Effects of increasing syringe availability on syringe-exchange use and HIV risk: Connecticut, 1990-2001.
ABSTRACT 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.
- SourceAvailable from: Jim Mcveigh01/2008;
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ABSTRACT: A pilot methadone maintenance program for heroin-dependent sentenced inmates in a men's prison in San Juan, Puerto Rico, was begun in 2002. One year later, data were collected from all 20 program partici-pants and a random sample of 40 inmates who did not participate. The data included (a) inmate self-reports concerning their drug use, attitudes about drug treatment, and expectations about behaviors upon release from prison, and (b) urine specimens for heroin and methadone testing. It was found that inmates enrolled in the program had been heavy users of heroin and reduced their heroin use by more than 94%. There was a high correlation between self-report and urine test results. Program participa-tion was associated with increased acceptance of methadone maintenance as a prison-based treatment for heroin dependence. The program appeared successful in reducing heroin abuse among heroin-dependent prisoners. Prison officials planned to expand the program.Journal of Correctional Health Care 04/2005; 11(3):295-305.
Journal of Urban Health: Bulletin of the New York Academy of Medicine
2002 The New York Academy of Medicine
Vol. 79, No. 4, December 2002
Effects of Increasing Syringe Availability
on Syringe-Exchange Use and HIV Risk:
Robert Heimer, Scott Clair, Wei Teng, Lauretta E. Grau,
Kaveh Khoshnood, and Merrill Singer
ABSTRACT Syringe-exchange programs (SEPs) in Connecticut operate with caps on the
number of syringes exchanged per visit. We investigated the effects of legislation in-
creasing 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, sy-
ringe 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 con-
trast, access to clean syringes increased when the New Haven SEP first began opera-
tions, 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
KEYWORDS HIV transmission, Injection drug use, Syringe exchange.
Injection drug use is the second leading risk factor for human immunodeficiency
virus (HIV) infection in the United States.1The most recent estimate of national
HIV incidence, although 6 years old, suggests that injection drug users (IDUs) may
comprise the majority of those with new infections.2Reducing syringe-borne spread
of HIV through interventions aimed at altering individual behaviors3,4has been
under way in the United States since the mid-1980s. In contrast, structural-level
interventions, which aim at changing the social and contextual factors influencing
HIV transmission, have been slower to develop.5–8
Among the first such structural interventions was a softening of the law in
Connecticut that had made the possession and purchase of syringes without a pre-
scription illegal. During the decade of the 1990s, three changes in legislation were
made with the intention of increasing IDU access to clean syringes. The first, passed
Drs. Heimer, Grau, and Khoshnood are with the Department of Epidemiology and Public Health, Yale
University School of Medicine, New Haven, Connecticut; and Drs. Clair, Teng, and Singer are with the
Hispanic Health Council, Hartford, Connecticut.
Correspondence: Robert Heimer, PhD, Department of Epidemiology and Public Health, Yale Univer-
sity School of Medicine, 60 College Street, New Haven, CT 06520.
SYRINGES AND HIV RISK IN CONNECTICUT557
by the Connecticut legislature in June 1990, permitted the legal establishment of a
syringe-exchange program (SEP) in New Haven and exempted SEP participants
from the prescription law.9The SEP was operated under explicit guidelines10; it
could exchange no more than 5 syringes per exchange, and all exchanges were 1
for 1. In a second set of changes,11in 1992, the state repealed its law banning the
over-the-counter sale and possession of syringes and simultaneously expanded the
number of SEPs from one to six and the number of syringes per visit from 5 to 10.
A third change,12in 1999, expanded the number of syringes that SEPs could ex-
change to 30.
