U.S. NEEDLE EXCHANGE DATA



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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs U.S. NEEDLE EXCHANGE DATA

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs This page in the original is blank.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs THE UNIVERSITY OF CALIFORNIA NEEDLE EXCHANGE PROGRAM EVALUATION PROJECT: METHODS, CONCLUSIONS, AND RECOMMENDATIONS PETER LURIE, JAMES G. KAHN, BENJAMIN BOWSER, and DONNA CHEN, JILL FOLEY, JOSEPH GUYDISH, T. STEPHEN JONES (Centers for Disease Control and Prevention), SANDRA LANE, ARTHUR L. REINGOLD, and JAMES SORENSON, Needle Exchange Program Evaluation Project, The University of California In this paper we describe the multidisciplinary methods used in our report on needle exchange programs (NEPs) in the US and abroad1, 2, 3, * and list our conclusions and recommendations. The project was funded through a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Association of Schools of Public Health, which contracted with the University of California, Berkeley to conduct the study. A significant amount of the work was subcontracted to the Institute for Health Policy Studies at the University of California, San Francisco. The project began in April 1992 and was funded through October 1993. Draft/Interim Reports were completed and submitted to the CDC on April 1 and July 16, 1993. METHODS Project Personnel We assembled a 12-person research team in which no investigator was identified in his or her writing as either in favor of or opposed to NEPs. In order to better understand the diverse epidemiological, social, and policy aspects of NEPs, and to design a research methodology appropriate to their evaluation, investigators representing a variety of disciplines were involved in the project. The research team included members with training in clinical medicine, nursing, psychology, anthropology, sociology, cost-benefit modeling, and epidemiology. In addition, project investigators were accompanied on site visits to seven cities by one of four CDC staff, including the Project Officer. *   Copies of the 2-volume, 700-page full report are available through the National AIDS Clearinghouse at 1-800-458-5231.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Goal and Research Questions The goal of the project was: ''To assess the public health impact of needle exchange programs." The central research questions surrounding NEPs were identified by team members. Revisions to the list of research questions were made based on comments solicited from members of the project Advisory Committee (see below), public health officials, NEP staff members, researchers and experts in drug treatment and injection drug use, and community leaders either favoring or opposing the programs. Three team members also made two trips to CDC headquarters in Atlanta, GA early in the project to seek further input on the research questions and to delineate methods for answering them. This process yielded a list of 14 research questions, grouped into seven categories: (1) NEP Descriptions; (2) Populations Reached by NEPs; (3) Community Responses to NEPs; (4) NEP Effect on HIV Risk Behavior; (5) Studies of Syringes; (6) NEP Effect on Disease Rates; and (7) NEP Cost-effectiveness (see Appendix 1). Project members were aware that in several cases available data might prove insufficient to answer the research question definitively. In each such case we intended to review available data, indicate gaps in existing information, and suggest research methods that might prove fruitful in answering that research question. Ensuring Community and Expert Input Due to the strong community reactions to NEPs in some settings, it was crucial to ensure adequate community and expert input. This was sought in three distinct manners: (1) Advisory Committee; (2) expert reviewers; and (3) Kaiser Family Foundation Forum. Advisory Committee A 13-member Advisory Committee based in the San Francisco Bay Area was formed. Members included injection drug use researchers, staff of the San Francisco NEP, a representative of the San Francisco Department of Public Health, and members of ethnic minority and religious groups. Care was taken to include members who supported and opposed NEPs. Two Advisory Committee meetings were held: shortly after the initiation of the project (June 26, 1992) and prior to submission of the first Draft/Interim Report (March 5, 1993). At each meeting, project investigators reported on progress made to date and sought input from the Advisory Committee. Expert Reviewers Letters describing the project's research questions and proposed methods were sent to 31 leading researchers, public health officials, and community members, and comments from 10 respondents were received and integrated into the project approach.