Obstacles to Needle Exchange Participation in Rhode Island:

Racial disparities in use of syringe service programs in King County, WA: a comparison of two cross-sectional surveys

BACKGROUND

Syringe service programs (SSPs) provide tools to people who inject drugs (PWID) to prevent overdose, reduce the risk of HIV and HCV infection, and reduce injection frequency. While effective, previous research suggests that SSPs may not adequately reach some marginalized or particularly vulnerable subpopulations of PWID.

METHODS

To identify disparities in SSP use, data from two cross-sectional surveys conducted in King County, Washington were compared: a survey of SSP clients and a community survey of PWID in King County. It was hypothesized that Black PWID, women, and gender minorities would be underrepresented in the SSP survey relative to the general population of PWID.

RESULTS

SSP clients identified as White at a significantly higher rate than the community sample of PWID (p = 0.030). Black (p < 0.001), American Indian/Alaska Native (p < 0.001), Latinx/Hispanic (p = 0.009), and Native Hawaiian/ Pacific Islander PWID (p = 0.034) were underrepresented in the SSP client survey. The gender of SSP clients was similar to the distribution seen in the community sample of PWID (p = 0.483).

CONCLUSIONS

Black PWID are underrepresented in Seattle-area SSPs, consistent with studies in other large US cities. Both nationally and in Seattle, overdose deaths have been increasing among Black PWID, and harm reduction strategies are vital to reversing this trend. SSPs should explore and test ways to be more accessible to minority populations.

“…I can use any syringe I find”: contextual determinants of HIV risk in public injecting settings in Nigeria

Purpose

The purpose of this study is to explore the contextual determinants of HIV risk among people who inject drugs (PWID) in public settings in Nigeria.

Design/methodology/approach

In-depth, individual interviews were conducted with 29 street-based PWID recruited through snowball sampling in Uyo, Nigeria. Interviews were tape-recorded, transcribed, coded and analysed hematically.

Findings

Homelessness and withdrawal pains encouraged consumption of drugs in public spaces (e.g. bunks, public parks). Conversely, the benefits of participation in street drug-use scenes, including reciprocity norms that guarantee free drugs during withdrawal and protection during overdose, fostered a preference for public injecting. Although participants recognized the need to inject with sterile syringes, scarcity of syringes compelled them to improvise with old syringes or share syringes, increasing risk for HIV transmission. HIV risk was exacerbated by unlawful and discriminatory policing practices, which deterred possession of syringes and encouraged risky behaviours such as rushing injection and sharing of equipment.

Practical implications

Contextual factors are key determinants of HIV risk for street-based PWID. Implementation of needle and syringe programmes as well as reforming legal frameworks and policing practices to support harm reduction are needed responses.

Originality/value

This is one of very few qualitative studies that explore risk factors for HIV transmission among PWID in West Africa. The focus on scarcity of sterile syringes and HIV risk is unique and has important policy implications.

Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Background

The Central Appalachian region of the United States is in the midst of a hepatitis C virus epidemic driven by injection of opioids, particularly heroin, with contaminated syringes. In response to this epidemic, several needle exchange programs (NEP) have opened to provide clean needles and other supplies and services to people who inject drugs (PWID). However, no studies have investigated the barriers and facilitators to implementing, operating, and expanding NEPs in less populous areas of the United States.

Methods

This qualitative case study consisted of interviews with program directors, police chiefs, law enforcement members, and PWID affiliated with two NEPs in the rural state of West Virginia. Interview transcripts were coded inductively and analyzed using qualitative data analysis software. Final common themes related to barriers and facilitators of past program openings, current program operations, and future program plans, were derived through a consensus of two data coders.

Results

Both NEPs struggled to find existing model programs, but benefited from broad community support that facilitated implementation. The largest operational barrier was the legal conundrum created by paraphernalia laws that criminalize syringe possession. However, both PWID and law enforcement appreciated the comprehensive services provided by these programs. Program location and transportation difficulties were additional noted barriers. Future program operations are threatened by funding shortages and bans, but necessitated by unexpected program demand.

Conclusion

Despite broad community support, program operations are threatened by growing participant volumes, funding shortages, and the federal government’s prohibition on the use of funds to purchase needles. Paraphernalia laws create a legal conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Future studies should examine additional barriers to using clean needles provided by rural NEPs that may blunt the effectiveness of NEPs in preventing disease transmission.

