Legal access to sterile injection equipment has been a primary strategy for preventing the acquired immune deficiency syndrome (AIDS) among persons who inject illicit drugs in almost all developed countries. This strategy has remained highly controversial in the United States, with only a small number of localities adopting it. This article reviews different techniques of providing legal access—over-the-counter sales and syringe exchanges—research design issues relevant to evaluating legal-access programs, and the findings from the large number of studies conducted to date. The findings are consistent in showing no increase in illicit drug use related to legal access and decreases in AIDS risk behavior related to legal-access programs. The design of legal-access programs for maximal impact and the ultimate effect of the decreases in AIDS risk behavior on transmission of the human immunodeficiency virus (HIV) remain to be determined.
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References
1.
1. HIV/AIDS Surveillance, Year-End Edition: U.S. AIDS Cases Reported through December 1990 (Atlanta, GA: Centers for Disease Control, 1991).
2.
2. WHO-EC Collaborating Center on AIDS, AIDS Surveillance in Europe: Quarterly Report No. 27 (Geneva: World Health Organization, 1990).
3.
3. For a recent review of the epidemiology of AIDS and HIV among drug injectors, see Samuel R. Friedman and Don C. Des Jarlais, “HIV among Drug Injectors: The Epidemic and the Response,”AIDS Care, 3(3):237-248 (1991).
4.
Charles F. Turner , Heather G. Miller, and Lincoln E. Moses, eds., AIDS: Sexual Behavior and Intravenous Drug Use (Washington, DC: National Academy Press, 1989).
5.
5. National Commission on AIDS, Report: The Twin Epidemics of Substance Use and HIV (Washington, DC: Government Printing Office, 1991), pp. 10-11.
6.
Mitchell S. Rosenthal , “Giving Away Needles Won't Stop AIDS,”New York Times, 17 Aug. 1991.
7.
Warwick Anderson , “The New York Needle Trial: The Politics of Public Health in the Age of AIDS,”American Journal of Public Health, in press.
8.
8. The amendment was adopted in response to an amendment sponsored by Senator Jesse Helms that would have banned federal support for both syringe-exchange programs and bleach-distribution programs unless the President certified them to be safe and effective. The substitute amendment thus provided for continued federal support of bleach-distribution programs while providing an opportunity for the Senate to vote “against drug abuse.” For a more detailed discussion of this issue, see Don C. Des Jarlais and William Bailey, “Almost Banning Bleach” (Paper delivered at the conference of the American Psychological Association, Boston, Aug. 1990).
9.
9. In the absence of any federal support for research on the topic, the American Foundation for AIDS Research (AmFAR) has become the leading source of funding for research on syringe exchanges in the United States. AmFAR supports research on the syringe-exchange programs in Portland, OR; Tacoma, WA; and San Francisco, CA.
10.
Samuel R. Friedmanet al. , “Social Intervention against AIDS among Injecting Drug Users,”British Journal of Addictions, in press.
11.
11. There are some difficulties in enforcing these laws, as law enforcement officials may not give them high priority compared to other criminal offenses, and trials of underground syringe-exchange staff in Massachusetts, New York, and California all failed to produce convictions. On the other hand, an active police presence outside a legal fixed-site syringe exchange may serve to discourage drug users from using the program.
12.
Don C. Des Jarlais and Samuel R. Friedman, “HIV Infection among Persons Who Inject Illicit Drugs: Problems and Prospects,”Journal of the Acquired Immune Deficiency Syndromes, 1(3):267-273 (1988).
13.
13. Don C. Des Jarlais and Bruce Stepherson, “History, Ethics and Politics in AIDS Prevention Research,”American Journal of Public Health, in press.
14.
14. Anderson, “New York Needle Trial.”
15.
Stanley H. Weisset al. , “Risk for HTLV-III Exposure and AIDS among Parenteral Drug Abusers in New Jersey” (Paper delivered at the First International Conference on AIDS, Atlanta, GA, Apr. 1985).
16.
Peter A. Selwynet al. , “Knowledge about AIDS and High-Risk Behavior among Intravenous Drug Abusers in New York City,”AIDS, 1(4):247-254 (Dec. 1987).
17.
Selwynet al. , “Knowledge about AIDS.”
18.
18. Don C. Des Jarlais, Samuel R. Friedman, and William Hopkins, “Risk Reduction for the Acquired Immunodeficiency Syndrome among Intravenous Drug Users,”Annals of Internal Medicine, 103(5):755-759 (Nov. 1985).
19.
