Syringe laws and pharmacy regulations are structural constraints on HIV prevention in the US

Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city

Background

The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access.

Methods

Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy.

Results

Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission.

Conclusion

Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.

Correlates of Transactional Sex and Violent Victimization among Men Who Inject Drugs in Los Angeles and San Francisco, California

Men who inject drugs (MWID) and engage in transactional sex (i.e., receive money or drugs in exchange for sex) are vulnerable to HIV and violence. However, MWID who engage in transactional sex have been less studied than women. We examine factors associated with transactional sex among MWID in Los Angeles and San Francisco and whether transactional sex is associated with violent victimization. MWID were recruited using targeted sampling methods in 2011-2013 and completed surveys that covered demographics, drug use, HIV risk, violence, transactional sex, and other items. Multivariable logistic regression was used to (1) determine factors independently associated with transactional sex and (2) determine if transactional sex was independently associated with violence victimization in the last 6 months among MWID. An interaction term between income source and sexual identity was included in the transactional sex model. Of the 572 male PWID in the sample, 47 (8%) reported transactional sex in the past 6 months. Self-reported HIV infection was 7% for MWID who did not report transactional sex, 17% for MWID who reported transactional sex, and 24% for MWID who reported transactional sex and reported gay or bisexual identity. In multivariable analysis, transactional sex was positively associated with gay or bisexual identity (GB without illegal income adjusted odds ratio [AOR] = 5.16; 95% confidence interval [CI] = 1.86-14.27; GB with illegal income AOR = 13.55, CI = 4.57-40.13), coerced sex in the last 12 months (AOR = 11.66, CI = 1.94-70.12), and violent victimization in the last 12 months (AOR = 2.31, CI = 1.13-4.75). Transactional sex was negatively associated with heroin injection (last 30 days) (AOR = 0.37; 95% CI = 0.18-0.78). Transactional sex was independently associated with violent victimization in the last 12 months (AOR = 2.04; 95% CI = 1.00-4.14) while controlling for confounders. MWID who engaged in transactional sex are at elevated risk for HIV and multiple forms of violent victimization. Interventions focused on this at-risk subpopulation are urgently needed and should include access to substance use disorder treatment, victimization services, and harm reduction services across the HIV care continuum.

Syringe Decriminalization Advocacy in Red States: Lessons from the North Carolina Harm Reduction Coalition

PURPOSE OF REVIEW

Syringe access programs (SAPs) are cornerstone harm reduction interventions for combatting the national opioid epidemic. The goal of this paper is to describe effective advocacy strategies for enacting syringe decriminalization legislation to foster the expansion of SAPs in high-need areas amidst political opposition.

RECENT FINDINGS

Decades or research shows that SAPs prevent the transmission of HIV among people who inject drugs (PWID) and are a cost-effective tool for linking PWID to medical care, health education, and social services. In the USA, state laws criminalizing distribution and possession of syringes impede the expansion of SAPs into areas where they are sorely needed. In 2016, North Carolina became the first state to legalize SAPs with a Republican super majority. This paper distills strategies for community organizations seeking to advance syringe decriminalization legislation in politically conservative states with histories of prioritizing punitive sanctions over public health responses to drug use.

Self-reported participation in voluntary nonprescription syringe sales in California's Central Valley

OBJECTIVES

California Senate Bill 41 (SB41), effective January 2012, is a human immunodeficiency virus/hepatitis C virus prevention measure designed to expand syringe access among injection drug users (IDUs) by allowing pharmacies to sell syringes without a prescription. This study assesses self-reported implementation of SB41 and characterizes barriers amenable to intervention.

DESIGN

Interviewer-administered survey.

SETTING AND PARTICIPANTS

Fresno and Kern Counties, CA. Pharmacists and other pharmacy staff (n = 404) at 212 pharmacies.

OUTCOME MEASURE

Self-reported nonprescription pharmacy sales to known or suspected IDUs.

RESULTS

Overall, 29.3% of participants said their pharmacy would sell nonprescription syringes to a known or suspected IDU, whereas a far higher proportion (79.3%) would sell nonprescription syringes to a person with diabetes. More than one-half said that their pharmacy requires nonprescription syringe purchasers to enter their signature and name and address in a log book although that is not required under SB41. Fewer than 2 out of 3 participants (61.1%) knew that it is legal to sell nonprescription syringes to IDUs. That knowledge, as well as having syringe sales practices based on both store policy and discretion, were positively associated with IDU syringe sales after controlling for other factors. Working at an independent pharmacy, agreeing that only people with "medical conditions" such as diabetes should be able to buy syringes, and viewing syringe sales to IDUs as "not good business" were independently but negatively associated with IDU syringe sales.

CONCLUSION

This study complements an earlier syringe purchase trial documenting low participation in voluntary nonprescription syringe sales under SB41 in Fresno and Kern Counties. In the absence of legislation requiring mandatory syringe sales, interventions should be developed to increase knowledge of the law and frame addiction as a medical condition, with a special focus on independent pharmacies. Informational interventions should stress the need to eliminate log book documentation requirements, which may serve as a barrier to IDU purchase.