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs We also solicited comments from the staff of the approximately 20 NEPs known to the project investigators at the beginning of the project; five responses were obtained. To promote accuracy in the descriptions of individual NEPs, staff at all sites visited were sent copies of sections of the report describing their NEP and given the opportunity to suggest corrections. Finally, five expert reviewers were contracted to review the full report and submit their comments. Two mathematical modeling experts also reviewed the chapter on cost-effectiveness.** Several additional chapters were reviewed by individuals at CDC and the National Institute on Drug Abuse who had specific expertise in the material covered in that chapter. Kaiser Family Foundation Forum On December 10 and 11, 1992 the Kaiser Family Foundation sponsored a forum entitled "Needle and Syringe Availability and Exchange for HIV Prevention" at the Foundation headquarters in Menlo Park, California. The approximately 60 attendees included researchers, NEP staff, law enforcement and public health officials, injection drug users (IDUs), and community members. Project members assisted in designing the Forum program, identifying speakers, developing a bibliography on NEPs, and producing a list of active NEPs for dissemination to Forum attendees. At the Forum, project members described the project methods, summarized the history of NEPs in North America, and offered preliminary descriptions of the NEPs visited.4, 5 Feedback obtained was integrated into the Draft/Interim and Final Reports. Consent and Confidentiality The research protocol was submitted to and approved by the Committee for Protection of Human Subjects at the University of California, Berkeley. Focus groups with IDUs were conducted anonymously, while other key informants were offered the opportunity to remain anonymous in the Final Report; only one accepted. IDUs participating in the focus groups were provided with a participant information sheet. NEPs were only listed in the Final Report if they provided permission. Formal Review of Existing Research Data analysis in this portion of the report included published and unpublished materials from the US and foreign countries. **   The expert reviewers were Don Des Jarlais, Mindy Fullilove, Edward Kaplan, Herbert Kleber, Douglas Owens, Beny Primm, and Beth Weinstein.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Assessment of Data Needs In order to assess the data necessary to answer the research questions, a Data Collection Outline was drawn up. For each research question, the outcome variables of interest were listed and likely data sources identified. This document formed the basis for interview protocols (see below) and the chapters in the Final Report addressing each research question. Data Collection To assemble a data file on NEPs, AIDSline and Medline computer searches were undertaken. In the articles identified by these searches, references were examined for additional articles related to the research questions. Abstracts from the annual International AIDS Conferences from 1988 to 1993 were examined. Authors of abstracts on NEPs were contacted by mail for original poster or oral presentation materials as well as any published articles based on the abstract or otherwise germane to NEPs. Conference abstracts from the annual American Public Health Association conferences (1987-1992) were also obtained and the authors similarly contacted. To identify additional unpublished materials, NEP staff were contacted and asked about internal program reports or other unpublished materials they were willing to share. Newspaper clippings, magazine articles, government and institutional reports, and book chapters dealing with NEPs were also collected. The American Public Opinion Index (1985-1991) and Gallup Index (1987-1991) were searched to identify local and national public opinion poll questions addressing NEPs. Per capita city AIDS case rates and selected HIV seroprevalence data were obtained from the CDC and demographic information on the cities visited came from the Bureau of the Census6and Statistics Canada.7 Information on drug treatment availability in the US cities where site visits were conducted was obtained from the National Drug and Alcoholism Treatment Unit Survey (NDATUS).8 Data sources used in an effort to track drug use trends over time were the Drug Abuse Warning Network (DAWN),9 Drug Use Forecasting (DUF),10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and the Uniformed Crime Reports (UCR).20 Data Synthesis All materials assembled were reviewed by the Project Director or the Research Assistants. Documents were coded according to which research question(s) they could help answer and filed with each NEP site to which they referred. All data sources were entered into a bibliography software program called End Note Plus21 and coded according to research question and NEP site. Table 1 describes the data sources reviewed. Project members were assigned responsibility for synthesizing information on one or more of the 14 research questions. This process included data collected in the manner described above as well as the interview and observational information collected during the site visits (see below).