Beyond equipment distribution in Needle and Syringe Programmes: an exploratory analysis of blood-borne virus risk and other measures of client need

Background

Despite high levels of equipment distribution through Needle and Syringe Programmes (NSPs) in Australia, the levels of reuse of equipment among people who inject drugs remain concerning. This paper used an exploratory analysis to examine the needs of NSP client that could be addressed by NSPs to enhance service impact and blood-borne virus risk practices.

Methods

People who inject drugs were recruited from six NSP sites in Sydney, Australia, to undertake a self-completed survey.

Results

Using the responses of 236 NSP client participants, three factors were identified in an exploratory factor analysis: recent risky injection (Eigenvalue 3.63, 20.2 % of variance); disadvantage and disability (Eigenvalue 2.26, 12.5 % of variance); and drug use milieu (Eigenvalue 1.50, 8.4 % of variance). To understand the distribution of these factors, the standardised factor scores were dichotomised to explore those participants with ‘above average’ vulnerability on each factor. A small group of NSP clients reported a cluster of vulnerability measures. Most participants (55.5 %) reported vulnerability on none or only one factor, indicating that 45.5 % could be considered as having double (35.6 %) or triple (8.9 %) vulnerability.

Conclusions

These results challenge NSPs to understand the heterogeneity among their client group and develop programmes that respond to their clients’ range of needs beyond those immediately associated with blood-borne virus (BBV) risk. This paper contributes to the growing evidence base regarding the need for BBV prevention efforts to examine strategies beyond equipment distribution.

Drug-related deaths and the sales of needles through pharmacies

BACKGROUND

Providing needles to people who inject drugs is a well-proven public health response to the transmission of HIV and other blood borne viruses. Despite over a quarter of a century of research, new concerns about potential unintended negative consequences of needle distribution continue to emerge. Specifically, a claim was recently made that the introduction of pharmacy sales of needles was followed by an increase in overdoses in pharmacy parking lots. If true, this would have serious implications for the design of needle access programs, particularly those involving pharmacy sales of needles.

METHODS

We examine spatial relationships between drug-related deaths and pharmacies in Los Angeles County (population 9.8 million) before and after the 2007 enactment of a California law allowing pharmacy sales of needles without a prescription. Seven thousand and forty-nine drugs related deaths occurred in Los Angeles county from 2000 to 2009 inclusive. Four thousand two hundred and seventy-five of these deaths could be geocoded, and were found to be clustered at the census tract level.

RESULTS

We used three methods to examine spatial relationships between overdose death locations and pharmacy locations for two years on either side of the enactment of the pharmacy sales law, and found no statistically significant changes. Among the 711 geocodable deaths occurring in the two years following the change in law, no death was found to occur within 50m of a pharmacy which sold needles.

CONCLUSION

These results are consistent with prior studies which suggest pharmacy sales of needles improve access to needles without causing increased harms to the surrounding community.

Negotiating access: social barriers to purchasing syringes at pharmacies in Tijuana, Mexico

BACKGROUND

One common public health response to the emergence of HIV has been the provision of sterile syringes to people who inject drugs. In Mexico specialized syringe exchanges are rare, and the sale of needles through pharmacies is often the only way people who inject drugs can obtain sterile syringes. However, people who inject drugs in Tijuana, Mexico report considerable social barriers to successfully purchasing syringes at pharmacies.

METHODS

Between October 2008 and March 2009 we conducted seven in-depth focus groups with 47 people who inject drugs in Tijuana, Mexico. Focus group transcripts were analysed using a descriptive and thematic approach rooted in grounded theory.

RESULTS

We found that injectors offered a number of explanations for why pharmacies were reluctant to sell them syringes, including fear of police; attitudes toward drug use; fear of stereotypical drug user behaviour such as petty theft, violence, or distressing behaviour; and related fears that an obvious drug using clientèle would drive away other customers. Injectors described a range of ways of attempting to re-frame or negotiate interactions with pharmacy staff so that these and related concerns were ameliorated. These included tactics as simple as borrowing cleaner clothing, through to strategies for becoming 'known' to pharmacy staff as an individual rather than as a member of a stigmatized group.

