The Impact of Syringe Deregulation on Sources of Syringes for Injection Drug Users: Preliminary Findings
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- Deren, S., Cleland, C.M., Fuller, C. et al. AIDS Behav (2006) 10: 717. doi:10.1007/s10461-006-9096-4
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In 2001, New York State enacted legislation to allow the provision of syringes by pharmacies and healthcare providers without prescription (ESAP, the Expanded Syringe Access Demonstration Program). A longitudinal study of IDUs (n=130) found that pre-ESAP, about half used only the safest source (needle exchange programs [NEPs]). Post-ESAP implementation, ESAP sources were initiated by 14%. Frequency of injection was related to ESAP use and those who used unsafe (or possibly unsafe) sources were as likely to use ESAP as those who had previously used only NEPs. The findings indicate that providing multiple sources of safe syringes for IDUs is necessary.
KEY WORDS:Injection drug use syringe access pharmacy
The sources of syringes used by injection drug users (IDUs) has been a topic of study related to HIV prevention since early in the epidemic, and use of “safe sources,” e.g., needle exchange programs and pharmacy-bought syringes, are the primary guarantees of noncontaminated syringes (Normand, Vlahov, and Moses, 1995). The increasing attention to HCV among injectors has further increased concerns about enhancing utilization of safe syringe sources (Hagan, Thiede, and Des Jarlais, 2004).
While there are some injection drug users who inject infrequently, some studies have reported frequencies of injection which approach 200 times per month (Colón et al., 2003). Thus, IDUs require multiple syringes within any given time period. Many studies of syringe sources have focused on current use of particular sources, or the source of the last syringe used. An understanding of the mix of syringe sources used, and changes in syringe sources over time may help inform intervention efforts. Furthermore, the impact of legislation to deregulate access to syringes, e.g., allowing pharmacy sales of syringes, can best be assessed by examining change in the mix of sources of syringes used.
In January 2001 New York State enacted the ESAP (Expanded Syringe Access Demonstration Program) legislation, providing for the availability of syringes from pharmacies and health care providers (doctors, hospitals, clinics) without prescriptions (up to 10 per transaction). Overall, results of the evaluation of the first few years of this legislation are positive, indicating that many pharmacies in NYS signed up to participate (Center for Urban Epidemiologic Studies, 2003); IDUs, albeit with variation by neighborhood and ethnicity, began using pharmacies as a source of syringes (Deren, Fuller, et al., 2003; Des Jarlais, McKnight, and Friedmann, 2002; Fuller et al., 2004), and there was some preliminary indication that use of ESAP sources for syringes may be related to declines in needle sharing among IDUs (Pouget et al., 2005). A report to the NYS legislature in 2003 (Center for Urban Epidemiologic Studies, 2003) contributed to the extension of the legislation through September 2007.
Most of these ESAP-related studies, however, focused on the last injection syringe used, and did not examine longitudinal data on changes in sources of syringes over time, before and after ESAP was enacted. Longitudinal data available from an on-going study, the Alliance for Research in El Barrio and Bayamón (ARIBBA), provided the opportunity for a natural experiment, in that injection drug users were recruited and interviewed in New York pre-ESAP (1998–1999), received follow-up interviews after ESAP legislation (2001–2002), and were asked about sources of syringes during all interviews.
This paper addresses four questions: (1) what were the sources of syringes used by a sample of active IDUs during a 30 day period pre-ESAP; (2) prior to ESAP, were syringe sources for IDUs stable over time (i.e., 6 months later); (3) after the institution of ESAP—did the mix of sources change and (4) what were the predictors (in terms of previous sources used and demographics) of changes in syringe sources?
The ARIBBA study recruited Puerto Rican injection drug users and crack smokers in East Harlem, New York and Bayamón, Puerto Rico during 1998–1999, for a comparative study of determinants of high risk behaviors (Deren, Oliver-Velez, et al., 2003). Participants were interviewed at baseline (T1) during 1998–1999, and received three follow-up interviews, as follows: 6, 36, and 42 months later (T2, T3, T4, respectively). Thus, T1 and T2 occurred prior to the enactment of the ESAP legislation and T3 and T4 occurred after enactment. The average time between the pre- and postlegislation points (T1 and T3) was 39 months (sd = 5.1). Questions regarding the total number of syringes used in the prior 30 days, and the sources of syringes, were asked at all four time points. For the purposes of the present analysis, to assess changes in syringe sources related to the ESAP legislation, only those in the New York sample who reported injection in the prior 30 days in at least one of the pre-ESAP and one of the post-ESAP interviews were included. Of the total of 569 IDUs recruited at baseline, 54.5% were followed up post-ESAP and of these, 42% reported still injecting; thus, the total sample for this analysis was 130 IDUs.
Variables and Analysis
Baseline variables included in the analysis are: sociodemographic characteristics (gender, age, homelessness [living on the street or in a shelter], education [High school graduation or GED]), and injection-related behaviors (number of years injecting, total number of injections in prior 30 days). Participants were also asked about the number of syringes they used in the prior 30 days, and the sources of their syringes, which included pharmacy/drug store (ESAP), needle exchange program (NEP), drug dealer, shooting gallery manager, syringe seller, friend/relative, acquaintance/stranger, or other. For purposes of this analysis NEP and ESAP sources were considered safe; all others were considered unsafe or possible unsafe sources of syringes.