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Table 1 Data Sources Reviewed Newspaper and magazine articles 499 Journal articles 475 Conference abstracts 381 Reports 236 Unpublished materials 159 Personal communications 106 Books and book sections 94 Other sources 22 Total 1,972 Drafts of all chapters were circulated within the group and modified accordingly. Six of the chapters addressing the research questions and seven additional chapters on the site visits were part of the first Draft/Interim Report. The second Draft/Interim Report contained the remaining chapters. Both Draft/Interim Reports were reviewed by both paid and unpaid outside reviewers, whose comments were then integrated into the Final Report. Site Visits Between May and September 1992, site visits to 15 cities were conducted: 10 in the US, three in Canada, and two in Europe (see Table 2). Except for the site visits to Santa Cruz, Boulder, and Amsterdam, which only lasted one day, all site visits were at least three days in duration. All site visits involved either two or three project investigators or CDC personnel, except the brief visit to Boulder, which was conducted by a single investigator. Identification of Sites and Interviewees Programs were identified from a list of NEPs in a published article22 and through the community and expert input process described above. They were selected in consultation with the CDC to reflect the range of existing NEPs with respect to size, legal status, geographical location, IDU HIV seroprevalence, and extent of prior evaluation research. The Project Director initially called the NEP staff to explain the purpose of the project and to obtain permission to visit the NEP. In no case was permission denied. NEP staff members were also used as initial sources for identifying other key informants. We supplemented these sources by adding individuals known to the investigators through their reading or discussions with other key informants as important figures in the

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs development of NEPs in that city. Key informants were selected in order to represent a diversity of views both in support of and opposition to NEPs. Table 2 Project Site Visits UNITED STATES     Berkeley, CA Portland, OR Boston, MA San Francisco, CA Boulder, CO (partial assessment) Santa Cruz, CA New Haven, CT Seattle, WA New York City, NY Tacoma, WA CANADA   Montreal, PQ Vancouver, BC Toronto, ON   EUROPE     Amsterdam, the Netherlands (partial assessment)     London, England (partial assessment)     Methodological Framework In order to achieve internal and external validity for our study we utilized methodological triangulation:23 multiple data collection methods with multiple iterations. This cross-checking helps to ensure a level of confidence in the results that would otherwise be lacking.24, 25, 26 Interviews, focus groups, and NEP site observations used the Rapid Assessment Procedure (RAP) method as a general framework. RAP is a collection of qualitative research strategies used for quick evaluation of health interventions.24 Training A training manual for conducting interviews, focus groups, and NEP site observations was produced and used as a guide by project members. In addition, a two hour training session was organized in which salient elements of the training manual were reviewed and interview role-playing conducted. Members of the CDC who participated in the site visits received a one hour training session by telephone. At least one project member who had attended the more comprehensive training session was present at all site visits.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Site Observations Observations of NEP sites were conducted in all cities visited (see Table 3). These observations lasted from one to four hours and occurred in the presence of NEP staff. In the 13 US and Canadian cities visited, we visited 18 NEPs that provided services at 102 different sites. Six sites operated by five programs in London and Amsterdam were also observed. Table 3 Observations, Interviews, and Focus Groups Conducted Total site observations 33 Interviews with:   NEP directors and staff 25 Public health officials 14 IDU researchers 22 Community leaders 49 Focus groups with:     NEP clients (11 focus groups) 82 NEP non-clients (7 focus groups) 47 Total number of persons interviewed 239 In order to create as little intrusion into NEP services as possible, investigators followed the direction of the NEP staff in terms of dress, location from which to observe the NEP, and number of observers. In several cases, IDUs had been told that researchers would be visiting the site on that particular day. A list of items to be observed at each site guided the observation process.24 These included physical characteristics of the site, the exchange process itself, and interactions with the local community. The observation guidelines were pre-tested at two sites and the results compared qualitatively for inter-rater reliability before adopting the final guidelines. Key Informant Interviews Interview protocols for four distinct types of interviews were developed: (1) NEP directors and staff; (2) public health officials; (3) IDU researchers; and (4) community leaders, including leaders from the following groups: law enforcement, ethnic minority groups, religious groups, local businesspeople, elected officials, and neighborhood groups. The protocols were designed as guides for the interviews; investigators were not expected to follow the questions in exact form or sequence. Rather, emphasis was placed on