CONCLUSION

Increasing the ability of pharmacy staff and people who inject drugs to successfully negotiate syringe sales are highly desirable. Interventions designed to improve this likelihood need to capitalize on existing solutions developed ad hoc by people who inject drugs and pharmacy staff, and should focus on broadening the range of 'identities' which pharmacy staff are able to accept as legitimate customers. Approaches to achieve this end might include sensitizing pharmacy staff to the needs of people who inject drugs; facilitating individual drug users meeting individual pharmacy staff; and working with drug users to reduce behaviours seen as problematic by pharmacy staff.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: exemplars from research with drug using populations

Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors' research on HIV risk amongst injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts.

Overview of HIV among injection drug users in New York City: critical next steps to eliminate racial/ethnic disparities

At the start of the HIV epidemic, 50% of new infections were among injection drug users (IDUs) in New York City. While HIV has declined among IDUs since the mid-1990s, parenteral transmission continues to overburden Blacks/Hispanic IDUs. Individual risk behaviors do not explain the distribution of HIV/AIDS among IDUs. Social and/or structural factors are likely fueling racial disparities creating a high-risk socioenvironmental context. While increased access to structural interventions (i.e., syringe exchange and pharmacy syringe access) is needed, it may not be sufficient to eliminate HIV/AIDS disparities among IDUs. Research on incorporating structural factors into intervention strategies is needed.

Continuing HIV risk in New York City injection drug users: the association of syringe source and syringe sharing

Sterile syringe access is an important means to reduce HIV risk, but many injection drug users (IDU) who obtain syringes from sterile sources continue to share syringes. We examined the factors associated with continuing syringe sharing in New York City. We recruited 500 active IDU in 2005 through respondent-driven sampling. In multiple logistic regression, not obtaining all syringes in the past year exclusively from sterile sources was associated with increased syringe sharing. Ensuring adequate syringe availability as well as engaging and retaining nonusers and inconsistent users in sterile syringe services may increase sterile syringe access and decrease syringe sharing.

Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes

OBJECTIVES

We assessed the effects of syringe exchange program (SEP) policy on rates of HIV risk behavior and HIV incidence among injection drug users.

METHODS

Using a multivariate generalized estimating equation and Cox regression methods, we examined syringe borrowing, syringe lending, and HIV incidence among a prospective cohort of 1228 injection drug users in Vancouver, British Columbia.

RESULTS

We observed substantial declines in rates of syringe borrowing (from 20.1% in 1998 to 9.2% in 2003) and syringe lending (from 19.1% in 1998 to 6.8% in 2003) following SEP policy change. These declines coincided with a statistically significant increase in the proportion of participants accessing sterile syringes from nontraditional SEP sources (P < .001). In multivariate analyses, the period following the change in SEP policy was independently associated with a greater than 40% reduction in syringe borrowing (adjusted odds ratio [AOR] = 0.57; 95% confidence interval [CI] = 0.49, 0.65) and lending (AOR = 0.52; 95% CI = 0.45, 0.60), as well as declining HIV incidence (adjusted hazard ratio = 0.13; 95% CI = 0.06, 0.31).

CONCLUSIONS

Widespread syringe distribution appears to be a more effective SEP policy than do more restrictive SEP policies that limit syringe access. Efforts should be made to ensure that SEP policies and program design serve to maximize rather than hinder syringe access.

Temporal trends in spatial access to pharmacies that sell over-the-counter syringes in New York City health districts: relationship to local racial/ethnic composition and need

Pharmacies that sell over-the-counter (OTC) syringes are a major source of sterile syringes for injection drug users in cities and states where such sales are legal. In these cities and states, however, black injectors are markedly less likely to acquire syringes from pharmacies than white injectors. The present analysis documents spatial and temporal trends in OTC pharmacy access in New York City health districts over time (2001-2006) and investigates whether these trends are related to district racial/ethnic composition and to local need for OTC pharmacies. For each year of the study period, we used kernel density estimation methods to characterize spatial access to OTC pharmacies within each health district. Higher values on this measure indicate better access to these pharmacies. "Need" was operationalized using two different measures: the number of newly diagnosed injection-related AIDS cases per 10,000 residents (averaged across 1999-2001), and the number of drug-related hospital discharges per 10,000 residents (averaged across 1999-2001). District sociodemographic characteristics were assessed using 2000 US decennial census data. We used hierarchical linear models (HLM) for descriptive and inferential analyses and investigated whether the relationship between need and temporal trajectories in the Expanded Syringe Access Demonstration Program access varied by district racial/ethnic composition, controlling for district poverty rates. HLM analyses indicate that the mean spatial access to OTC pharmacies across New York City health districts was 12.71 in 2001 and increased linearly by 1.32 units annually thereafter. Temporal trajectories in spatial access to OTC pharmacies depended on both need and racial/ethnic composition. Within high-need districts, OTC pharmacy access was twice as high in 2001 and increased three times faster annually, in districts with higher proportions of non-Hispanic white residents than in districts with low proportions of these residents. In low-need districts, "whiter" districts had substantially greater baseline access to OTC pharmacies than districts with low proportions of non-Hispanic white residents. Access remained stable thereafter in low-need districts, regardless of racial/ethnic composition. Conclusions were consistent across both measures of "need" and persisted after controlling for local poverty rates. In both high- and low-need districts, spatial access to OTC pharmacies was greater in "Whiter" districts in 2001; in high-need districts, access also increased more rapidly over time in "whiter" districts. Ensuring equitable spatial access to OTC pharmacies may reduce injection-related HIV transmission overall and reduce racial/ethnic disparities in HIV incidence among injectors.