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.

Police Encounters Among Needle Exchange Clients in Baltimore: Drug Law Enforcement as a Structural Determinant of Health

OBJECTIVES

We piloted a monitoring mechanism to document police encounters around programs targeting people who inject drugs (PWID), and assessed their demographic predictors at 2 Baltimore, Maryland, needle exchange program (NEP) sites.

METHODS

In a brief survey, 308 clients quantified, characterized, and sited recent police encounters. Multivariate linear regression determined encounter predictors, and we used geocoordinate maps to illustrate clusters.

RESULTS

Within the past 6 months, clients reported a median of 3 stops near NEP sites (interquartile range [IQR] = 0-7.5) and a median of 1 arrest in any location (IQR = 0-2). Three respondents reported police referral to the NEP. Being younger (P = .009), being male (P = .033), and making frequent NEP visits (P = .02) were associated with reported police stops. Among clients reporting arrest or citation for syringe possession, Whites were significantly less likely than non-Whites to report being en route to or from an NEP (P < .001). Reported encounters were clustered around NEPs.

CONCLUSIONS

Systematic surveillance of structural determinants of health for PWID proved feasible when integrated into service activities. Improved monitoring is critical to informing interventions to align policing with public health, especially among groups subject to disproportionate levels of drug law enforcement.

Antibodies against Mycobacterial proteins as biomarkers for HIV-associated smear-negative tuberculosis

Serology data are limited for patients with sputum smear-negative HIV-associated active tuberculosis (TB). We evaluated the serum antibody responses against the mycobacterial proteins MPT51, MS, and echA1 and the 38-kDa protein via enzyme-linked immunosorbent assay (ELISA) in South African (S.A.) HIV-positive (HIV(+)) smear-negative TB patients (n = 56), U.S. HIV(+) controls with a positive tuberculin skin test (TST(+); n = 21), and S.A. HIV-negative (HIV(-)) (n = 18) and HIV(+) (n = 24) controls. TB patients had positive antibody reactivity against MPT51 (73%), echA1 (59%), MS (36%), and the 38-kDa protein (11%). Little reactivity against MPT51 and echA1 was observed in control groups at low risk for TB, i.e., S.A. HIV(-) (0% and 6%, respectively), and at moderate risk for TB development, i.e., U.S. HIV(+) TST(+) controls (14% and 10%, respectively). By contrast, more reactivity was detected in the S.A. HIV(+) control group at higher risk for TB (25% and 45%, respectively). Our data hold promise that antibody detection against MPT51 and echA1 might have adjunctive value in the detection of HIV(+) smear-negative TB and might reflect increasing Mycobacterium tuberculosis infection activity in asymptomatic HIV(+) individuals.

Pharmacy nonprescription syringe distribution and HIV/AIDS: a review

OBJECTIVE

To summarize current research findings on pharmacy nonprescription syringe distribution to prevent the spread of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) among injection drug users (IDUs), including research on pharmacist attitudes and behavior, drug user attitudes and behavior, and the health impact on HIV/AIDS risk behavior.

DATA SOURCES

Data were collected using PubMed and PsycINFO through July 2011. Search terms used were pharmacist or pharmacy and syringe or syringe exchange or needle or needle exchange. Two journals (Journal of Urban Health and Journal of the American Pharmacists Association) with a high number of hits were manually inspected. Reference sections for each article also were examined.

STUDY SELECTION

Studies were included if they examined attitudes toward, experiences with, or the impact of pharmacy nonprescription syringe distribution for the purpose of preventing the spread of HIV/AIDS among IDUs in the United States. Studies were excluded that mentioned these topics in passing or did not report empirical results.

DATA SYNTHESIS

47 studies were identified that met the inclusion criteria. Studies included a diverse range of perspectives, including pharmacist viewpoints, IDU attitudes, and evaluations.

CONCLUSION

According to the available literature, many pharmacists express willingness to sell and report selling syringes to customers without a prescription. IDUs show willingness to use pharmacies to obtain syringes. Finally, pharmacy syringe sale and the legalization of this practice appear to have a positive impact on HIV risk behavior. Accordingly, the nonprescription sale of syringe should be promoted. However, the literature remains incomplete and future research is required.

Risk factors for tuberculosis

The risk of progression from exposure to the tuberculosis bacilli to the development of active disease is a two-stage process governed by both exogenous and endogenous risk factors. Exogenous factors play a key role in accentuating the progression from exposure to infection among which the bacillary load in the sputum and the proximity of an individual to an infectious TB case are key factors. Similarly endogenous factors lead in progression from infection to active TB disease. Along with well-established risk factors (such as human immunodeficiency virus (HIV), malnutrition, and young age), emerging variables such as diabetes, indoor air pollution, alcohol, use of immunosuppressive drugs, and tobacco smoke play a significant role at both the individual and population level. Socioeconomic and behavioral factors are also shown to increase the susceptibility to infection. Specific groups such as health care workers and indigenous population are also at an increased risk of TB infection and disease. This paper summarizes these factors along with health system issues such as the effects of delay in diagnosis of TB in the transmission of the bacilli.

