Three Studies Examine Syringe Exchange Policies in the U.S.
Syringe exchange programs have proven to be an effective means of reducing
transmission of blood-borne infections such as HIV, hepatitis B, and
hepatitis C among injection drug users (IDUs). However, political
considerations have limited the implementation of such programs and
restricted their sources of funding.
Three recent journal articles provided data from studies of syringe exchange
programs and policies in the U.S.
In the first study, reported in the February 6, 2007 online edition of
Addiction, researchers sought to determine whether dispensation policies are
associated with adequate syringe coverage among syringe exchange program
Existing programs vary in terms of dispensation policies. Some, for example,
have a strict 1-for-1 exchange policy with numerical limits, while others
offer unlimited syringe distribution.
The authors studied 24 syringe exchange programs in California, which
collectively served 1576 injection drug-using clients. Participants were
classified as having adequate syringe coverage if they received at least as
many syringes as the number of self-reported injections during the past 30
Adequacy of syringe coverage by dispensation
policy was as follows:
- unlimited need-based distribution: 61%;
- unlimited 1-for-1 exchange plus a few additional syringes: 50%;
-limited (up to a set number per visit) 1-for-1 exchange plus a few extras:
- unlimited 1-for-1 exchange with no extras: 42%;
- limited 1-for-1 exchange with no extras: 26%.
In a multivariate analysis, adequate syringe
coverage was significantly higher for all other dispensation policies
compared to limited 1-for-1 exchange with no extras.
Programs that provided additional syringes
beyond the 1-for-1 exchange generally resulted in more clients having
adequate coverage compared with strict 1-for-1 exchange programs (50% vs
38%; P = 0.009).
Similarly, programs that allowed for unlimited
syringe exchange or distribution resulted in better coverage than programs
with per-visit numerical limits (42% vs 27%; P = 0.05).
Providing less restrictive syringe dispensation
is associated with increased prevalence of adequate syringe coverage among
clients," the authors concluded. "Syringe exchange programs should adopt
syringe dispensation policies that provide IDUs sufficient syringes to
attain adequate syringe coverage."
In the third study, which appeared in the February 3, 2007 online edition of
Drug and Alcohol Dependence, researchers assessed whether adequate syringe
coverage -- enough to allow for 1 injection per syringe -- is associated
with changes in injection-related risk behaviors and syringe disposal.
This study looked at the same population of IDUs from 24 California syringe
exchange programs described above. Individual syringe coverage was
calculated as a proportion of syringes retained from program site visits to
the total number of reported injections during the past 30 days.
Participants were divided into 4 groups based on extent of syringe coverage:
less than 50%;
150% or more.
Compared to clients with adequate syringe
coverage (100%-149%), those with less than 50% syringe coverage were
significantly more likely to report receptive syringe sharing (using a
syringe after someone else) during the past 30 days (adjusted OR 2.3; 95% CI
Clients with 150% or better syringe coverage
were less likely to report receptive syringe sharing (adjusted OR 0.5; 95%
Similar associations were observed for other
measures of distributive syringe sharing and syringe re-use.
No differences in safe syringe disposal were
observed based on extent of syringe coverage.
Individual syringe coverage is strongly
associated with safer injection behaviors without impacting syringe disposal
among syringe exchange program clients," the researchers concluded. "Syringe
coverage is a useful measure for determining if IDUs are obtaining
sufficient syringes to lower HIV risk."
These results should help allay concerns that
providing extra syringes beyond a strict 1-for-1 exchange might encourage
clients to unsafely dispose of used syringes rather than bringing them back
to the distribution site.
Finally, the third study, reported in the January 31, 2007 online edition of
the American Journal of Public Health, explored why syringe exchange
programs are available in some cities but not others.
"Community activism can be important in shaping public health policies," the
authors wrote as background. "For example, political pressure and direct
action from grassroots activists have been central to the formation of
syringe exchange programs in the United States."
They hypothesized that such programs are unevenly distributed across
geographic areas as a result of political, socioeconomic, and organizational
characteristics of localities, including needs, resources, and local
Looking at different U.S. metropolitan
statistical areas in the year 2000, they found that the following
characteristics predicted the presence of a syringe exchange program:
- percentage of the population with a college
- existence of a local chapter of the activist group AIDS Coalition to
Unleash Power (ACT UP);
- percentage of men who have sex with men in the population.
However, they found that need -- such as number
of at-risk IDUs -- was not a predictor of whether a locality had a syringe
These results suggest that activist pressure
has played a key role in the establishment of harm reduction measures such
as syringe exchange programs.
R N Bluthenthal, G Ridgeway, T Schell, and
others. Examination of the association between syringe exchange program
(SEP) dispensation policy and SEP client-level syringe coverage among
injection drug users. Addiction. February 6, 2007 [Epub ahead of print].
R N Bluthenthal, R Anderson, N M Flynn, and others. Higher syringe coverage
is associated with lower odds of HIV risk and does not increase unsafe
syringe disposal among syringe exchange program clients. Drug and Alcohol
Dependence. February 3, 2007 [Epub ahead of print].
B Tempalski, P L Flom, S R Friedman, and others. Social and Political
Factors Predicting the Presence of Syringe Exchange Programs in 96 US
Metropolitan Areas. American Journal of Public Health. January 31, 2007