The role of harm reduction in controlling HIV among injecting drug users

Injecting drug users (IDU) now account for one in 10 new HIV infections world wide. Yet it has been known since the early 1990s that HIV among IDU can be effectively, safely and cost-effectively controlled by the early and vigorous implementation of a comprehensive package of strategies known as 'harm reduction'. This concept means that decreasing drug-related harms is accorded an even higher priority than reduction of drug consumption. Strategies required involve: explicit and peer-based education about the risk of HIV from sharing injecting equipment; needle syringe programmes; drug treatment (including especially opiate substitution treatment) and community development. Many countries experiencing or threatened by an HIV epidemic among IDU have now adopted harm reduction but often implementation has been too little and too late. Although coverage is slowly improving in many countries, HIV is still spreading faster among IDU than harm reduction programmes while coverage in correctional centres lags far behind community settings. The scientific debate about harm reduction is now over. National and international support for harm reduction is growing while almost all the major UN organizations responsible for drug policy now support harm reduction. Only a small number of countries, led by the USA, are still vehemently opposed to harm reduction. Excessive reliance on drug law enforcement remains the major barrier to increased adoption of harm reduction. Sometimes zealous drug law enforcement undermines harm reduction. A more balanced approach to drug law enforcement is required with illicit drug use recognized primarily as a health and social problem.

Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales

The aim of this study was to compare demographic and drug use profiles of non-needle and syringe programmes (NSP) attendees with NSP attendees from the same geographic area. Two data sources were used. One was from an annual national survey of injecting drug users (IDU) at NSP and analysis was restricted to survey sites in Kings Cross and Kogarah in 2003 (NSP survey). The other was from a survey of IDU who do not use NSP as their primary source of injecting equipment within the same broad geographical region (Access survey). Of the total 264 survey participants, 102 had never attended a NSP (non-NSP attendees) and 162 had previous experience of NSP (NSP attendees). Compared with NSP attendees, non-NSP attendees were less likely to report severe drug problems and more likely to report lower prevalence of HIV, hepatitis B and hepatitis C infection. Nevertheless, about 20% of non-NSP attendees reported re-use of needles and syringes after someone else in the previous month. Compared to NSP attendees, a lower rate of usage of health services was reported by non-NSP attendees. Strategies to promote access to NSP and harm reduction services, including testing for blood-borne viruses, information provision and consideration of referral to treatment among non-NSP attendees are recommended.

Multilevel community-based intervention to increase access to sterile syringes among injection drug users through pharmacy sales in New York City

OBJECTIVES

Research has indicated that there is minimal use of pharmacies among injection drug users (IDUs) in specific neighborhoods and among Black and Hispanic IDUs. We developed a community-based participatory research partnership to determine whether a multilevel intervention would increase sterile syringe access through a new policy allowing nonprescription syringe sales in pharmacies.

METHODS

We targeted Harlem, NY (using the South Bronx for comparison), and disseminated informational material at community forums, pharmacist training programs, and counseling or outreach programs for IDUs. We compared cross-sectional samples in 3 target populations (pre- and postintervention): community members (attitudes and opinions), pharmacists (opinions and practices), and IDUs (risk behaviors).

RESULTS

Among community members (N = 1496) and pharmacists (N = 131), negative opinions of IDU syringe sales decreased in Harlem whereas there was either no change or an increase in negative opinions in the comparison community. Although pharmacy use by IDUs (N=728) increased in both communities, pharmacy use increased significantly among Black IDUs in Harlem, but not in the comparison community; syringe reuse significantly decreased in Harlem, but not in the comparison community.