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs making the interviewee comfortable and allowing answers to emerge during the course of conversation. For each interview, one project member was assigned responsibility for guiding the interview, although all project members had the opportunity to clarify respondent answers or add questions of their own; another investigator was responsible for recording respondent answers and writing up the interview. Except for the interviews of NEP directors and staff, which lasted up to three hours, most interviews were completed in one hour. A total of 231 interviews were conducted during the site visits (see Table 3). In eight cases, key informants were unavailable at the time of the site visit and were subsequently interviewed by telephone using the same procedures. The purpose of the study was explained to key informants who were asked for permission for direct attribution of their comments. Except for one individual in the Boston area who had operated an illegal NEP, such permission was always granted, although some respondents provided additional "off the record" information which was not included in the Final Report. Permission to record the interviews on audio tape was sought; in only two cases was permission denied. The interviews also provided the opportunity to augment the data collection effort and to clarify local investigator's research findings. IDU Focus Groups IDU focus group guidelines were prepared and reviewed in a fashion similar to the interview protocols. These included inquiries into their use of the NEP, factors promoting or deterring use of the NEP, enforcement of exchange rules, and suggestions for program improvement. Separate interview protocols were designed for clients of the NEP and those not using the program. In initial telephone contacts with NEP staff, the Project Director discussed conducting anonymous focus groups with IDUs who were clients of the NEP and with those not using the NEP. NEP staff provided guidance on how best to recruit client focus group members. In most circumstances, fliers or sign-up sheets were provided to the NEP staff, who then identified potential subjects from those volunteering, paying attention to achieving an appropriate mix of gender, ethnicity, and opinion of the NEP. Eighty-two clients from 11 NEPs were interviewed. IDUs rarely or never using the NEP were recruited from the clientele of drug treatment programs and ongoing street-based research projects. Again, recruiters were asked to seek a representative group with respect to gender, ethnicity, and opinion of the NEP. Forty-seven non-clients from seven NEPs were interviewed. One investigator took responsibility for leading the focus group session and explaining the purpose of the study. This was facilitated by providing focus group attendees with a participant information sheet. Individuals attending the focus groups were provided with refreshments and reimbursed between $10 and $15 for their time. The focus groups were attended by between two and 10 IDUs, lasted approximately one hour and were not recorded on tape, except in Montreal where the focus groups were conducted in

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs French and recorded for later translation. NEP staff were not present during the client focus groups. Qualitative Analysis Project members were provided with blank computer templates of the interview and focus group protocols and recorded the interviews by reporting interviewee responses in spaces on the template below the appropriate questions. Information provided by subjects that was not directly responsive to any protocol question was noted as an addendum to the interview write-up. These write-ups were completed using notes taken during the interviews and/or tape recordings of the interviews. Each interview and observation write-up was circulated to all investigators present at the interview to confirm the accuracy of recorded information and to identify additional information for inclusion. A binder with hard copies of all interview write-ups was provided to each investigator. Interview write-ups were also entered into a computerized qualitative database software program called askSam.27 This software is frequently used in ethnographic research and permits the categorization and indexing of data so that sections of separate interviews addressing the same research question can be easily assembled. The database was used in the synthesis of the site visit findings. Mail Survey of NEPs Not Visited In order to obtain as complete a description of US NEPs as possible, the site visits were supplemented by a mail survey of 20 NEPs not visited by project members. After the surveys were completed in May 1993, we identified four additional US NEPs. A five-page questionnaire seeking basic descriptive information was sent to the 20 NEPs. Phone follow-up was used to increase the response rate and to clarify any uncertainties regarding the responses received. The information obtained through the mail survey was integrated into the description of NEPs. Cost-Effectiveness Modeling Cost-effectiveness modeling involved a four-step process: (1) an assessment of NEP budgets; (2) the systematic evaluation of studies of NEP impact on HIV risk behaviors; (3) the assessment and further development of existing mathematical models of NEP impact on HIV transmission; and (4) the use of mathematical models to estimate the cost-effectiveness of NEPs, defined as cost per HIV infection averted. In this section, we describe only methods used to evaluate existing research. We summarized the methods and findings of all available studies addressing the effects of NEPs on HIV risk behaviors and needle-borne disease rates using a similar

