Effects of Increasing Syringe Availability on Syringe-Exchange Use and HIV Risk: Connecticut, 1990-2001

Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
Journal of Urban Health (Impact Factor: 1.9). 01/2003; 79(4):556-70. DOI: 10.1093/jurban/79.4.556
Source: PubMed


Syringe-exchange programs (SEPs) in Connecticut operate with caps on the number of syringes exchanged per visit. We investigated the effects of legislation increasing the cap on drug injectors' access to clean syringes through the SEPs in New Haven and Hartford. The mixed design of this study included longitudinal and cross-sectional data from individuals and ecological data from program operations. Five parameters-syringe return rate, syringes per visit to the SEP, syringe reuse rate, syringe human immunodeficiency virus (HIV) prevalence, and syringe sharing-were monitored through syringe tracking and testing of SEP syringes and by interviewing injectors. Two increases in the cap-from 5 to 10 and then from 10 to 30-had little effect on the five parameters that measured injectors' access to clean syringes. In contrast, access to clean syringes increased when the New Haven SEP first began operations, when syringes first became available at pharmacies in Hartford, and when the agency running the Hartford SEP changed. Legislation providing piecemeal increases in the cap may not, by themselves, be sufficient to increase injectors' access to clean syringes and decrease the risk of human immunodeficiency virus transmission in this population.