CONCLUSIONS

Targeting the individual and the social environment through a multilevel community-based intervention reduced high-risk behavior, particularly among Black IDUs.

Syringe-Exchange Programs and HIV Prevention

Injection drug users and their sexual partners and children represent an increasing proportion of Americans living with HIV or AIDS. Syringe-exchange programs (SEPs), which are based on the theory of harm reduction, are effective in preventing the transmission of HIV and other pathogens through injection drug use. Most programs also serve as gateways to other vital medical services. Yet SEPs remain controversial. This article describes the controversy, considers the evidence, and discusses the nursing implications.

Relationships of deterrence and law enforcement to drug-related harms among drug injectors in US metropolitan areas

OBJECTIVE

To understand associations of punitive policies to the population prevalence of injection drug users and to HIV seroprevalence among injectors.

DESIGN AND METHODS

A lagged-cross-sectional analysis of metropolitan statistical area data. Estimates of drug injectors per capita and of HIV seroprevalence among injectors in 89 large US metropolitan areas were regressed on three measures of legal repressiveness (hard drug arrests per capita; police employees per capita; and corrections expenditures per capita) controlling for other metropolitan area characteristics.

RESULTS

No legal repressiveness measures were associated with injectors per capita; all three measures of legal repressiveness were positively associated with HIV prevalence among injectors.

CONCLUSIONS

These findings suggest that legal repressiveness may have little deterrent effect on drug injection and may have a high cost in terms of HIV and perhaps other diseases among injectors and their partners--and that alternative methods of maintaining social order should be investigated.

Effects of an intensive street-level police intervention on syringe exchange program use in Philadelphia, PA

Repeated measurements and mixed-effects models were used to analyze the effects of an intensive long-term street-level police intervention on syringe exchange program use. Utilization data for 9 months before and after the beginning of the intervention were analyzed. Use fell across all categories and time periods studied, with significant declines in use among total participants, male participants, and Black participants. Declines in use among Black and male participants were much more pronounced than decreases among White and female participants.

Sterile syringe access conditions and variations in HIV risk among drug injectors in three cities

AIM

Better sterile syringe access should be associated with a lower likelihood of syringe re-use and receptive syringe sharing, although few empirical studies have examined gradients in syringe access using both individual and ecological data. In this study, we compare syringe re-use and receptive syringe sharing among injection drug users (IDUs) with syringe exchange program (SEP) and legal over-the-counter pharmacy access with limits on syringes that can be purchased, exchanged or possessed to IDUs with no pharmacy sales but unlimited syringe access through SEPs. We address three questions: (1) Does residing in an area with no legal syringe possession increase the likelihood of police contact related to possessing drug paraphernalia? (2) Among direct SEP users, is use of more permissive SEPs associated with less likelihood of syringe re-use and receptive syringe sharing? (3) Among non-SEP users, is residing in an area with pharmacy access associated with lower likelihood of syringe re-use and receptive syringe sharing?

DESIGN

Quantitative survey of IDUs recruited from SEPs, subject nomination and outreach methods. Multivariate analyses compared police contact, syringe re-use and receptive syringe sharing among IDUs recruited in three cities.

FINDINGS

In multivariate analyses, we found that police contact was associated independently with residing in the area with no legal possession of syringes; among SEP users, those with access to SEPs without limits had lower syringe re-use but not lower syringe sharing; and that among non-SEP users, no significant differences in injection risk were observed among IDUs with and without pharmacy access to syringes.

CONCLUSION

We found that greater legal access to syringes, if accompanied by limits on the number of syringes that can be exchanged, purchased and possessed, may not have the intended impacts on injection-related infectious disease risk among IDUs.

Pharmacist support for selling syringes without a prescription to injection drug users in Rhode Island

OBJECTIVE

To examine pharmacists' attitudes and obstacles to syringe sales to IDUs without prescriptions in Rhode Island, around the time that such sales became legal in the state.

DESIGN

Self-administered written survey.

SETTING

Rhode Island.

PARTICIPANTS

400 randomly selected pharmacist members of the Rhode Island Pharmacists Association.

MAIN OUTCOME MEASURES

Responses to survey items.

