and/or sexual partners; and 17% from other health services. Across SEPs, acquisition and disposal varied widely. Most interviewees discarded their syringes on the streets, in open fields, or in the garbage or sewage. Restrictions on syringe availability and unsafe practices may be functioning as barriers to the public health recommendation of one-time use of sterile syringes for IDUs and discouraging community support to SEPs. Further increase in access to legal, inexpensive and timely sterile syringes, as well as counselling about the merits of one-time use and safer disposal must be reinforced as part of efforts to minimise high-risk behaviours and curb the spread of blood-borne infections.     

Factors Associated With Buying and Selling Syringes Among Injection Drug Users in a Setting of One of North America's Largest Syringe Exchange Programs

We performed analyses of syringe buying and syringe selling among Vancouver injection drug users, recruited from May 1996 and followed up between November 2002 and August 2003, in the context of one of North America's largest syringe exchange programs (SEPs). An interviewer-administered questionnaire, approximately 45 minutes in duration, was used to collect information regarding risk factors for HIV infection and sources of sterile syringes. Seventy participants (15%) reported syringe selling and 122 (26%) reported syringe buying. Syringe sellers were more likely to be female, reside in unstable housing, need help injecting, and have visited the SEP at least once weekly. Syringe buyers were more likely to need help injecting, have difficulty finding new syringes, have binged on drugs, and have visited the SEP at least once weekly. Syringe buying most frequently occurred when the SEP was closed.     

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.     

Factors associated with buying and selling syringes among injection drug users in a setting of one of North America's largest syringe exchange programs

We performed analyses of syringe buying and syringe selling among Vancouver injection drug users, recruited from May 1996 and followed up between November 2002 and August 2003, in the context of one of North America's largest syringe exchange programs (SEPs). An interviewer-administered questionnaire, approximately 45 minutes in duration, was used to collect information regarding risk factors for HIV infection and sources of sterile syringes. Seventy participants (15%) reported syringe selling and 122 (26%) reported syringe buying. Syringe sellers were more likely to be female, reside in unstable housing, need help injecting, and have visited the SEP at least once weekly. Syringe buyers were more likely to need help injecting, have difficulty finding new syringes, have binged on drugs, and have visited the SEP at least once weekly. Syringe buying most frequently occurred when the SEP was closed.     

Secondary syringe exchange among users of 23 California syringe exchange programs

This article describes the secondary syringe exchange (SSE) practices of injection drug users (IDUs) attending 23 syringe exchange programs (SEPs) in the state of California during 2002 (n=539). The sample was primarily heroin injecting, about two thirds male, half White and half other racial/ethnic groups. Participants were interviewed with a structured questionnaire that included items on sociodemographic factors, drug use practices, sexual practices, use of SEP and other social services, and satisfaction with SEP services. Interviews lasted about 30 minutes. SSE was highly prevalent: 75% of IDUs reported participating in SSE in the 6 months before interview. Program characteristics, such as legal status, SSE policy, and exchange policy, did not affect the prevalence of SSE among SEP clients. Infectious disease risk behaviors were significantly more common among SSE participants than nonparticipants. SSE participants were more likely to share syringes (p<.001) and cookers (p<.001) in the previous 6 months. SSE was significantly associated with being stuck with another person's syringe (needle-stick), a little-discussed "occupational hazard" of this practice. In multivariate analysis, the adjusted odds ratio of needle-stick among SSE participants was 2.8 (95% confidence interval, 1.3, 6.0). The high prevalence of SSE and the infectious disease risk associated with it warrant additional research to determine the causality of these associations. In the interim, SEPs should consider reinforcing HIV prevention education messages and training IDUs who engage in SSE in safe handling of biohazardous materials.     

Decreased Odds of Injection Risk Behavior Associated With Direct Versus Indirect Use of Syringe Exchange: Evidence From Two California Cities

Background: While there is substantial evidence that syringe exchange programs (SEPs) are effective in preventing HIV among people who inject drugs (PWID), nearly all the evidence comes from PWID who obtain syringes from an SEP directly. Much less is known about the benefits of secondary exchange to PWID who get syringes indirectly from friends or acquaintances who visit an SEP for them. Objectives: We evaluated the effectiveness of direct versus indirect syringe exchange in reducing HIV-related high-risk injecting behavior among PWID in two separate studies conducted in Sacramento and San Jose, California, cities with quite different syringe exchange models. Methods: In both studies associations between direct and indirect syringe exchange and self-reported risk behavior were examined with multivariable logistic regression models. Study 1 assessed effects of a “satellite” home-delivery syringe exchange in Sacramento, while Study 2 evaluated a conventional fixed-site exchange in San Jose. Results: Multivariable analyses revealed 95% and 69% reductions, respectively, in high-risk injection associated with direct use of the SEPs in Sacramento and San Jose, and a 46% reduction associated with indirect use of the SEP in Sacramento. Conclusions/Importance: The very large effect of direct SEP use in Sacramento was likely due in part to home delivery of sterile syringes. While more modest effects were associated with indirect use, such use nevertheless is valuable in reducing the risk of HIV transmission of PWID who are unable or unwilling to visit a syringe exchange.     

Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients

OBJECTIVE: To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal. DESIGN: HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days. RESULTS: Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. CONCLUSIONS: Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.     

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.     

Improving access to sterile syringes and safe syringe disposal for injection drug users in methadone maintenance treatment

We evaluated a novel intervention designed to improve access to sterile syringes and safe syringe disposal for injection drug users (IDUs) newly enrolled in methadone maintenance, through interviews with two sequential cohorts of 100 recent entrants into a methadone program in the Bronx, NY. A substantial number of participants had injected in the previous 6 months, and most continued injecting during the early weeks of treatment. The intervention was associated with significant behavior changes among IDUs, including increased use of pharmacies as a primary source of syringes (11% vs. 37%, p < .05) and decreases in both purchasing of syringes on the street (51% vs. 27%, p < .05) and needle sharing (40% vs. 7%, p < .01). The intervention had no impact on the prevalence of injection or on syringe disposal practices. Our findings suggest that drug treatment programs can serve an important role in reducing injection-related risk behavior by facilitating access to sterile syringes.     

Syringe access,syringe sharing,and police encounters among people who inject drugs in New York City: A community-level perspective

BackgroundInjection drug user (IDU) experience and perceptions of police practices may alter syringe exchange program (SEP) use or influence risky behaviour. Previously, no community-level data had been collected to identify the prevalence or correlates of police encounters reported by IDUs in the United States.MethodsNew York City IDUs recruited through respondent-driven sampling were asked about past-year police encounters and risk behaviours, as part of the National HIV Behavioural Surveillance study. Data were analysed using multiple logistic regression.ResultsA majority (52%) of respondents (n = 514) reported being stopped by police officers; 10% reported syringe confiscation. In multivariate modelling, IDUs reporting police stops were less likely to use SEPs consistently (adjusted odds ratio [AOR] = 0.59; 95% confidence interval [CI] = 0.40–0.89), and IDUs who had syringes confiscated may have been more likely to share syringes (AOR = 1.76; 95% CI = 0.90–3.44), though the finding did not reach statistical significance.ConclusionsFindings suggest that police encounters may influence consistent SEP use. The frequency of IDU-police encounters highlights the importance of including contextual and structural measures in infectious disease risk surveillance, and the need to develop approaches harmonizing structural policing and public health.     

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.     

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 exchange programs: Impact on injection drug users and the role of the pharmacist from a U.S. perspective

ObjectiveTo present a summary of the existing literature on syringe exchange programs (SEPs) and to discuss the potential role of pharmacists in providing support for injection drug users (IDUs) and such programs.Data sourcesTo identify relevant articles published since 2000, a search of PubMed and Medline was conducted using syringe exchange programs and needle exchange programs as search terms. A manual review of each article's citation list was also conducted.Data extractionBy the authors.Data synthesisInformation is presented in four categories: state and federal support of SEPs, characteristics of SEP users, epidemiological studies, and social reluctance for SEP support. The information summarized in these sections is then used as a foundation for a review of the potential role of the pharmacist.ConclusionSEPs have demonstrated a clear effect in improving the health outcomes of IDUs by decreasing the transmission of blood-borne disease and lowering high-risk injecting behaviors. Despite conflicting support for SEPs at both the federal and local levels, pharmacists can play a pivotal role in the health of IDUs by providing sound medical advice and, in some states, acting as an alternative channel for obtaining clean syringes. Efforts should continue to focus on educating pharmacists about this role and how their individual actions can benefit the health of the entire population.     

Pharmacy Access to Sterile Syringes for Injection Drug Users: Attitudes of Participants in a Syringe Exchange Program

ObjectiveTo examine attitudes of participants of a van-based syringe exchange program (SEP) toward the hypothetical prospect of pharmacy-based syringe access.DesignOne-time, cross-sectional survey.SettingBaltimore, Maryland.Participants206 injection drug users who participate in the Baltimore SEP.InterventionsFace-to-face interviews.Main Outcome MeasuresLocation preferred for obtaining syringes, drug and syringe use, past experience with pharmacies, and willingness to pay.ResultsThe sample was 67% men, 95% African American, and 95% unemployed; mean age was 39.8 years. A total of 19% of respondents had bought syringes at a pharmacy during the prior six months. Some 37% reported having been turned down when asking for syringes at a pharmacy, most commonly due to lack of identification to prove diabetic status (50%). If legal restrictions were lifted, 92% of respondents would obtain syringes from pharmacies, and would be willing to pay a mean price of $0.80 (median = $1.00) per syringe. Women were more likely than men to report the intention to switch from van-based SEP to pharmacy (57% versus 38%, p = .045).ConclusionIf current legal restrictions were lifted, pharmacies would be a viable syringe source appealing particularly to women, suggesting gender-specific access issues that should be addressed. The per-syringe price that study participants would be willing to pay exceeds typical retail prices, suggesting that pharmacists could charge enough per syringe to recoup operational costs.