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs distinguishing between legal and illicit syringes. (Though this would obviously not be foolproof, since illicit syringes could also be marked by anyone who chose to do so.) When the regulations for legal exchanges were first drafted, tagging of syringes to be distributed was included, and State Health Department officials made several public statements that tagging would be included in the final regulations. The rapid expansion of the legalized exchanges brought forth the difficulties in attempting to tag syringes. Discussions with syringe manufacturers led to a quick conclusion that it would not be economically feasible for manufacturers to modify their production processes to produce relatively small lots of "pre-tagged" syringes. The manufacturers also noted that post-production tagging compromised the sterility of the syringes. The two large-scale legal exchanges (formerly underground exchanges) found that the tagging operation rapidly became the rate limiting factor in their ability to deliver syringe exchange services. The funding level of the syringe exchanges required the exchanges to use volunteers for the task of tagging syringes. Large-scale tagging was creating a severe morale problem among the volunteers. The leaders of the two large exchanges reached a point where they believed it would be impossible to continue large-scale operations if the tagging was required. As the exchanges proceeded during the first year, there were persistent reports of police harassment of IDUs participating in the exchanges, including confiscation of legally obtained tagged syringes and taking of the cards that identified the IDUs (by a code number) as participants in the legal exchanges. These reports undermined the rationale for having syringes that could be easily identified as legal. Concerns about liability issues if a tagged syringe should be involved in a needlestick injury of a person who did not inject illicit drugs were also raised, although there were no reports of needlestick injuries. The need to know the percentage of distributed syringes that were returned to the exchanges was still considered important by the State Health Department and several of the exchanges themselves. The eventual resolution to the problem of continued tagging of syringes was to omit tagging from the regulations and to have the evaluators conduct a 'Tagging Alternative Study" (TAS). In this study, a sample of syringes will be tagged, with systematic measurement of the returned syringes over the next month. This study will provide an estimate of the percentage of syringes returned for each of the different exchanges over the one month measurement period. The study could be repeated for either all exchanges or for selected exchanges if a need should arise in the future. The "tagging question" is an example of an issue where the perceived needs of the different organizations within the system were in sharp conflict. This issue reflects a more general conflict between having tightly regulated exchanges and the HIV prevention goal of providing sterile injection equipment to as many injecting drug users as possible. This more general conflict has been a dominant theme during the first year of operation, and we expect it to continue as a dominant theme for the indefinite future.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Subject Characteristics To date 2849 interviews have been conducted; this analysis is based on 1752 baseline interviews conducted between the months of October 1992 and June 1993. Less than one percent of the interviews have been excluded from this analysis due to unreliability of the responses (as determined by the interviewer who recorded reliability on a Likert scale based on consistency of respondents' answers and on face-to-face judgment of the validity of the data. Of the 1752 subjects included in this analysis 70% were male and 30% were female. IDUs participating in this study were racially/ethnically diverse (38% Latino, 35% African American, 28% White). The mean age of participants was 36 (SD=8) and ranged from 18 to 67 years old (Table 1). Seventy-two percent (1256) of participants reported having been tested for HIV. Of these, 1112 reported knowing the results, 70% reported testing negative, 27% reported testing positive, 1.5% of the test results were inclusive and 1% of the participants refused to reveal their status. The mean age of first injection was 19 (SD=5.5). Respondents had long histories of injecting drug use; the average length of injection was 16 years (SD = 9.0) (Table 2). Only 59 respondents (3%) had been injecting for 1 year or less. Participants had been using syringe exchange for an average of 5.8 (SD= 9.0) months, and reported an average use of 15.2 (SD= 13.1) syringes per week. Respondents reported obtaining 14 (93%) of their syringes from the exchange per week (Table 2). Self-Reported Change in Risk-Taking Behavior Participants reported that in the 30 days prior to using the syringe exchange, they injected with previously used works an average of 11.6% of the time compared to 3.9% of the time in the last 30 days while using the needle exchange (p<.001). Prior to using the exchange, respondents reported injecting an average of 95.2 times per month compared with 85.6 times per month during