19. Johanna A. R. van den Hoek, Harry H.J.A. van Haastrecht, and Roel A. Coutinho, “Risk Reduction among Intravenous Drug Users in Amsterdam under the Influence of AIDS,”American Journal of Public Health, 79:1355-1357 (1989).
20.
20. Ernst C. Buning, “The Role of the Needle Exchange Project in Preventing 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, Oct. 1989).
21.
21. Harry J. A. van Haastrechtet al., “The Course of the HIV Epidemic among Intravenous Drug Users in Amsterdam, the Netherlands,”American Journal of Public Health, 81(1):59-62 (Jan. 1991).
22.
22. Ernst C. Buninget al., “Preventing AIDS in Drug Addicts in Amsterdam” (letter), Lancet, ii:1435 (June 1986).
23.
23. Erik J. C. van Ameijden, Johanna A. R. van den Hoek, and Roel A. Coutinho, “Risk Factors for HIV Seroconversion in Injecting Drug Users in Amsterdam, the Netherlands” (Paper delivered at the Seventh International Conference on AIDS, Florence, Italy, June 1991).
24.
24. Ernst C. Buning, G.H.A. van Brussel, and G. W. van Santen, “Amsterdam's Drug Policy and Its Implications for Controlling Needle Sharing,” in Needle Sharing among Intravenous Drug Abusers: National and International Drug Perspectives, National Institute on Drug Abuse, Research Monograph Series no. 80, ed. R. J. Battjes and R. W. Pickens (Rockville, MD: National Institute on Drug Abuse, 1988), pp. 59-74.
25.
25. Jean-Paul C. Grund, Charles D. Kaplan, and Nico F. P. Adriaans, “Needle Sharing in the Netherlands: An Ethnographic Analysis, American Journal of Public Health, in press.
26.
26. J. R. Robertsonet al., “Epidemic of AIDS-Related Virus (HTLV-III/LAV) Infection among Intravenous Drug Abusers,”British Medical Journal, 292:527-529 (Feb. 1986).
27.
Anita de Rossiet al. , “Trends of HTLV-I and HIV Infections in Drug Addicts” (letter), European Journal of Cancer and Clinical Oncology, 24(2):279-280 (1988).
28.
28. J. F. Peuthereret al., “HTLV-III Infection in Intravenous Drug Abusers in Edinburgh” (Paper delivered at the Second International Conference on AIDS, Paris, June 1986).
29.
29. Gerry V. Stimsonet al., Injecting Equipment Exchange Schemes: Final Report (London: Monitoring Research Group, Goldsmith's College, 1988).
30.
30. One exchange program, operated by a drug abuse treatment program, did attempt to use the exchange primarily as a means of recruiting clients, and eventually it closed because it was not able to attract enough clients.
31.
31. Hilary Kleeet al., “The Sharing of Injection Equipment among Drug Users Attending Prescribing Clinics and Those Using Needle-Exchanges,”British Journal of Addiction, 86:217-223 (1991).
32.
32. Russell Newcombe, “The Liverpool Syringe Exchange Scheme for Drug Injectors: Initial Evidence of Effectiveness in HIV Infection” (Paper delivered at the First International Conference on the Global Impact of AIDS, London, Mar. 1988).
33.
33. Graham J. Hartet al., “Evaluation of Needle Exchange in Central London: Behaviour Change and Anti-HIV Status over One Year,”AIDS, 3(5):261-265 (May 1989).
34.
34. Adam N. Crosieret al., “Prevalence of HIV Infection among Injecting Drug Users in London” (Paper delivered at the Seventh International Conference on AIDS, Florence, Italy, June 1991).
35.
35. Bengt Ljungberget al., “HIV Prevention among Injecting Drug Users: Three Years of Experience from a Syringe Exchange Program in Sweden,”Journal of the Acquired Immune Deficiency Syndromes, 4(9):890-895 (Sept. 1991).
36.
36. Kerstin I. Kall and Robert G. Olin, “HIV Status and Changes in Risk Behavior among Intravenous Drug Users in Stockholm 1987-88,”AIDS, 4(2):153-157 (Feb. 1990).
37.
idem , “Syringe HIV Seroprevalence and Behavioral and Demographic Characteristics of Intravenous Drug Users in Sydney, Australia, 1987,”AIDS, 2(5):373-377 (1988).
38.
38. Pierre Espinozaet al., “Has the Open Sale of Syringes Modified the Syringe Exchanging Habits of Drug Addicts?” (Paper delivered at the Fourth International Conference on AIDS, Stockholm, Sweden, June 1988).
39.
39. F. R. Ingold and S. Ingold, “The Effects of the Liberalization of Syringe Sales on the Behaviour of Intravenous Drug Users in France,”Bulletin on Narcotics, 41(1-2):67-81 (1989).
