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.

Study 1

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 clients.

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 days.

 Results

	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: 41%; - 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."

Study 2

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%;
	50%-99%;
	100%-149%;
	150% or more.

Results

	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 1.4-3.6).
	Clients with 150% or better syringe coverage were less likely to report receptive syringe sharing (adjusted OR 0.5; 95% CI 0.3-0.8).
	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.

Study 3

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 opposition.

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 education;
- 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 exchange program.

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