RESULTS

Of the 400 pharmacists contacted, 131 (33%) completed and returned the survey; of these, 101 (77%) were pharmacists who worked in stores that provided direct nonprescription syringe sales to the public. The majority of these 101 pharmacists were willing to sell syringes to a suspected IDU without a prescription (65%), favored providing free sharps containers for disposal (68%), and supported providing pamphlets on safer injection practices (88%). Willingness to sell syringes to IDUs without a prescription was significantly correlated with various beliefs about possible consequences of sales.

CONCLUSION

The high level of support for nonprescription syringe sales to IDUs is promising. The correlation between the willingness to sell syringes to IDUs without a prescription and various beliefs suggests that future educational interventions might encourage pharmacists to sell syringes to this population without a prescription to decrease HIV and hepatitis transmission.

Report of the Council on Scientific Affairs: methadone maintenance and needle-exchange programs to reduce the medical and public health consequences of drug abuse

Extensive evaluation studies show that methadone maintenance therapy (MMT) reduces heroin use and associated problems in a cost-effective manner, without negative public health impact. MMT is limited by inadequate funding and understanding of relevant research, extensive regulation, and limits on the freedom of physicians to provide methadone in a variety of medical settings. Broad-based medical, public health, and scientific support exists for expansion of MMT with greater emphasis on consistency and quality, and provision of ancillary services. Programs for the exchange, free distribution, and legal pharmacy sale of needles and syringes reduce injection drug use and prevent the spread of bloodborne pathogens; drug abuse treatment and other services are important components. Neither strategy increases existing drug use nor leads to drug use initiation. The scientific literature supports assertions that drug abuse issues should be treated primarily as medical and public health rather than criminal justice issues. The effectiveness of both strategies warrants increased support for services, easing of federal and state restrictions governing their availability, and advocacy in their support.

Investigation of a secondary syringe exchange program for homeless young adult injection drug users in San Francisco, California, U.S.A

This study investigated an HIV prevention program for homeless young adult injection drug users (IDUs) that combined a secondary syringe exchange program (SEP) with community-level activities. Homeless young IDUs were recruited from street-based settings in San Francisco, and a structured questionnaire was administered. The secondary SEP operated in a circumscribed geographic area, and for analytic purposes respondents were assigned to the intervention site group if they primarily spent time in this area (n = 67), or the comparison site group if they primarily spent time elsewhere (n = 55). Almost all (96%) intervention site youth had used the secondary SEP in the past 30 days and were significantly more likely to regularly use SEP. In bivariate analysis, comparison site IDUs were more likely to share syringes, reuse syringes, share the cotton used to filter drugs, and use condoms with casual sex partners only inconsistently. In multivariate analysis, comparison site remained positively associated with sharing syringes (adjusted odds ratio [AOR], 3.748; 95% confidence interval [CI], 1.406-9.988), reusing syringes (AOR, 2.769; 95% CI,1.120-6.847), and inconsistent condom use with casual sex partners (AOR, 4.825; 95% CI, 1.392- 16.721). This suggests that the intervention was effective in delivering SEP services to homeless young adult IDUs, and that IDUs who frequented the intervention site had a lower HIV risk than comparison group IDUs.

Characteristics and utilization patterns of needle-exchange attendees in Chicago: 1994-1998

The objectives of this study were to describe characteristics and utilization patterns of participants attending a needle-exchange program (NEP) in Chicago, Illinois. Since 1994, demographics of NEP attendees and program utilization data were collected systematically at 22 sites operated by the Chicago Recovery Alliance (CRA). Descriptive statistics were used to assess time trends, site variations, and characteristics of attendees in day sites versus evening sites. A total of 11,855 injection drug users (IDUs) visited the NEP at least once from 1994 to 1998. Median age was 41 years, and 74% were male. Overall race distribution was African-American 50%, Caucasian 38%, Puerto Rican 10%, other 2%. Over time, there was a proportional decrease in African-American users (55.4% to 39.9%, P < .001), a significant increase in Puerto Rican users (1.4% to 14.1%, P < .001), and a stable proportion of Caucasian users (42%). Each year, 15-20% of all clients were first-time attenders. Overall, participants attending evening versus day sites were younger (median age 39 years vs. 42 years, P < .001) and more ethnically diverse. Over a 4-year period, this NEP reached a diverse population of IDUs and recruited a stable proportion of first-time users. Compared to daytime NEP venues, evening NEP sites attracted younger clients and those who were more diverse ethnically. To maximize coverage of sterile syringes, NEPs should strive for diversification in terms of hours of operation and location.