Difficulty accessing syringes mediates the relationship between methamphetamine use and syringe sharing among young injection drug users

Injection drug users (IDU) who use methamphetamine (MA) are at an increased risk of HIV infection due to engagement in injection-related risk behavior including syringe sharing. In this cohort study of young IDU aged 18-30, we investigated the relationship between injection MA use and syringe sharing, and whether difficulty accessing sterile syringes mediated this association. Behavioral questionnaires were completed by 384 IDU in Vancouver, Canada between October 2005 and May 2008. Generalized estimating equations were used to estimate direct and indirect effects. The median age of participants was 24 (IQR: 22–27) and 214 (55.7%) were male. Injecting MA was independently associated with syringe sharing. Mediation analyses revealed that difficulty accessing sterile syringes partially mediated the association between injecting MA and syringe sharing. Interventions to reduce syringe sharing among young methamphetamine injectors must address social and structural barriers to accessing HIV prevention programs.

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.

Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed

HIV can spread rapidly between people who inject drugs (through injections and sexual transmission), and potentially the virus can pass to the wider community (by sexual transmission). Here, we summarise evidence on the effectiveness of individual-level approaches to prevention of HIV infection; review global and regional coverage of opioid substitution treatment, needle and syringe programmes, and antiretroviral treatment; model the effect of increased coverage and a combination of these three approaches on HIV transmission and prevalence in injecting drug users; and discuss evidence for structural-level interventions. Each intervention alone will achieve modest reductions in HIV transmission, and prevention of HIV transmission necessitates high-coverage and combined approaches. Social and structural changes are potentially beneficial components in a combined-intervention strategy, especially when scale-up is difficult or reductions in HIV transmission and injection risk are difficult to achieve. Although further evidence is needed on how to optimise combinations of interventions in different settings and epidemics, we know enough now about which actions are effective: the challenge is to deliver these well and to scale.

Pharmacy participation in non-prescription syringe sales in Los Angeles and San Francisco counties, 2007

Increasing sterile syringe access for injection drug users (IDUs) is one way to prevent HIV and hepatitis C virus (HCV) transmission in this population. In 2005, California Senate Bill 1159 allowed counties to adopt the Disease Prevention Demonstration Project (DPDP). Where enacted, the DPDP allows pharmacies that register with the county to sell up to ten syringes to adults without a prescription. In the current study, we describe pharmacy participation in nonprescription syringe sales (NPSS) in two counties in California and examine factors associated with NPSS. Telephone and in-person interviews were conducted in Los Angeles (LA) and San Francisco (SF) with 238 pharmacies in 2007 (n = 67 in SF; n = 171 in LA). Quantitative survey items captured pharmacy registration with the county, pharmacy policies/practices, episodes and conditions of NPSS and refusals to sell, potential negative consequences of NPSS, and staff attitudes regarding HIV and HCV prevention for IDUs. Overall, 42% of pharmacies reported NPSS (28% in LA and 81% in SF), although only 34% had registered with the county (17% in LA and 76% in SF). Many pharmacies required proof of a medical condition (80% in LA and 30% in SF) and refused NPSS if the customer was a suspected IDU (74% in LA, 33% in SF). Few negative consequences of NPSS were reported. In multivariate logistic regression analysis, we found that the odds of NPSS were significantly higher among pharmacists who thought syringe access was important for preventing HIV among IDUs [adjusted odds ratio (AOR) = 2.95; 95% confidence interval (CI) = 1.10-7.92], were chain pharmacies (AOR = 12.5; 95% CI = 4.55-33.33), and were located in SF (AOR = 4.88; 95% CI = 1.94-12.28). These results suggest that NPSS were influenced by pharmacists' perception. NPSS might be increased through greater educational efforts directed at pharmacists, particularly those in non-chain pharmacies.

Barriers to pharmacy-based syringe purchase among injection drug users in Tijuana, Mexico: a mixed methods study

Injection drug users (IDUs) may be denied purchase of sterile syringes even where purchase without a prescription is legal. This study examined barriers to over-the-counter (OTC) syringe purchase among IDUs in Tijuana, Mexico. A quantitative survey and subsequent focus groups were used to quantify barriers to purchase, identify their correlates and provide in-depth exploration of syringe purchase experiences. Of 627 IDUs, 81% purchased a syringe in the past 6 months and 16% were refused or overcharged. Factors independently associated with refusal/overcharging were homelessness, receptive syringe sharing, >5 uses per syringe, and number of lifetime abscesses. Few pharmacies sold syringes to IDUs, who adapted by limiting purchase attempts to pharmacies known to sell syringes consistently. Failed purchases occurred when drug withdrawal required purchase at unusual times or locations, often following release from jail. IDUs reported syringe sharing, syringe reuse, and searching through unsecured medical waste for syringes in response to failed purchase attempts. Interventions to expand OTC syringe sales to IDUs, particularly near detention facilities, will facilitate safer injection practices.