Bivariate analyses were conducted to examine the relationship of baseline individual sociodemographics and injection-related variables to use of unsafe or possibly unsafe sources post-ESAP implementation.
The majority of the sample (78%) was male, 28% were homeless, and average age was 38.1 years (sd = 8.2) at baseline. The sample had injected for an average of 18 years (sd = 10.4), and reported an average of about eighty injections in the prior 30 days. In terms of sources of syringes at baseline, about half of all participants (46%) reported using NEP as their only source of syringes during the prior 30 days, 41% used unsafe/possibly unsafe sources (other) and 13% used both NEP and other sources. There were no statistically significant differences in these characteristics at baseline among IDUs using different syringe sources.
A comparison of syringe sources from baseline to 6-month follow-up (n = 98), both pre-ESAP time periods, found that there was 100% congruence, that is, those who reported using NEP only at baseline also reported NEP only at 6 months, those who reported mix of NEP and other sources continued reporting this mix at 6-month follow-up, and those reporting only unsafe or possible unsafe source also continued this practice.
In bivariate analysis, the only baseline variable significantly related to ESAP use (p < .05) was number of injections in the prior 30 days (OR = 1.42, 95% CI =1.04–1.93); those who injected more frequently were more likely to report using ESAP sources (average number of injections was divided by 50, therefore 1 unit corresponds to 50 injections). Those using unsafe (or possibly unsafe) sources were as likely to use ESAP sources as those who had used only NEPs prior to ESAP implementation. There was no relationship between ESAP use and the following variables: gender, age, education, homelessness and years injecting.
For all study participants, sources of syringes remained stable over a 6 month period prior to ESAP, and about half used the safest syringe source, NEP. These NEPs had been well-established in these communities, and have contributed to the decline to under 1/100 PYR in HIV incidence among IDUs in New York City reported since the early 1990s (Des Jarlais et al., 2000).
The stability in sources of syringes may indicate that implementing changes in sources used may be difficult, especially within a short time frame. In a community with multiple NEPs (as was East Harlem) after ESAP was introduced, relatively few IDUs accessed ESAP sources, perhaps due to lack of advertisement as well as the availability of several NEPs (Deren, Fuller, et al., 2003; Pouget et al., 2005). It is encouraging, however, that ESAP was “taken up” not only by those who had previously used only safe sources (i.e., NEP), but was just as likely to be used by those who had used unsafe or possibly unsafe sources. It is also important to note that of those who began any ESAP use, about half used ESAP in conjunction with other sources, and they were primarily the NEP. Finally, the increase in ESAP sources was accompanied by an increase in NEP as a source of syringes, perhaps indicating that the introduction of ESAP, and efforts by the NYS Department of Health officials and others (Klein, Estel, Candelas, and Plavin, 2002) to inform the public about the advent of ESAP and the importance of safe syringe use, may have increased awareness of the importance of using sterile syringes or reduced the stigma associated with procuring syringes from NEPs. This increase in use of NEP was especially seen by those who had used only “other” sources, which is encouraging in terms of a trend to safer syringe use.
Providing multiple sources of clean syringes is necessary; many IDUs reported using a mix of sources. For example, of those who initiated use of ESAP sources, the majority (72% or 13/18) also used other sources.
The stability of syringe sources found pre-ESAP indicates that instituting changes in sources which provide syringes should be accompanied by extensive information campaigns, outreach efforts, etc., to disseminate the fact that there has been a change in law, and to provide a clear description of these changes. This is particularly important regarding ESAP-type legislation, since IDUs may have questions about the legality of carrying syringes [e.g., in New York, there is still a statute making the possession of a syringe illegal, and some IDUs are still uncertain about the legality of syringe possession, despite the fact that ESAP and NEP syringes are legal (Deren, Fuller, et al., 2003)].
Additional research questions require study. These include study of the longer term impact of the ESAP legislation, e.g., will more IDUs start using ESAP in the future as a source of syringes? If this increase occurs, will ESAP use replace other safe or unsafe sources? Will organizations/services providing different sources of syringes work together to enhance access to safe sources? Many of the NEPs in East Harlem provided information to IDUs on ESAP pharmacies, indicating that cross-referrals among syringe sources can work together to enhance safe injection. Research is also needed on the impact of ESAP on syringe sources used by various types of injectors. For example, some research indicates that minorities were less likely to use ESAP sources (Des Jarlais et al., 2002; Fuller et al., 2004); other work indicates that new injectors, who initiate injection when they are older may be more likely to use safe sources (Carneiro, Fuller, Doherty, and Vlahov, 1999). Undertaking examination of the impact of ESAP on syringe sources in communities where NEPs are not readily available is particularly important, since in these locales ESAP may serve as the primary source of sterile syringes.
This research was supported by grants# R01DA014219 (D. Vlahov, PI) and R01DA010425 (S. Deren, PI) from the National Institute on Drug Abuse.