In this article, we look at the effect of increasing syringe availability on five
parameters by which we can gauge the effectiveness of SEPs in Connecticut in re-
ducing HIV transmission. The first parameter is the return rate, which measures
the extent to which SEPs meet their customers’ need for clean syringes. The second
parameter is the number of syringes obtained per visit to the SEP. The third parame-
ter is syringe reuse, which measures the numbers of times IDUs use each syringe
before discarding it or returning it to the SEP. The fourth parameter is the preva-
lence of syringes containing blood infected with HIV-1; this measures the likelihood
that a shared syringe could transmit HIV-1. The fifth and final parameter is syringe
sharing, which measures the percentage of IDUs who, sometime in the month prior
to interview, used a syringe previously used by another IDU. Some of the data
included in this study (Table 1) are ecological, and came from tracking and testing
data for the New Haven or Hartford SEP as a whole.13Other data have been col-
lected from individuals using standardized survey instruments14,15or from individ-
ual-level syringe-tracking data.10,16
Analysis of the changes in these parameters as a function of the legislative
changes permitting SEPs to exchange first 5, then 10, and now 30 syringes measures
the penetrance of clean syringes into populations of IDUs who avail themselves of
SEPs and can be used to explore the extent to which relaxation of the strictures on
TABLE 1. Methods for assessing syringe access
MethodsData source Dates
Return ratesTracking marked syringes NH:
Syringes/visit Program logs
Re-use ratesEstimates from syringe tracking
Syringe HIV PrevalenceTesting syringes returned to the
Htfd, Hartford; NH, New Haven.
558HEIMER ET AL.
syringe availability has been correlated with decreased HIV-1 transmission risks
among IDUs in Connecticut. While none of the parameters on its own would be
sufficient to firmly establish the linkage between legal change and reduced HIV
risk, if the trends from multiple parameters were synchronous, it would suggest
that structural changes in the laws regulating syringe availability, by themselves,
might be sufficient to reduce HIV risk.
Syringe-Exchange Program Operations
The New Haven Needle Exchange Program (NHNEP) began in November 1990
and has been operated throughout its existence by the Health Department of the
City of New Haven. Until the end of September 1992, the program exchanged
syringes on a 1-for-1 basis to a maximum of 5 syringes per visit to NHNEP. After
that, the cap on syringes was increased to 10 until the end of September 1999,
when the cap was increased to 30 per visit. Data were collected for 36 months from
the start of the program through October 1993. Beginning in late 1999, New Ha-
ven IDUs were recruited through a targeted sampling plan as part of a study funded
by the National Institute on Drug Abuse of syringe-access patterns. The Hartford
Syringe Exchange Program (HSEP) began in February 1993, operated by the Hart-
ford Health Department. In June 1995, operation of HSEP was assumed by the
nonprofit agency AIDS Project Hartford. From the program’s outset until the end
of September 1999, the program exchanged syringes on a 1-for-1 basis to a maxi-
mum of 10 syringes per visit to HSEP; after that, the cap on syringes was increased
to 30 per visit.
All syringes distributed by the SEPs were marked. In New Haven, the syringes
distributed by NHNEP possessed printed markings on their barrels that were dis-
tinct from markings found on any syringes available in the United States and were
uniquely labeled with sequential numbers. Syringe-tracking methodologies have
been described in detail elsewhere.10,13,17,18Briefly, all syringes distributed by NHNEP
were sequentially numbered, and all returned syringes were collected and analyzed.
This allowed the creation of two databases that, when merged, allowed us to calcu-
late the percentage of syringes originating from the program that were returned. Of
those recovered, more than 90% were returned with their unique tracking number
In Hartford, syringe tracking was carried out in two phases. From April 1993
through April 1997, syringes distributed by the SEP were labeled sequentially. All
syringes returned to the exchange during discrete 2-week periods were collected.
Beginning in 1998, syringes distributed were no longer sequentially numbered, but
instead were specially manufactured with markings on their barrels distinct from
those found on any syringes available anywhere else in the world. Syringe-tracking
data from 2- and 8-week collection cycles were included in this last analysis.
The proportion of syringes originating from an SEP that were returned provides an
ecologic assessment of the extent to which that SEP fulfills the need of customers
by revealing the percentage of syringes that IDUs have obtained from sources other
SYRINGES AND HIV RISK IN CONNECTICUT559
than the SEP. For the assessment of return rates, labeling of the syringes originating
from the SEPs was essential. Return rates were computed based on the tracking
data by dividing the number of returned syringes that originated from the SEP by
the total number of syringes returned to the SEP.