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

BACKGROUND

Injecting 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.

METHODS

Between 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.

RESULTS

In our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes.

CONCLUSIONS

Given 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.

Greater drug injecting risk for HIV, HBV, and HCV infection in a city where syringe exchange and pharmacy syringe distribution are illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004-2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU's used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs.

Predictors of success in implementing HIV prevention in rural America: a state-level structural factor analysis of HIV prevention targeting men who have sex with men

Relatively few studies have examined the impact of modifying structural factors on HIV prevention efforts in the United States despite their high potential for lowering HIV prevalence rates. The aim of this study was to identify state-level characteristics of successful HIV prevention implementation. Structured interviews with 73 key informants in 13 rural states identified 'more successful' and 'less successful' states in HIV prevention. States were compared on demographic, religious, gay community, and funding variables. The 7 more successful states had both a wider variety and more MSM-targeted interventions. Overall funding, degree of epidemic, and "ruralness" were not significantly associated with success. Rather, successful states had less religious and Evangelical Protestant adherents and more 'gay community' infrastructure. They also spent a greater proportion of funds contracting community-based organizations and on MSM-targeted programming. Success in HIV prevention varies across rural states. Key demographic, social and economic indicators distinguish success in HIV prevention.

Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities

AIMS

To identify factors associated with receptive syringe sharing among injection drug users (IDUs) and elucidate the association between syringe possession arrests and syringe sharing.

DESIGN

Cross-sectional study.

SETTING

Mexican border cities of Tijuana, Baja California and Ciudad Juarez, Chihuahua.

PARTICIPANTS

IDUs in Tijuana (n = 222) and Ciudad Juarez (n = 206) were recruited using respondent-driven sampling (RDS). IDUs were > or = 18 years and had injected illicit drugs in the past month.

MEASUREMENTS

An interviewer-administered survey was used to collect quantitative data on socio-demographic, behavioral and contextual characteristics, including self-reported syringe sharing and arrests for syringe possession. Associations with receptive syringe sharing were investigated using logistic regression with RDS adjustment.

FINDINGS

Overall, 48% of participants reported ever being arrested for carrying an unused/sterile syringe, even though syringe purchase and possession is legal in Mexico. Arrest for possessing unused/sterile syringes was associated independently with receptive syringe sharing [adjusted odds ratio (AOR) = 2.05; 95% confidence interval (CI): 1.26, 3.35], as was injecting in a shooting gallery (AOR = 3.60; 95% CI: 2.21, 5.87), injecting in the street (AOR = 2.05; 95% CI: 1.18, 3.54) and injecting methamphetamine (AOR = 2.77; 95% CI: 1.41, 5.47) or cocaine (AOR = 1.96; 95% CI: 1.15, 3.36). More than half of participants (57%) had been arrested for possessing a used syringe; in a second model, arrest for used syringe possession was also associated independently with receptive sharing (AOR = 2.87; 95% CI: 1.76, 4.69).

CONCLUSIONS

We documented high levels of syringe-related arrests in two Mexican-US border cities and an independent association between these arrests and risky injection practices. Public health collaborations with law enforcement to modify the risk environment in which drug use occurs are essential to facilitate safer injection practices.

Determinants of injection drug user (IDU) syringe sharing: the relationship between availability of syringes and risk network member characteristics in Winnipeg, Canada

AIMS

Despite the establishment of syringe exchange programmes, syringe-sharing behaviour remains common among some injection drug users (IDU). Previous studies have identified several individual- and social network-level variables associated with syringe sharing. We examine the extent to which each of these variables is related independently to this behaviour within a diverse study population.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey of 435 IDU conducted between December 2003 and September 2004 in Winnipeg, Canada.

MEASUREMENTS

Individual and social-network variables were obtained from a survey instrument administered through a personal interview. Syringe sharing was defined as receptive syringe sharing in the last 6 months. Logistic regression analysis with generalized estimating equations was used to determine simultaneously the role of individual-level and risk network member-level variables on the odds of syringe sharing.

FINDINGS

Individuals' relationship to a risk network member (sex partner, OR: 15.3 95% CI: 7.6-30.8; family member, OR: 3.4 95% CI: 1.3-9.0) and difficulty of access to syringes (OR: 3.6 95% CI: 1.3-9.9) were predictive of syringe sharing. Dyads who 'often' pooled resources to obtain drugs were at 4.9 times (95% CI: 2.1-11.6) the odds of syringe sharing, while those who 'sometimes' pooled resources were at 2.8 times (95% CI: 1.1-6.7) the odds, compared to those who 'never' pooled resources together.

CONCLUSIONS

Syringe sharing in this population depended on both the availability of clean syringes and social network relationships. Adopting interventions that take into account relationships and behaviours that shape social norms present in networks/dyads would be a necessary prevention strategy alongside the provision of clean syringes.

