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Article Excerpt
Injection drug users (IDUs) who have difficulty acquiring sterile syringes are 3.5 times more likely to inject with a used syringe than other IDUs (Wood et al., 2002). While syringe exchange programs (SEPs) are designed to increase access to sterile equipment, these programs often cannot meet the demand for syringes. Estimates of the number of syringes exchanged by SEPs versus those needed by IDUs reveal a large disparity (Remis et al., 1998). Hours of operation, staffing levels, availability of mobile services, maximums on the number of syringes that can be exchanged per visit or per day, and other factors limit the ability of SEPs to reach many IDUs and provide an adequate supply of sterile equipment and reduce syringe-related transmission of infectious diseases such as HIV and hepatitis C (HCV) (Strike et al., 2002a; Wood et al., 2003; Grund et al., 1992).
While SEPs are one important source of sterile equipment, there are many others. In some jurisdictions, syringes may also be purchased over the counter (OTC) in pharmacies. As well, informal and/or unsanctioned sources of sterile equipment appear to play an important role in the acquisition of sterile syringes. Encouraging collective exchange of syringes (i.e., exchange of syringes for a group of users) as well as individual exchange has been shown to expand the availability of sterile equipment for a larger proportion of active IDUs (Grund et al., 1992). In Vancouver an informal and unsanctioned SEP provided exchange services to IDUs who had not used Vancouver's formal SEP programs (Wood et al., 2003). Training peers to distribute, trade or sell sterile equipment and/or bleach kits has been recommended as a way to reach IDUs (Valente et al., 1998; Stopka et al., 2003). The ability of these informal networks to reach otherwise unreachable IDUs suggests that other models of syringe distribution may help to fill the gap between demand and access to sterile equipment.
Given the importance of easy access to sterile equipment to HIV prevention, we were interested to examine syringe accessibility and the role of peer syringe exchangers in an environment characterized by legal syringe exchange and OTC sales. In Toronto, Canada, syringe exchange and OTC sales have been available since 1989, and the prevalence of HIV among IDUs has remained at or below 10% (Millson et al., 2005). The SEP provides syringe exchange, distribution of other sterile injection equipment (e.g., cookers, cottons and alcohol swabs), condoms, nursing services, counseling, referrals, and support to local area injection drug users from a fixed site and a mobile service. As well, the SEP contracts out exchange services to other local area agencies in order to increase the coverage of exchange services without increasing human resource and other program costs (Strike et al., 2002a). In 2000, over 20 agencies (e.g., pharmacies, AIDS service organizations, community health centers, temporary shelters, drop-in centers, and a hospital emergency department) provided satellite exchange services to IDUs across the city (Challacombe et al., 2001). In Toronto, possession of an unused needle and syringe is not illegal. However, individuals caught in possession of a used needle may be charged with a criminal offense should there be trace amounts of an illegal substance in the needle or syringe (Canadian HIV Legal Network, 2002).
Using data from a qualitative study and a program evaluation, we examined syringe accessibility issues with a particular focus on answering the following questions: From where or whom and in what quantities do IDUs obtain syringes? What programmatic, social or economic factors influence these patterns of acquisition? What is the relationship, if any, with HIV risk behaviors?
Methods
Data for these analyses were drawn from a qualitative study conducted between 2000 and 2001. IDUs who had injected in the 30 days prior to the interview were recruited through SEP staff members, posters in laundromats, field outreach, and snowball sampling. Data were collected using short field and in-depth interviews. Both field and in-depth interviews were semistructured, qualitative interviews with questions about current and former drug use, drug treatment experiences, overdose, other health risks, HIV testing, service needs, and barriers to service use. Throughout the study, each interviewer wrote extensive field notes concerning recruitment, participants, and participants' drug use and social networks.
Toronto, a city with an estimated population of 2.5 million in 2001 (Statistics Canada, 2004), is geographically and ethnically diverse. Using a targeted strategy, IDUs from varied neighborhoods, ethnic groups, gender and ages were recruited. The field interviews focused on collecting a breadth of information about drug use, whereas the in-depth interviews focused on collecting more detailed information about social and drug-use networks, social and financial support, and sexual relationships and related risk behaviors. After completion of field interviews, participants who represented the diversity being sought in terms of ethnicity and location within the city were recruited for the in-depth interviews. Interviews were conducted in locations selected by participants (e.g., syringe exchanges, coffee shops, homes, squats, agencies and outdoor locations). Eighty field interviews and 40 in-depth interviews were conducted. Participants in the short field interviews were paid $10 to compensate for travel and other costs of participation, while in-depth interview participants received $30.
The taped interviews were transcribed, verified, and entered into the Ethnograph v5.0 for qualitative data management and analysis. Field notes were transcribed and entered into the Ethnograph v5.0. The initial transcripts were team-coded using an iterative reading and coding process to identify data elements, themes, and concepts by the study team. For this manuscript, the data were further analyzed to examine specific syringe-acquisition themes.
Data were also drawn from an evaluation of a Toronto peer-run SEP program; SEP program staff, clients and managers, as well as clinical and non-clinical staff from the parent community health center, were interviewed using structured, qualitative interviews. Detailed interview notes were taken and later transcribed. Qualitative analyses for the program evaluation were conducted using a word processing package.
Results
Before the syringe exchange opened in 1989 and OTC sales in pharmacies were more readily available, sterile syringes tended to be scarce and difficult to access in Toronto. Not surprisingly, this socio-legal environment encouraged the re-use and sharing...
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