Syringes per Visit to the Syringe-Exchange Program
The mean number of syringes returned by clients per visit to the exchange was
calculated by a variety of methods. In New Haven between November 1990 and
August 1993 and again between July and October 2001 and in Hartford between
April 1993 and March 1997, the data came from syringe-tracking and syringe-
testing records and were individual and cross sectional in nature. Additional data
have been collected by self-report from samples of 185 customers of the Hartford
SEP between July 1998 and November 2001 and 89 customers of NHNEP between
December 1999 and November 2001.
Syringe Reuse Frequencies
Two estimates of syringe reuse among NHNEP customers in the months between
the start of the program in November 1990 through October 1993 involve ecologic
measures calculated from syringe-tracking data. These methods have been described
in detail elsewhere.19More recent data on syringe reuse in New Haven were col-
lected by self-report from 320 individual IDUs between December 1999 and No-
vember 2001. Individuals were asked: “How many shots do you usually get from
a syringe before you stop using it?” For this sample, 89 NHNEP customers and
231 noncustomers were interviewed by convenience sampling of 40 IDUs in each
of eight city neighborhoods.
In Hartford, data on syringe reuse came from three cross-sectional studies. The
first source was an analysis funded by the Centers for Disease Control and Preven-
tion of the effects of legalizing syringe possession and over-the-counter pharmacy
sales15; the analysis was conducted between August 1992 and June 1993. A ques-
tionnaire was used for the second and third sources; it was administered first to a
sample of 129 IDUs (50 customers, 79 noncustomers) between July 1998 and Octo-
ber 1999 and later to a sample of 336 IDUs (135 customers, 201 noncustomers)
between December 1999 and November 2001. The question on syringe reuse was
phrased identically to that used in New Haven. The first sample was assembled by
snowball sampling beginning with SEP customers and then recruiting two waves of
noncustomers; the second was assembled by convenience sampling of 40 IDUs in
each of eight city neighborhoods.
Syringe HIV Prevalences
Syringe HIV prevalence, that is, the percentage of syringes contaminated with blood
from an HIV-positive individual, was determined. New Haven syringes were tested
using a polymerase chain reaction (PCR) method that was capable of detecting a
single molecule of HIV-1 cDNA from infected cells.20Hartford syringes were tested
using an enzyme immunoassay (EIA) that was capable of detecting antibodies to
HIV-1, on average, in as little as 0.001 µl of blood.21Comparison of the two meth-
ods revealed that, when the contents of individual syringes were tested, 90% of 50
syringes gave identical results in the two assays.22Testing parallel samples of sy-
ringes returned at the three separate intervals during the New Haven evaluation
revealed prevalences that were statistically identical within, but not between, inter-
560HEIMER ET AL.
The percentage of IDUs sharing at least one syringe in the 30 days prior to being
interviewed was determined. In New Haven, the data came from two sources, the
first longitudinal and the second cross sectional. The first source was interviews of
192 NHNEP customers conducted between 1990 and 1993 on their enrollment in
the program and follow-up interviews conducted 9 to 33 months later. The second
source was interviews of 320 active drug users conducted between December 1999
and November 2001. In Hartford, data also came from two sources, both of cross-
sectional design. The first source was the analysis of the effects of legalizing phar-
macy syringe sales15conducted between August 1992 and June 1993. The second
source was two sets of cross-sectional interviews with IDUs conducted between July
1998 and October 1999 and between December 1999 and November 2001.
The five measures of SEP penetrance and effectiveness were analyzed comparing
the results between periods when the cap on exchanges was 5, 10, or 30 syringes.