Placing the dynamics of syringe exchange programs in the United States

Drawing upon the broader health, social, and political geography literature, this paper outlines a framework for considering place-based processes through which syringe exchange availability may be understood. It is argued that the geographic distribution of syringe exchange programs (SEPs) in the United States is linked to the social and political conditions of particular localities through three place characteristics: (1) structural constraints; (2) social and spatial distancing of injection drug users; and (3) localized action. Although SEPs remain controversial and face ongoing obstacles from the government, law enforcement and local communities, they continue to operate through the efforts of grassroots organizations and local activists. Action on this issue occurs locally, and the characteristics of place-based factors affect whether particular areas adopt SEPs.

Changes in injecting practices associated with the use of a medically supervised safer injection facility

Injection drug users (IDUs) are vulnerable to serious health complications resulting from unsafe injection practices. We examined whether the use of a supervised safer injection facility (SIF) promoted change in injecting practices among a representative sample of 760 IDUs who use a SIF in Vancouver, Canada. Consistent SIF use was compared with inconsistent use on a number of self-reported changes in injecting practice variables. More consistent SIF use is associated with positive changes in injecting practices, including less reuse of syringes, use of sterile water, swabbing injection sites, cooking/filtering drugs, less rushed injections, safe syringe disposal and less public injecting.

Street policing, injecting drug use and harm reduction in a Russian city: a qualitative study of police perspectives

We undertook a qualitative exploration of police perspectives on injecting drug use and needle and syringe access among injecting drug users (IDUs) in a Russian city which has witnessed explosive spread of HIV associated with drug injecting. Twenty-seven in-depth qualitative interviews were conducted in May 2002 with police officers of varying rank who reported having regular contact with IDUs. All interviews were tape-recorded, transcribed, translated and coded thematically. Accounts upheld an approach to policing which emphasised high street-based visibility and close surveillance of IDUs. IDUs were depicted as 'potential criminals' warranting a 'pre-emptive' approach to the prevention of drug-related crime. Street policing was described as a means of maintaining close surveillance leading to the official registration of persons suspected or proven to be users of illicit drugs. Such registration enabled further ongoing surveillance, including through stop and search procedures. While aware of drug users' reluctance to carry injecting equipment linked to their fears of detention or arrest, accounts suggested that the confiscation of previously used injecting equipment can constitute evidence in relation to drugs possession charges and that discovery of clean injecting equipment may be sufficient to raise suspicion and/or further investigation, including through stop and search or questioning. Our findings suggest an uneasy relationship between street policing and needle and syringe access, whereby policing strategies can undermine an HIV prevention ethos promoting needle and syringe accessibility among IDUs. We conclude that facilitating partnerships between policing agencies and HIV prevention initiatives are a critical feature of creating environments conducive for risk reduction.

Model Projections on the Required Coverage of Syringe Distribution to Prevent HIV Epidemics Among Injecting Drug Users

BACKGROUND

Although syringe distribution is effective in preventing HIV transmission among injecting drug users (IDUs), there is little evidence on the required coverage to substantially reduce HIV transmission.

METHODS

A mathematical model is developed to explore the relationship between the endemic HIV prevalence among IDUs and the coverage of syringe distribution. Data from IDU populations in the United Kingdom and Belarus are used to explore the implications of increasing coverage and the effect of changes in other behaviors.

RESULTS

Projections suggest that there is a coverage threshold, which, if reached, could lead to substantial decreases in HIV prevalence. The threshold largely depends on the frequency that IDUs inject and (safely) reuse their syringes, and corresponds to less than 4 syringe-sharing events per IDU per month. Other factors, such as the injecting cessation rate and efficacy of syringe cleaning, only have substantial impact near threshold coverage levels.

CONCLUSIONS

Our results support a policy of increasing the coverage of syringe distribution but highlight the difficulty in producing a universal coverage target. Great public health benefit could be conferred by encouraging the safe reuse of an IDU's own syringes and small stable injecting groups. Policies that discourage this will negate the impact of syringe distribution interventions.

"Vivo para consumirla y la consumo para vivir" ["I live to inject and inject to live"]: high-risk injection behaviors in Tijuana, Mexico

Injection drug use is a growing problem on the US-Mexico border, where Tijuana is situated. We studied the context of injection drug use among injection drug users (IDUs) in Tijuana to help guide future research and interventions. Guided in-depth interviews were conducted with 10 male and 10 female current IDUs in Tijuana. Topics included types of drug used, injection settings, access to sterile needles, and environmental influences. Interviews were taped, transcribed verbatim, and translated. Content analysis was conducted to identify themes. Of the 20 IDUs, median age and age at first injection were 30 and 18. Most reported injecting at least daily: heroin ("carga", "chiva", "negra"), methamphetamine ("crico", "cri-cri"), or both drugs combined. In sharp contrast to Western US cities, almost all regularly attended shooting galleries ("yongos" or "picaderos") because of the difficulties obtaining syringes and police oppression. Almost all shared needles/paraphernalia ["cuete" (syringe), "cacharros" (cookers), cotton from sweaters/socks (filters)]. Some reported obtaining syringes from the United States. Key themes included (1) pharmacies refusing to sell or charging higher prices to IDUs, (2) ample availability of used/rented syringes from "picaderos" (e.g., charging approximately 5 pesos or "10 drops" of drug), and (3) poor HIV/AIDS knowledge, such as beliefs that exposing syringes to air "kills germs." This qualitative study suggests that IDUs in Tijuana are at high risk of HIV and other blood-borne infections. Interventions are urgently needed to expand access to sterile injection equipment and offset the potential for a widespread HIV epidemic.