the last 30 days (p<.0001). There was a significant decrease in the number of participants who reported injecting with syringes used by others in the last 30 days compared with 30 days prior to using the exchange: with rented or bought used syringes, 21.7% prior, 5.8% current; with borrowed works, 29.3% prior, 12.1% current. The number of IDUs who reported using alcohol pads to clean their skin when injecting increased significantly, from 33.0% prior to 80.0% current (Table 3). A total of 1337 participants responded to questions about renting or buying used syringes both 30 days prior to using the exchange and during the past 30 days. Of these, 1047 (78%) did not rent or buy used works prior to using the exchange and 290 (22%) did. In the last 30 days since using the exchange, 1259 (94%) did not inject with works used by others and 78 (6%) did. Among the 1047 who did not practice this behavior previously, only 11 (1%) began to do so. In comparison, among the 290 who did rent or

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs buy used works prior to using the exchange, 223 (77%) no longer did (McNemar Chi square, p<.001). A total of 1328 participants responded to questions about borrowing or using used works. Of these, 939 (71%) did not practice these behaviors in the 30 days prior to using the exchange and 389 (29%) did. Among those who did not, only 23 (2%) initiated this behavior. In the last 30 days while using the exchange, 1167 (88%) reported not borrowing or using used works and 161 (12%) did. In comparison, among those who previously borrowed or used works, 251 (65%) have not in the last 30 days (McNemar Chi square, p<.001). A total of 1269 participants responded to queries about using alcohol pads while injecting. Of these, 851 (67%) did not use alcohol pads prior to using the exchange and 418 (33%) did. Among those who did not, only 9 (2%) still do not. During the last 30 days while using the exchange, 1015 (80%) reported using alcohol pads, and 254 (20%) reported not using them. Among those who did not previously use alcohol pads, 606 (71%) have begun since using the exchange (McNemar Chi square, p<.001). Of the 1752 participants interviewed, 60% reported that they had anal, oral, or vaginal sex in the last 30 days. Table 4 presents the sex risk behaviors of these 1055 sexually active participants. DISCUSSION In contrast to questions about the use of bleach by IDUs to disinfect syringes (Center for Disease Control, 1982; Contoreggi et al., 1992; Vlahov et al., 1991), there is no need to conduct research on the efficacy of commercially manufactured needles and syringes in preventing HIV transmission. If only one person uses the needle and syringe, the chances of HIV transmission are as close to zero as anything in epidemiology. The effectiveness of syringe exchanges in reducing HIV transmission among injecting drug users is thus solely a question of the ability of the service providers to provide exchange services and the subsequent behavior of the persons utilizing the services. The ability to provide services is largely determined by the specific operational procedures of the syringe exchange program, which in turn are substantially determined by the other organizations within the syringe exchange system and the availability of volunteers, and indirectly determined by a wide variety of supporters and opponents of syringe exchange. The New York syringe exchange system is the first attempt to establish a multi-exchange system within the United States. If syringe exchanges are to be an important factor in preventing HIV infection in the United States, it is very likely that they will operate within state-wide systems (or possibly a federal system). The systems issues that have arisen in New York are thus likely to be replayed in other states and possibly at a federal level. The different organizations involved in the New York syringe exchange system have many differences in their organizational cultures. The potential for miscommunications and organizational cultural conflict, or serious conflicts of interest cannot be underestimated. That most of the problems have been successfully resolved so far is

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs something we attribute to the skills and good will of the individuals who have been devoting many long hours to the system issues. There also have been recurrent problem themes, such as the conflict between having tightly regulated, legally compliant exchanges and reaching the largest number of IDUs per dollar of funding. This conflict also occurs for single, isolated exchanges, but is much more complicated within a system of exchanges. (The smallest exchange in the New York system currently has 85 enrolled participants, while the largest has 5,888 enrolled participants.) The effectiveness of the exchange will also depend upon the behavior of the participants. Similar to other studies (Buning, 1989; Hagan et al., 1991; Hart et al., 1989), participants in the NYC syringe exchange have demonstrated a reduction, but not elimination, of some high risk behaviors. This is particularly evident for syringe sharing behaviors. Overall the data indicate that there has been a significant reduction in renting and buying used syringes and a marked decrease in borrowing used works. These findings are consistent with international studies which have shown that exposure to harm reduction strategies and access to clean equipment reduces some high risk behaviors associated with HIV infection. However, despite the evidence of drug-related risk