In New Haven, comparisons of syringe reuse frequency and HIV-1 syringe preva-
lence were made between times before and after the establishment of the SEP. Sy-
ringe return rates, the number of syringes per visit, and the number of uses per
syringe were compared using analyses of variance (ANOVAs) with Bonferonni post
hoc tests when appropriate. Syringe HIV-1 prevalence and sharing rates were com-
pared using chi-square statistics. Tests for temporal trends within periods and be-
tween periods were analyzed using linear regression.
During the tracking and testing period in New Haven, from November 1990
through August 1993, a total of 85,630 syringes were returned to the SEP. Of these,
56,230 were returned when the cap was 5 syringes per visit (November 1990 to
September 1992), and 29,400 were returned when the cap was 10 (October 1992
to October 1993). During the period when the cap was 5, an average of 2,445
syringes was returned per month. After the cap was increased to 10, an average of
2,262 syringes was returned. The syringe return rates were similar before and after
the cap changed: 63.3% before October 1, 1992, and 62.1% afterward. The data
on return rates by month reveal that the most important change observed in the 36
months of study occurred in the first 3 months of the study, when the return rates
climbed from 26.8% to 54.4% (Fig. 1, top). Linear regression analyses of the return
rates thereafter revealed a small, but significant, increase of 0.68% per month dur-
ing the period before the cap was increased to 10 (r2= 0.615). During the 13
months after the increase, there was no significant deviation from the mean return
rate (r2= 0.286). The mean return rates in the 13 months before and after the
increase in the cap were not statistically different, 65.7% ± 2.8% before the in-
crease and 61.4% ± 7.9% afterward, despite a noticeable decline in return between
May and July 1993.
In Hartford, the data suggest a trend toward increasing syringe return rates
during the course of 7 years of program operations (Fig. 1, bottom). However, on
closer analysis, several features suggest that a simple linear relationship does not
accurately characterize what occurred. First, consistent with the data from New
SYRINGES AND HIV RISK IN CONNECTICUT561
that were returned was determined by syringe tracking for (A) New Haven and (B) Hartford.
Return rate of SEP syringes. The percentage of syringes originating from the exchange
562HEIMER ET AL.
Haven, there was an increase in return rates immediately following the program’s
start. The return rate for syringes collected in April 1993 was 34.5%, and by June
and for every month thereafter, return rates exceeded 40%. For the period from
June 1993 through May 1995, when the program was operated by the Hartford
Health Department, the average return rate was 45.3% ± 6.8%. Once the opera-
tions of the Hartford SEP shifted from the health department to AIDS Project Hart-
ford, the average return rate increased to 57.2% ± 4.5% for the period from August
1995 through July 1999. After the cap was increased to 30, the average return rate
was 67.5% ± 14.5%.
Syringes Per Visit
NHNEP, operating with a cap of 5 syringes per visit, saw the number of syringes
exchanged per visit increase from 1.7 in November 1990, to 4.1 in October 1991,
and to 4.5 in September 1992 (Fig. 2, top). Thus, the increase was concentrated in
the first year of the program. Following the increase in the cap to 10, the mean
number of syringes exchanged per visit transiently increased, but the monthly aver-
ages for the 13 months prior to and following the increase in the cap were not
significantly different (4.3 ± 0.37 versus 5.1 ± 0.60, P > .05). Once the cap was in-
creased to 30, the mean number of syringes obtained per visit increased significantly
to 8.4 in early 2000 and 13.5 in late 2001 (P < .001).
HSEP also experienced an increase in the mean number of syringes per ex-
change, but unlike New Haven, the increase did not occur during the first year of
program operations (Fig. 2, bottom). During these first 2 years, when the program
was operated by the city health department, the average was 2.7 ± 0.7. The mean
number increased significantly (P < .05) to 4.4 ± 0.7 when operations were assumed
by AIDS Project Hartford, but remained unchanged (3.9 ± 0.4, P > .05) when the
cap increased to 30.
