Early reports focused on the psychological and cultural factors involved in sharing (e.g., Des Jarlais et al., 1986; Howard and Borges, 1972), often describing the sharing activity as a ritual engaged in by injection drug users to bond with each other. However, with the emergence of AIDS, several ethnographers have reexamined the relative importance of such factors in relation to other more pragmatic factors, such as needle scarcity (Carlson, 1991; Kane and Mason, 1992; Koester, 1992). For example, researchers have established that legal restrictions play an important role in the scarcity of needles and syringes within the injection drug user community (Des Jarlais and Friedman, 1992; Feldman and Biernacki, 1988; Koester, 1989; Murphy, 1987). These findings are consistent with empirical findings of a large-scale longitudinal study (Mandell et al., 1994). An analysis of baseline data on 2,524 injection drug users indicates that sharing behavior is related to economic and legal considerations as well as to the frequency of injection and drug class.
Koester (1994) recently provided a detailed description and explanation of how the scarcity of sterile needles caused by these legal constraints has contributed to the sizable amount of sharing among injection drug users. At first glance, it would appear that, given the misdemeanor offenses associated with conviction on paraphernalia possession in many states, such convictions would not constitute a serious deterrent to having injection drug users purchase sterile needles from pharmacies (it is legal to purchase them without a prescription in most states) to ensure that they have access to sterile equipment when they need to inject drugs. Koester's data indicate that most of his study participants did, in fact, frequently purchase needles from pharmacies. Nonetheless, these same individuals also stated that the imminent fear of arrest for possession of paraphernalia (which deterred them from carrying sterile needles) was greater than the distant threat of AIDS. Several researchers have reported that knowledge about the risk of infection associated with sharing is insufficient to affect behavior change (Inciardi, 1990; Friedman et al., 1992; Page et al., 1990a). In a study of out-of-treatment injection drug users (Celentano et al., 1991), 98 percent of active injection drug users reported that they were aware that HIV was transmitted through sharing contaminated needles and syringes, yet 70 percent reported sharing. Such findings were also observed with in-treatment injection drug users (Magura et al., 1989). These researchers reported that 40 percent of their sample reported sharing in the last month and that knowledge of AIDS risk was not empirically associated with that behavior.
Although fear of AIDS is often not a decisive motivation, it does bring about some meaningful behavioral changes among injection drug users. Since the early years of the AIDS epidemic, studies have reported significant risk