reduction among participants of syringe exchanges in NYC, sexual risk reduction still lags behind (Abdul-Quader et al., 1990; Deren et al., 1993; Des Jarlais, 1992). Our data indicate that participants are having unprotected sex more than half of the time, whether with primary or casual partners. This suggests that syringe exchange programs may need to expand their efforts at sexual risk reduction education, but will more than likely require increased funding in order to accomplish this expansion. Research is still needed which will explore the determinants of consistent use of condoms among this population. These data from the first year of the NYC syringe exchange evaluation, are consistent with data from other studies which have shown that syringe exchanges are not attracting new injectors (Des Jarlais et al., 1988). Our data indicate that the majority of IDUs attending syringe exchange are long time injectors (average length of injection 16 years) and that only 59 (3%) have been injecting for less than one year. The most important single datum for assessing the New York syringe exchanges will obviously be the HIV seroconversion rate among the participants. Previous studies have shown seroconversion rates from 6 to 11 per 100 person-years at risk among persons continuing to inject illicit drugs in high seroprevalence areas. We will eventually be able to compare the rate observed among New York syringe exchangers to these other studies, with appropriate multivariate controls. The important question, however, will not be a statistically significant difference, but an epidemiologically substantial difference. It is quite possible that in an area like New York, both more extensive and more intensive prevention services will be needed in addition to syringe exchanges. ACKNOWLEDGMENTS This study was funded by the American Foundation for AIDS Research (AMFAR). We would like to acknowledge all syringe exchange staff who have cooperated with this

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs evaluation and who have provided access to the participants, our interviewing staff, Judith Milliken for her work on this manuscript, and Lee Kochems for his comments. REFERENCES Abdul-Quader, A.S., Tross, S., Friedman, S.R., Kouzi, A.C., & Des Jarlais, D.C. (1990). Street-Recruited Intravenous Drug Users and Sexual Risk Reduction in New York City. AIDS, 4:1075-1079. Broadhead, R.S., & Margolis, E. (1993). Drug Policy in the Time of AIDS: The Development of Outreach in San Francisco. The Sociological Quarterly , 34(3):497-522. Buning, E.C. (Oct, 1989). The Role of the Needle Exchange Project in Prevention HIV Infection among Drug Users in Amsterdam. (Paper delivered at the ''What Works Conference: An International Perspective on Drug Abuse Treatment and Prevention Research, New York). Centers for Disease Control and Prevention. (1982). Acquired Immune Deficiency Syndrome (AIDS) Precautions for Clinical and Laboratory Staffs. Morbidity and Mortality Weekly Report, 31:557-580. Centers for Disease Control, Atlanta, G.A. (January 1993). HIV/AIDS Surveillance, Year-End Edition. U.S. AIDS Cases Reported through December 1992. Contoreggi, C., Jones, S., Simpson, P., Lange, W., & Meyer, W. (1992). A Model of Syringe Disinfection as Measured by Polymerase Chain Reaction for Human Leukocyte antigen and HIV Genome. VIII International Conference on AIDS, Amsterdam, The Netherlands. Abstract P.C. 4280;2:291. Deren, S., Paone, D., Friedman, S., Neaigus, A., Des Jarlais, D.C., & Ward, T. (Autumn, 1993). Berlin Conference Summary on IDUs and HIV/AIDS: Interventions, Behavior Change and Policy. AIDS Care, 5(4). Des Jarlais, D.C. (1992). The First and Second Decades of AIDS among Injecting Drug Users. British Journal of Addiction, 87:347-353. Des Jarlais, D.C., & Friedman, S.R. (1992).AIDS and Legal Access to Sterile Drug Injection Equipment. The Annals of the American Academy of Political and Social Science, 521:42-65. Des Jarlais, D.C., Friedman, S.R., Sotheran, J.L., & Stoneburner, R. (1988). The Sharing of Drug Injection Equipment and the AIDS Epidemic in New York City: The First Decade. In: Needle Sharing among Intravenous Drug Abusers: National and International Perspectives. R. Battjes, & R. Pickens, R. (eds.). Pp. 1160-1175. Hagan, H., Des Jarlais, D.C., Purchase, D., Reid, T., Friedman, S.R. (1991). The Tacoma Syringe Exchange. Journal of Addictive Diseases, 10(4):81-88. Hart, G.J., Andrea, Carvell, A.L.M., Woodward, N., Johnson, A.M., Williams, P., & Parry J.V. (1989). Evaluation of Needle Exchange in Central London: Behavior Change and Anti-HIV Status Over One Year. Current Science Ltd., 0269-9370: 261-265. Johnson, A.M., Parry, J.V., Best, S.J., Smith, A.M., de Silva, M., & Mortimer, P.P. (1988). HIV Surveillance by Testing Saliva. AIDS, 3:369-371.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Kaplan, E.H., O'Keefe, E. (1993). Let the Needles do the Talking! Evaluating the New Haven Needle Exchange. Interfaces, 23:7-26. New York City Department of Health, Office of AIDS Surveillance. (January 30, 1993). New York City AIDS Surveillance Report. New York State Department of Health AIDS Institute (1993). Authorization to Conduct Hypodermic Syringe and Needle Exchange Programs(10 NYCRR Section 80.135, p. 5). Paone, D., Des Jarlais, D.C., Caloir, S., & Friedmann, P. (1993). AIDS Risk Reduction Behaviors among Participants of Syringe Exchange Programs in New York City, USA. (Abstract) IXth International Conference on AIDS, Berlin, June 7-11. Vlahov, D., Munoz, A., Celantano, D. et al. (1991). HIV Seroconversion and Disinfection of Injection Equipment among Intravenous Drug Users, Baltimore, Maryland. Epidemiology, 2(6):444-446.