Syringe Reuse Rates
Two estimates of syringe reuse rates among IDUs in New Haven were calculated
from syringe-tracking data for 1990–1993. In the first estimate, the average num-
ber of injections per syringe was 10.8 among individuals who did not use NHNEP
in 1990 (Fig. 3, top). Syringe reuse among NHNEP customers decreased from 7.1
injections per syringe at the start of NHNEP to 4.0 after 6 months, 4.0 after 18
months, 3.0 after 27 months, and 2.6 after 33 months (Fig. 3, top). In the second
estimate (data not shown), syringe reuse frequencies were 7.1 prior to the start of
the exchange, falling to 4.0, 4.0, 3.0, and 2.6 after 6, 18, 27, and 33 months of
NHNEP operations, respectively.19From self-report in 2000 and 2001, syringe re-
use rates were 3.0 among 89 SEP customers and 4.7 among the 231 who obtained
syringes from other sources, including pharmacies and less-reliable sources (Fig. 3,
top). Changes in the cap from 5 to 10 were associated with a small, but nonsignifi-
cant, decrease in the average number of injections per syringe, while the increase to
30 was not associated with change in reuse rates among SEP customers.
In Hartford, syringe reuse rates were obtained before and after pharmacy sales
without a prescription were legalized (1992 versus 1993) and before and after the
increase in the cap to 30 (1998 versus 2000). Legalization of syringe purchases did
not appreciably decrease reuse (P > .6), and the reuse rates among IDUs who were
not HSEP customers remained unchanged up to 7 years later (Fig. 3, bottom). In
both 1998 and 2000–01 customers of HSEP tended to reuse their syringes fewer
times than did IDUs who obtained syringes from other sources. Differences between
SYRINGES AND HIV RISK IN CONNECTICUT 563
visiting the SEPs was determined from syringe tracking or self-reported data for (A) New Haven
and (B) Hartford.
Syringes per visit to the SEP. The mean number of syringes obtained by clients
564HEIMER ET AL.
syringe tracking or self-reported data for (A) New Haven and (B) Hartford.
Syringe reuse rates. The mean number of injections per syringe was determined from
SYRINGES AND HIV RISK IN CONNECTICUT 565
customers and noncustomers, on the whole, were significant (P < .05 for both pe-
HIV Prevalence in Returned Syringes
In New Haven, 5,954 syringes returned to NHNEP were tested to determine the
prevalence of syringes containing blood from an individual infected with HIV-1.
In syringes collected before and at the start of NHNEP, prevalences were 62.8%
(n = 180) and 67.5% (n = 160), respectively (Fig. 4, top). Within 4 months, the
prevalence had fallen to 44.0% (n = 111). Thereafter, despite month-to-month fluc-
tuations, the prevalence remained constant. There was no statistical difference in
prevalence in the 13 months before the cap increased to 10 (38.5% ± 9.7%, n =
2,090) and the 11 months after the increase (38.9% ± 12.5%, n = 1,672).
In Hartford, 7,461 syringes returned to HSEP were tested to determine the
prevalence. The testing data revealed three distinct sets of prevalences, with a sharp
decline in prevalence between August and October 1995 and a smaller decline after
March 1997 (Fig. 4, bottom). A total of 2,036 syringes were tested during the first
period, and prevalences ranged between 51% and 62%, with a mean prevalence of
55.1% ± 3.6%. Between October 1995 and March 1997, a total of 1,010 syringes
were tested, with a mean prevalence of 36.0% ± 2.1%. The difference was statisti-
cally significant (P < .001). After testing resumed in January 1999, 4,128 syringes
were tested, with a prevalence of 27.4%, a significant decrease from the previous
period of testing (P < .001). During this last period, the cap was increased from 10
to 30. Syringe prevalence before the increase was 26.4% (n = 3,229) and 29.0%
(n = 953) afterward, and the difference was not statistically significant (P > .12).