40.
40. Dietmar Fuchset al., “Anti-HIV-1 Antibodies, Anti-HTLV-1 Antibodies and Neopterin Levels in Parenteral Drug Addicts in the Austrian Tyrol,”Journal of the Acquired Immune Deficiency Syndromes, 1(1):65-66 (1988).
41.
41. Don C. Des Jarlaiset al., “HIV-1 Infection among Intravenous Drug Users in Manhattan, New York City, from 1977 through 1987,”Journal of the American Medical Association, 17 Feb. 1989, pp. 1008-1012.
42.
42. Buninget al., “Preventing AIDS in Drug Addicts.”
44. G. Angaranoet al., “Rapid Spread of HTLV-III Infection among Drug Addicts in Italy,”Lancet, ii:1302 (1985).
45.
45. Don C. Des Jarlais and William Hopkins, “ `Free' Needles for Intravenous Drug Users at Risk for AIDS: Current Developments in New York City,”New England Journal of Medicine, 5 Dec. 1985, p. 1476.
46.
Anderson , “New York Needle Trial.”
47.
47. Anderson, “New York Needle Trial.”
48.
48. The Pilot Needle Exchange Study in New York City: A Bridge to Treatment: A Report on the First Ten Months of Operation (New York: New York City Department of Health, Dec. 1989).
49.
49. Des Jarlais and Stepherson, “History, Ethics and Politics.”
50.
idem , “Risk Reduction and Stabilization of HIV Sero-prevalence among Drug Injectors in New York City and Bangkok, Thailand” (Paper delivered at the Seventh International Conference on AIDS, Florence, Italy, June 1991).
51.
Friedmanet al. , “Social Intervention against AIDS.”
52.
52. Des Jarlais, Friedman, and Hopkins, “Risk Reduction.”
53.
53. Van Ameijden, van den Hoek, and Coutinho, “Risk Factors for HIV Seroconversion.”
54.
54. K. Oliver, personal communication, Aug. 1991.
55.
55. Holly Haganet al., “Lower HIV Seroprevalence, Declining HBV Incidence and Safer Injection in Relation to the Tacoma Syringe Exchange” (Paper delivered at the Seventh International Conference on AIDS, Florence, Italy, June 1991).
56.
56. Holly Haganet al., “The Incidence of HBV Infection and Syringe Exchange Programs” (letter), Journal of the American Medical Association, in press.
57.
57. John A. Newmeyeret al., “Preventing AIDS Contagion among Intravenous Drug Users,”Medical Anthropology, 10(2-3):167-175 (1987).
58.
John K. Watters , D. M. Iura, and K. W. Iura, AIDS Prevention and Education Service to Intravenous Drug Users through the Midcity Consortium to Combat AIDS: Administrative Report of the First Six Months (San Francisco, CA: Midcity Consortium, 1986), p. 9.
59.
59. Art Agnos, Mayor of San Francisco, opening-ceremony address to the Sixth International Conference on AIDS, San Francisco, CA, 1990.
60.
60. John K. Watterset al., “Epidemiology and Prevention of HIV in Intravenous Drug Users in San Francisco, 1986-1989” (Paper delivered at the Sixth International Conference on AIDS, San Francisco, CA, June 1990).
61.
61. John K. Watterset al., “Update on Changes in HIV-1 Seroprevalence and Risk Behavior among Intravenous Drug Users in San Francisco” (Paper delivered at the annual meeting of the American Public Health Association, Boston, MA, Nov. 1988).
62.
62. Elaine O'Keefe, Edward Kaplan, and Kaveh Khoshnood, Preliminary Report: City of New Haven Needle Exchange Program (New Haven, CT: New Haven Health Department, 1991).
63.
63. Kenrad E. Nelsonet al., “Diabetes Is Protective against HIV Infections in IV Drug Users” (Paper delivered at the Sixth International Conference on AIDS, San Francisco, CA, June 1990).
64.
64. Samuel R. Friedman, Paula H. Kleinman, and Don C. Des Jarlais, “History, Biography, and HIV Infection among Drug Injectors: A Methodological Caution” (letter), American Journal of Public Health, in press.
65.
65. Rand L. Stoneburneret al., “A Larger Spectrum of Severe HIV-Related Disease in Intravenous Drug Users in New York City,”Science, 11 Nov. 1988, pp. 916-919.
66.
66. Kenrad E. Nelsonet al., “HIV-1 Seroconversions in a Cohort of Intravenous Drug Users” (Paper delivered at the Seventh International Conference on AIDS, Florence, Italy, June 1991).