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs TABLE 1-Demographic Descriptors of Needle Exchange Participants n=1752 Mean Age   35.7 (SD= 8.0) Gender         Male 1192 (70%)   Female 557 (30%) Ethnicity   Latino 668 (38%)   Black 604 (35%)   White 443 (25%)   Other 33 (2%) Marital Status   Married/Common Law 415 (24%)   Never Married 805 (46 %)   Divorced/Separated 447 (26 %)   Widowed 70 ( 4%) Have Children   Yes 1297 (74%)   No 449 (26%) Ever in Prison/Jail Overnight         Yes 1238 (71%)   No 503 (29%) Living Arrangements-Past 6 months1   Own House/Apartment 738 (43%)   Someone else's House/Apt 647 (38%)   Hotel/Rooming House 130 ( 8%)   Shelter/Welfare Hotel 90 ( 5%)   Streets 259 (15%)   Jail 49 ( 3%)   Shanty 36 (2%)   Other 36 (2%) Source of Income-Past 6 months1   Regular Job 165 (10%)   Temporary Work 183 (11%)   Self-Employed/Panhandling 339 (20%)   Welfare 834 (49%)   Other Benefits 349 (21%)   Income from Spouse/Friends 129 ( 8%)   Sex for pay/Sex for drugs 101 ( 6%)   Illegal/Possibly illegal Sources 525 (31%)   Other 43 ( 3%) Education (N=1735)   Did not complete High School 732 (42%)   Completed High School 1006 (58%) (1) Percents may add up to more than 100 since more than one response may apply.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs TABLE 2 Drug Use Characteristics of Needle Exchange Participants N = 1752 Mean Age of First Drug Injection     19.4 (sd= 5.5) Mean Number of Years Injecting     16.4 (sd= 9.0) Mean Number of Months Using Exchange     5.8 (sd= 6.5) Mean # of Syringes Used Per Week     15 Mean # of Syringes From Exchange (%)     14 (93%) Type of Drug Injected         Heroin only 362 (24%)   Cocaine only 121 ( 8%)   Speedball only 261 (18%)   Multiple drugs 712 (49%) History of Drug Treatment         Yes 1322 (76%)   No 414 (24%) Currently in Drug Treatment         Yes 644 (46%)   No 751 (54%)

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs TABLE 3Sharing Behaviors of Participants 30 Days Prior to Using the Needle Exchange and in the Last 30 Days (N = 1269) Sharing behavior 30 days prior to using the exchange In the last 30 days p value rent/buy used works yes 290 (22) 78 (6)   no 1047 (78) 1259 (94) p<.001 borrow/use used works yes 389 (29) 161 (12)   no 939 (71) 1167 (88) p<.001 use alcohol pads yes 418 (33) 1015 (80)   no 851 (67) 254 (20) p<.001

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs TABLE 4Risk Behaviors Practiced by Sexually Active Needle Exchange Participants in the Last 30 Days n=1055 Sexual Behaviors   # (%) Same Sex Primary Partner   44 ( 4) Primary Partner of the Opposite Sex           Yes 753 (71)   No 303 (29) Condom Use With Primary Partner           always 231 (31)   sometimes 123 (17)   never 379 (52)* Casual Partner of the Opposite Sex           Yes 292 (28)   No 764 (72) Condom Use With Casual Partner           always 143 (50)   sometimes 68 (24)   never 77 (27)* * May not equal 100% due to rounding

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs DISCUSSION: U.S. NEEDLE EXCHANGE DATA ANDREW MOSS Andrew Moss observed that almost a decade has passed since the first open operation of needle exchanges, yet the issue is still being hotly debated and the same arguments for and against needle exchanges are still being made. Now, however, much more is known about the operation and impact of individual needle exchange programs, and systematic studies of needle exchanges are beginning to emerge. He noted that, first, needle exchanges attract a large clientele. Second, they tend to attract older users, many of whom have long histories of injection drug use. Third, they do not seem to increase injection drug use in any way that can be observed or measured. Fourth, they may reduce needle sharing among injectors. Fifth, data are lacking—and may never be available—with which to isolate the impact of needle exchanges on HIV incidence from other factors. He remarked with interest on the finding that the Tacoma needle exchange had an individual-level protective effect against needle-borne transmission of hepatitis-B. Sixth, the data presented do not all point uniformly in the same direction: in particular, although needle exchanges attract older injectors, the data from the San Francisco presentation indicate a decline in sharing associated with needle exchange use by younger, not older, people. In addition, although many of the needle exchanges attracted a largely white clientele, African-Americans are known to be a high-risk group among injectors. Given the data, Moss asked, should a push be made for large-scale federal and state funding of needle exchanges? His own response to the question was a qualified yes, for two reasons: first, the United States does not have a unified strategy for reducing HIV infection among injecting drug users, despite the fact that injection drug use is a major HIV risk factor in this country. Second, other serious diseases prevalent among the injector population, especially tuberculosis, are associated with HIV transmission, and reducing the incidence of HIV will have a positive impact on the incidence of those diseases as well. If the United States does move to the big model of federal and state funding of needle exchanges, Moss pointed out, the question then becomes how to do it in a way that does not destroy what has largely powered needle exchanges to date—social activism by people who have knowledge of and sympathy for people who inject illegal drugs.