In New Haven, prior to enrollment, 60 of 192 IDUs (31.3%) reported having used
someone else’s syringe within the past 30 days. When interviewed after using NHNEP
between 9 and 33 months, only 37 of the IDUs (19.3%) reported having used
someone else’s syringe. Participation in NHNEP was associated with a significant
38.3% decline in syringe sharing (P < .01). Interviews in 1999–2001 revealed that
84.1% (269 of 320) obtained their syringes from safe sources (either NHNEP or
pharmacies) and that 19.6% (62 of 316) reported having used someone else’s sy-
ringe. Among the 87 participants reporting that the SEP was their primary source
of syringes, 14 (16.1%) reported having used someone else’s syringe. Thus, after
nearly a decade, there was no further significant decline in the self-reported rates
of syringe sharing (P < .50).
In Hartford, cross-sectional data were collected before and after syringes be-
came legally available.15In mid-1992, prior to legal availability, 44 of 124 IDUs
(35.5%) reported having used someone else’s syringe. Approximately a year later,
only 32 of 134 (23.9%) reported doing so, a significant 32.7% decrease (P < .01).
A follow-up study, conducted 6 years later, just before the cap was increased to 30,
revealed that 42 of 129 IDUs (32.6%) reported having used someone else’s syringe
within the past 30 days. Among these were 45 SEP customers, of whom 10 (22.2%)
reported sharing syringes. A second follow-up study was conducted after the cap
was increased to 30. Interviews in 1999–2001 revealed that 63.7% (214 of 336)
obtained their syringes from safe sources (either HSEP or pharmacies), and that
17.0% (57 of 335) reported having used someone else’s syringe. Of the 134 partici-
pants reporting that the SEP was their primary source of syringes, 19 (14.2%) had
566HEIMER ET AL.
blood infected with HIV-1 was determined (A) for New Haven by polymerase chain reaction and
(B) for Hartford by enzyme immunoassay.
HIV prevalence in returned syringes. The prevalence of syringes contaminated with
SYRINGES AND HIV RISK IN CONNECTICUT567
shared syringes in the past 30 days. The difference between the percentages before
and after the cap increased was not significant (P < .20).
Syringe availability through SEPs in Connecticut has gone through four phases since
1990, each as a result of legislative change. At each transition, the number of sy-
ringes that could be exchanged per visit to an SEP was increased from 0 to 5, then
to 10, and most recently to 30. The data on the number of syringes exchanged per
visit (Fig. 2) clearly indicate that, in practice, the caps were adhered to by both the
Hartford and New Haven SEPs. We have attempted to investigate the impact of
legislation increasing syringe availability among IDUs in Connecticut on the actual
access to clean syringes experienced by IDUs in New Haven and Hartford. By em-
ploying a combination of syringe-tracking and syringe-testing methods and survey
methods, we have developed individual-level and ecological data to test the hypoth-
esis that increases in the number of syringes that SEP customers could exchange per
visit resulted in actual increases in syringe availability and decreased risk for HIV
transmission. The results, however, revealed that increasing the cap had little effect
on increasing syringe availability or decreasing risk of HIV transmission (Table 2).
Return rates, syringes per visit, syringe reuse rates, and the prevalence of syringes
used by IDUs infected with HIV-1 were not consistently improved concomitant
with increased syringe availability by law.
There were several limitations to this study. First, the data that define each
parameter can come from a variety of sources, and consistent methods of collection
throughout the decade-long study period were not used. Nonetheless, analysis of
multiple methods to estimate syringe reuse appeared to yield consistent results. Sec-
ond, over the decade, some differences, especially in the self-reported data, might
be expected to have occurred as a result of changing awareness of HIV-1 transmis-
sion among IDUs. For this reason, we have included self-reported data on syringe
reuse, which has not been emphasized in HIV prevention education messages and,
therefore, is less subject to response biases.19Third, all of the data, whether ecologic
TABLE 2. Associations between increasing cap and syringe access
Syringes HIV+, %
Syringes HIV+, %
0 to 5
0 to 10
5 to 10
10 to 30
10 to 30
HD to APF
HD to APF, Hartford City Health Department to AIDS Project Hartford;
ND, not determined.