Characterization of novel Mycobacterium tuberculosis and Mycobacterium smegmatis mutants hypersusceptible to beta-lactam antibiotics

Our laboratory previously constructed mutants of Mycobacterium tuberculosis and Mycobacterium smegmatis with deletions in the genes for their major beta-lactamases, BlaC and BlaS, respectively, and showed that the mutants have increased susceptibilities to most beta-lactam antibiotics, particularly the penicillins. However, there is still a basal level of resistance in the mutants to certain penicillins, and the susceptibilities of the mutants to some cephalosporin-based beta-lactams are essentially the same as those of the wild types. We hypothesized that characterizing additional mutants (derived from beta-lactamase deletion mutants) that are hypersusceptible to beta-lactam antibiotics might reveal novel genes involved with other mechanisms of beta-lactam resistance, peptidoglycan assembly, and cell envelope physiology. We report here the isolation and characterization of nine beta-lactam antibiotic-hypersusceptible transposon mutants, two of which have insertions in genes known to be involved with peptidoglycan biosynthesis (ponA2 and dapB); the other seven mutants have insertions which affect novel genes. These genes can be classified into three groups: those involved with peptidoglycan biosynthesis, cell division, and other cell envelope processes. Two of the peptidoglycan-biosynthetic genes (ponA2 and pbpX) may encode beta-lactam antibiotic-resistant enzymes proposed to be involved with the synthesis of the unusual diaminopimelyl linkages within the mycobacterial peptidoglycan.

Injecting Equipment Sharing Among Injecting Drug Users in Togliatti City, Russian Federation

OBJECTIVE

To compare risk factors for injecting equipment sharing among injecting drug users (IDUs) in Togliatti City, Russia.

DESIGN

Unlinked, anonymous, cross-sectional community-recruited survey with oral fluid sample collection.

METHODS

Between September and October 2001, 426 IDUs completed an interviewer-administered questionnaire and oral fluid samples were tested for HIV. Univariate and multivariate analyses compared potential risk factors for injecting equipment sharing.

RESULTS

More than half (56% [234/418]) of the sample were positive for antibodies to HIV. A third (36%) had injected with used needles and syringes in the last 4 weeks. IDUs who reported syringe exchanges or outreach workers as their main sources of new needles and syringes in the last 4 weeks had 0.3 times the odds of sharing compared with those obtaining them from a pharmacy or shop, whereas those whose main source was buying them from the streets or obtaining them from friends, sexual partners, or other drug users had 12 times the odds of receptive needle and syringe sharing. IDUs who reported being last arrested or detained by the police for a drug-related offense had higher odds of sharing.

CONCLUSIONS

Findings highlight the delicate balance in HIV prevention between potentially competing strategies of law enforcement and syringe distribution.

An external evaluation of a peer-run "unsanctioned" syringe exchange program

In Vancouver, British Columbia, Canada, difficulty accessing syringes at night has been shown to be strongly associated with human immunodeficiency virus (HIV) risk behavior among the city's injection drug users (IDUs). On September 1, 2001, the Vancouver Area Network of Drug Users (VANDU) initiated an unsanctioned all-night needle-exchange program on a street corner in the heart of the neighborhood where many of the city's IDUs are concentrated. An external evaluation of the population reached by the VANDU exchange was performed through the Vancouver Injection Drug User's Study, a prospective cohort study of IDUs begun in 1996. Persons accessing syringes through the exchange were compared to those active injectors who acquired their syringes from other sources, including the city's fixed site exchange, which closes at 8:00 PM. Overall, 587 active IDUs were seen during the period September 2001 to June 2002; of these individuals, 165 (28.1%) reported using the VANDU exchange. In multivariate analyses, participants who used the VANDU table were more likely to frequently inject cocaine (adjusted odds ratio [AOR]=1.56; 95% confidence interval [CI]=1.00-2.44), inject in public (AOR=2.71; 95% CI=1.62-4.53), and require help injecting (OR=2.13; 95% CI=1.33-3.42). Interestingly, use of the table was also independently associated with safer syringe disposal (AOR=2.69; 95% CI=1.38-5.21). Results indicate that the unsanctioned exchange appears to have reached those IDUs at highest risk of HIV infection. Although the cross-sectional nature of the study design warrants caution, we also found that use of the nighttime exchange was strongly associated with higher rates of safe syringe disposal. The data suggest that drug user organizations can play a major role in reducing harm among their peers by reaching the highest risk drug users with harm reduction services. The findings also suggest that other forms of syringe-exchange programs should consider the benefits of offering fixed site nighttime service.

Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment

We undertook a qualitative study to explore the micro-environment of drug injecting, risk reduction and syringe exchange practices among injecting drug users (IDUs) in Togliatti City, Russia. Semi-structured qualitative interviews (n=57) were undertaken with current IDUs in May 2001. Findings highlight a recent transition away from hanka (a home-produced liquid opiate derived from opium poppy) towards the injection of heroin powder, and a drug use culture in which injecting predominates. Findings emphasise that risk reduction practices may be influenced less by availability of injecting equipment than by an interplay of situational and micro-environmental factors. Principal among these is a reported fear of police detainment or arrest among IDUs which encourages a reluctance to carry needles and syringes, and which in turn, is associated with needle and syringe sharing at the point of drug sale. We note the role of policing practices in influencing risk reduction and the potential role of policing agencies in supporting HIV prevention initiatives among IDUs.

The impact of needle-exchange programs on the spread of HIV among injection drug users: a simulation study

To determine the impact of the implementation of a needle-exchange program (NEP) on the spread of human immunodeficiency virus (HIV) in an injection drug user (IDU) community. We conducted a Monte Carlo simulation study of a theoretical population of 10000 IDUs. The population was followed monthly from 1984 to 2000. HIV was assumed to be transmitted only by needle sharing. The NEP was introduced in 1989 and evaluated over a period of 11 years. The impacts of the proportion of the population attending the NEP, the risk level of IDUs attending the NEP, the reduction in needle-sharing frequency, and the number of new needle-sharing partners acquired at the NEP on prevalence and incidence of HIV were determined. Increasing the proportion of the population who always attend the NEP and eliminating needle-sharing incidents among IDUs who always attended the NEP were the most effective ways of reducing the spread of HIV. Attracting high-risk users instead of lower risk users to the NEP also reduced the spread of HIV, but to a lesser extent. NEPs are effective at reducing the spread of HIV; even under the worst case scenario of low risk users more likely to attend the NEP, one additional partner per month as a result of attending the NEP, and poor NEP attendance, the estimated prevalence was still less than that from the scenario without an NEP. Under our model, NEPs were shown to reduce the spread of HIV significantly. Efforts should be focused on getting as many IDUs as possible to become regular NEP attenders and stop sharing needles rather than partially reducing the frequency of sharing by a larger number of IDUs.

Molecular epidemiology and drug resistance of Mycobacterium tuberculosis isolates from Ethiopian pulmonary tuberculosis patients with and without human immunodeficiency virus infection

We have analyzed the molecular epidemiology and drug resistance of 121 Mycobacterium tuberculosis isolates from consecutive patients with culture-positive pulmonary tuberculosis attending a university hospital outpatient department in Addis Ababa, Ethiopia. Restriction fragment length polymorphism analysis and spoligotyping were used to analyze the DNA fingerprinting patterns. Fifty-one (41.2%) of the isolates were found in 13 clusters with two or more identical DNA patterns. Two such clusters contained 49.0% of all clustered isolates. In a multivariate logistic regression model, human immunodeficiency virus (HIV)-positive serostatus was significantly associated with clustering of isolates for patients of both sexes (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.17 to 5.80). There was a trend toward increased clustering of isolates from tuberculous women residing in Addis Ababa (OR, 2.10; 95% CI, 0.85 to 5.25). In total, 17 of 121 isolates (14.0%) were resistant to one or more of the antituberculosis drugs isoniazid (8.3%), streptomycin (7.4%), rifampin (2.5%), and ethambutol (1.7%). The high rate of drug-resistant isolates (29.6%) coincided with the peak prevalence of HIV infection (77.8%) in patients 35 to 44 years old. The majority (62.5%) of resistant isolates in this group were found within clusters. The simultaneous accumulation of certain bacterial clones in a patient population likely reflects recent transmission. Hence, we conclude that tuberculosis is commonly caused by recent infection with M. tuberculosis in HIV-positive Ethiopian patients. Furthermore, with the rapidly increasing prevalence of HIV infection in Ethiopia, the burden of tuberculosis, including drug-resistant tuberculosis, is likely to increase. Strengthening of classical tuberculosis control measures by promoting active case finding among HIV-positive adults with tuberculosis is warranted to reduce rates of transmission.

Erasing the world's slow stain: strategies to beat multidrug-resistant tuberculosis

Multidrug-resistant tuberculosis (MDR) is perceived as a growing hazard to human health worldwide. Judgments about the true scale of the problem, and strategies for containing it, need to come from a balanced appraisal of the epidemiological evidence. We conclude in this review that MDR is, and will probably remain, a locally severe problem; that epidemics can be prevented by fully exploiting the potential of standard short-course chemotherapy (SCC) based on cheap and safe first-line drugs; and that best-practice SCC may even reduce the incidence of MDR where it has already become endemic. On the basis of the available, imperfect data, we recommend a three-part response to the threat of MDR: widespread implementation of SCC as the cornerstone of good tuberculosis control, improved resistance testing and surveillance, and the careful introduction of second-line drugs after a sound evaluation of cost, effectiveness, and feasibility.