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    • "Specifically, in Hartford, where a strict one-for-one policy of syringe exchange was in place, the maximum number of syringes obtainable per visit was increased from 10 syringes to 30 syringes. (Heimer et al., 2002b) In Chicago, the syringe dispensing policy changed in the summer of 2000 from a syringe exchange (two-for-one with a cap of ten syringes and one-for-one exchange for >10 syringes) to a need-based syringe distribution (i.e., receiving as many syringes 'as needed'). Details of the three DOB study sites and their varying legal and service provision characteristics are given in Table 1. "
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    ABSTRACT: Syringe exchange programs (SEPs) can reduce HIV risk among injecting drug users (IDUs) but their use may depend heavily on contextual factors such as local syringe policies. The frequency and predictors of transitioning over time to and from direct, indirect, and non-use of SEPs are unknown. We sought, over one year, to: (1) quantify and characterize transition probabilities of SEP attendance typologies; (2) identify factors associated with (a) change in typology, and (b) becoming and maintaining Direct SEP use; and (3) quantify and characterize transition probabilities of SEP attendance before and after changes in policy designed to increase access. Using data collected from 583 IDUs participating in a three-city cohort study of SEPs, we conducted a latent transition analysis and multinomial regressions. Three typologies were detected: Direct SEP users, Indirect SEP users and Isolated IDUs. Transitions to Direct SEP use were most prevalent. Factors associated with becoming or maintaining Direct SEP use were female sex, Latino ethnicity, fewer injections per syringe, homelessness, recruitment city, injecting speedballs (cocaine and heroin), and police contact involving drug paraphernalia possession. Similar factors influenced transitions in the syringe policy change analysis. Policy change cities experienced an increase in Indirect SEP users (43-51%) with little increased direct use (29-31%). We found that, over time, IDUs tended to become Direct SEP users. Policies improving syringe availability influenced SEP use by increasing secondary syringe exchange. Interactions with police around drug paraphernalia may encourage SEP use for some IDUs and may provide opportunities for other health interventions.
    Drug and alcohol dependence 09/2010; 111(1-2):74-81. DOI:10.1016/j.drugalcdep.2010.03.022 · 3.42 Impact Factor
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    • "are likely to contribute to geographic variations in HIV prevalence among IDUs. For example, structurally, laws that restrict access to syringes and laws that criminalize possession of a syringe have been shown to increase the prevalence and frequency of syringe sharing (Bluthenthal et al., 1999; Heimer et al., 2002). Binge cocaine use has also been associated with increased frequency of syringe sharing (Wood et al., 2002). "
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    ABSTRACT: This study examines the association between using and sharing high dead-space syringes (HDSSs)--which retain over 1000 times more blood after rinsing than low dead-space syringes (LDSSs)--and prevalent HIV and hepatitis C virus (HCV) infections among injecting drug users (IDUs). A sample of 851 out-of-treatment IDUs was recruited in Raleigh-Durham, North Carolina, between 2003 and 2005. Participants were tested for HIV and HCV antibodies. Demographic, drug use, and injection practice data were collected via interviews. Data were analyzed using multiple logistic regression analysis. Participants had a mean age of 40 years and 74% are male, 63% are African American, 29% are non-Hispanic white, and 8% are of other race/ethnicity. Overall, 42% of participants had ever used an HDSS and 12% had shared one. HIV prevalence was 5% among IDUs who had never used an HDSS compared with 16% among IDUs who had shared one. The HIV model used a propensity score approach to adjust for differences between IDUs who had used an HDSS and those who had never used one. The HCV models included all potential confounders as covariates. A history of sharing HDSSs was associated with prevalent HIV (odds ratio=2.50; 95% confidence interval=1.01, 6.15). Use and sharing of HDSSs were also associated with increased odds of HCV infection. Prospective studies are needed to determine if sharing HDSSs is associated with increased HIV and HCV incidence among IDUs.
    Drug and alcohol dependence 12/2008; 100(3):204-13. DOI:10.1016/j.drugalcdep.2008.08.017 · 3.42 Impact Factor
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    • "Increasing the cap appeared to have little impact in increasing coverage by either of the metrics applied to the tracking data. This is consistent with previous reports using other metrics that the gradual increase in the cap in New Haven did little to increase syringe availability or reduce risk (Buchanan et al., 2006; Heimer et al., 2002). On the other hand, coverage decreased significantly when the state legalized over-the-counter sale of syringes in 1992. "
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    ABSTRACT: Evaluations of syringe-exchange programme effectiveness that attempt to measure "coverage" by determining the percentage of the at-risk population reached by a programme are insufficient since programmes must provide syringes on a continual basis. Determining the relationship between the extent of programme coverage and its impact (i.e., reductions in disease risk or incidence) is complicated by the lack of controlled trials with cohorts of drug users and instead has to be estimated by imputation, mathematical modelling, or ecological data analysis. This report offers an approach to determine community-wide impact and discusses the limitations of that approach. Easily created programme tracking data were maintained by exchanges in New Haven, CT, USA and Chicago, IL, USA. Data compiled by month quantified the number of unique participants visiting syringe-exchange programmes and the number of syringes distributed. "Coverage", defined either as the percentage of individuals reached or percentage of community syringe need met, was estimated by incorporating measures of the size of the injector population or injection frequency. These measures of coverage are placed in the context of changing programme operations to estimate the effect of these changes on coverage. Finally, data on AIDS cases from New Haven and Chicago were used to estimate the community-wide impact of syringe exchange. Two mobile syringe-exchange programmes operated with very different exchange policies. Programme data revealed that coverage of individuals rarely exceeded 10% and was higher in New Haven than in Chicago. On the other hand, coverage measured as the percentage of syringe need met was higher at the Chicago exchange that employed the less restrictive policy. The impact of syringe exchange in the two cities was measured by comparing subsequent AIDS cases. The relative reduction in injection-related AIDS cases as a function of all new AIDS diagnoses was 21.7% in New Haven and 41.4% in Chicago. A modest investment in the collection of programme data can yield reliable and interpretable information on the extent of programme reach and retention. Limitations to the approach result from the ecological nature of the data and from the need to use data from outside the programme that may be less reliable. For the cases presented here, coverage rates will vary as a function of the programme policies; however, even modest coverage rates - well below those recommended by UNAIDS - can have significant impacts on HIV epidemics. Restrictive policies appeared to increase the coverage if measured only by the proportion of monthly participants and not by the proportion of syringe need met by a programme. More generally, programmes can collect programmatic data and some rapid assessment data (estimates of IDU population and injection frequency) to estimate of the impact of their programmes.
    The International journal on drug policy 05/2008; 19 Suppl 1:S65-73. DOI:10.1016/j.drugpo.2007.12.004 · 2.54 Impact Factor
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