568HEIMER ET AL.
or individual in nature, were cross sectional and not longitudinal. Changes over time
may have been due to differences in the sampling methods, as well as to changes in
individual behaviors. Nevertheless, the consistency of each parameter over time and
the fact that multiple parameters told the same story (Table 2) suggested that the
strength of using multiple parameters to monitor the consequences of the piecemeal
increase in syringe availability outweighs its weaknesses.
In New Haven, the only consistent improvements noted during the 10 years
under study occurred when the SEP first began. The improvement in New Haven
has been estimated to have resulted in at least a one-third reduction in new HIV-1
infections.17,18,23The reason we believe that we were able to see such a large decrease
was that the opening of NHNEP in November 1990 occurred in a climate of ex-
treme syringe shortage brought about by the laws that made the purchase or posses-
sion of syringes without a prescription a crime.9In Hartford, a similar relaxation
in syringe shortage occurred after purchase and possession became legal throughout
Connecticut in October 1992. By the time HSEP began 5 months later, no signifi-
cant changes in return rates, syringe per visit, and syringe HIV prevalence were
observed during the first few months of the program. Instead, changes were ob-
served in the middle of 1995, and these can be attributed to structural improve-
ments made in operations of HSEP that resulted from the transfer of the program
from the city health department to the nonprofit organization AIDS Project Hart-
ford.11In both cities, the data reveal that few, if any, of the five parameters changed
as a direct result of increasing the cap (Table 2).
This finding stands in contrast to findings elsewhere following increases in sy-
ringe availability. In Hawaii,24for instance, syringe exchange began in 1990 with a
cap of 5, which was increased to 25 in 1993, and removed completely in 1996.
Customers of the Hawaiian exchanges report declining levels of sharing in response
to these changes and have HIV prevalence rates that have declined from 5% to less
than 1%. In Vancouver, Canada, in response to an outbreak of HIV infections
among IDUs, the program was expanded, and the cap on the number of syringes
per exchange was removed. What distinguishes the approach in Hawaii and in
Vancouver from that taken in Connecticut is that in the former locales syringe
availability increased in conjunction with increases in SEP services and hours of
operation. Connecticut merely increased the cap; it failed to provide funding to
expand program operations.12
In summary, our study revealed two aspects of the attempt to reduce the trans-
mission of HIV-1 among IDUs in Connecticut by providing legal access to clean
syringes. First, the largest increase in access occurred when syringes, which had
been made scarce by laws prohibiting sale and possession without a prescription,
were first made legally available. Second, there were no consistent increases associ-
ated with legislative action to incrementally increase availability, whether from 5
to 10 or from 10 to 30. These findings, and the difference between Connecticut
and Hawaii, emphasize the need for increased resources for SEPs and for reducing
the barriers IDUs face in accessing clean syringes. Sometimes, the legal availability
of syringes is not as important as finding appropriate and acceptable ways to get
those syringes into the hands of those who need them. While legal availability is
necessary, as evidenced by changes in New Haven associated with the start of
NHNEP, it may not be sufficient to reduce HIV risk and transmission among IDUs.
Other factors—including police harassment of IDUs and the SEPs that serve them,
the provision of other services that enhance SEP operations, and the structure and
SYRINGES AND HIV RISK IN CONNECTICUT 569
operating procedures of the program—may be more important once syringes be-
come legally available.11,12,25–27
This work was supported over the course of the past decade by grants from the
National Institutes of Health (DA-06767, DA-09224, DA-12569, MH-56826), the
Robert Wood Johnson Foundation, and amfAR (American Foundation for AIDS
Research). Portions of this article were presented at the 128th annual meeting of
the American Public Health Association and the 12th International Conference on
the Reduction of Drug-Related Harm. The research protocols described in this arti-
cle were approved by institutional review boards at each participating institution.
We would like to thank David Dooley and Bini Jariwala-Freeman, who tested thou-
sands of syringes, and the staffs of the SEPs in New Haven and Hartford, whose
cooperation in implementing the syringe-tracking and syringe-testing system was
1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. Atlanta,
GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Ser-
2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropoli-
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