What do pharmacists think about New York state's new nonprescription syringe sale program? Results of a survey

Access to sterile syringes can prevent transmission of blood-borne diseases such as human immunodeficiency virus (HIV) and hepatitis B and C. We conducted survey of attitudes of pharmacists to aid in development of the Expanded Syringe Access Demonstration Program (ESAP) in New York State. ESAP is an HIV prevention initiative that authorizes nonprescription sale of hypodermic needles and syringes by registered pharmacies in New York State beginning January 1, 2001. As part of planning for program implementation, the New York State Department of Health (NYSDOH), in collaboration with the New York State Education Department, conducted mailed survey of all 4, 392 licensed pharmacies in New York State during the summer of 2000. Some surveys (171) were returned as undeliverable. Of the 4,221 eligible respondents, 874 (20.7%) completed surveys were received, of which 574 (65.7%) indicated that their pharmacy would likely participate in ESAP. An additional 11.0% were not sure. Only 139 (15.9%) indicated that they would definitely not participate; 7.4% left this question blank. There were 608 responses to questions on safe disposal practices. Of these, 315 (51.8%) respondents indicated that their pharmacy sold sharps containers, and an additional 29 made them available at no cost. Only 133 (21.9%) respondents to this question did not offer sharps containers and were not interested in doing so. In all, 54 responses indicated that they accepted used hypodermic needles and syringes for disposal. Some (170, 28%) that did not accept sharps for disposal were interested in doing so. More than half (382, 63.0%) did not wish to do so. NYSDOH considered respondent suggestions and minimized ESAP requirements. By March 31, 2001, only 3 months after ESAP became effective, more than half of all licensed pharmacies in New York State were registered for ESAP. Survey results provided useful information to NYSDOH and good indication of likelihood of registration. The high level of pharmacy participation in ESAP may be reflective of NYSDOH attention to issues raised by pharmacists, as well as the direct effects of outreach to pharmacy chains regarding ESAP.

Structural interventions to reduce HIV transmission among injecting drug users

OBJECTIVE

To review current knowledge of 'structural' interventions to reduce HIV transmission among injecting drug users. Structural interventions are defined as programs or policies that change the environments in which risk behavior occurs, without attempting to change knowledge, attitudes or social interaction patterns of the persons at risk. Structural interventions may either facilitate enactment of existing motives to avoid HIV transmission or make enacting risk behavior more difficult.

METHODS

Nonquantitative literature review.

RESULTS AND CONCLUSIONS

Preventing HIV infection among injecting drug users must be considered within the context of the continuing global spread of psychoactive drug use, and injecting drug use in particular. Some policies that are designed to reduce drug use may tend to increase HIV transmission among persons who do inject drugs. Evaluation of structural interventions can be difficult, as populations of drug users are usually the relevant unit of analysis. Typically, pre versus post comparisons must be used, hopefully with multiple pre and post data points. Structural interventions are often associated with 'large effects', increasing confidence that the intervention is the cause of the reduction in HIV-risk behavior. Increasing the availability of sterile injection equipment, through pharmacy sales or syringe exchange or both, is the most common and best-studied structural intervention for injecting drug users. The studies to date indicate that this usually, but not always, leads to large reductions in HIV-risk behavior. Involving drug users in the design and implementation of HIV-prevention programs can be considered a 'meta-structural' intervention that should lead to programs with increased effectiveness.

Structural factors in HIV prevention: concepts, examples, and implications for research

INTRODUCTION

HIV-prevention behavior is affected by the environment as well as by characteristics of individuals at risk. HIV-related structural factors are defined as barriers to, or facilitators of, an individual's HIV prevention behaviors; they may relate to economic, social, policy, organizational or other aspects of the environment.

IMPACT OF STRUCTURAL INTERVENTIONS

A relatively small number of intervention studies demonstrates the potential of structural interventions to increase HIV prevention in the United States and internationally. The promise of structural interventions has also been shown in studies of interventions to prevent disease or promote public health in areas other than HIV.

FRAMEWORK OF STRUCTURAL FACTORS

Frameworks help define and exemplify structural barriers and facilitators for HIV prevention. One framework developed at Centers for Disease Control and Prevention gives examples of structural facilitators in terms of the economic resources, policy supports, societal attitudes, and organizational structures and functions associated with governments, service organizations, businesses, workforce organizations, faith communities, justice systems, media organizations, educational systems, and healthcare systems. Frameworks should assist researchers and health officials to identify important areas for structural research and programming.

CONCLUSIONS

A structural approach is timely and innovative. Despite limitations, including the challenge of a new perspective on prevention and the difficulty of evaluating their effects, researchers and public health officials are urged to pursue structural interventions to prevent HIV.