Social scientists with the University of Connecticut, Storrs, have released the results of an empirical study on the closure of an established needle exchange, and its impact on the risk behaviors of the exchange's injection drug-using clients and the community-at-large. The study was conducted by sociologists Robert S. Broadhead, Ph.D., Yael Van Hulst, M.A. and Douglas D. Heckathorn Ph.D., funded by a multi-year grant from the National Institute on Drug Abuse. The study was released during a formal presentation by the study's authors at a colloquium series sponsored by the Yale AIDS Program on January 28, 1999. The study also appears in the February 1999 issue of Social Problems, a prestigious social science journal of the Society for the Study of Social Problems.
In April 1998, the Secretary of the U.S. Department of Health and Human Services, Donna Shalala, declared that, "A meticulous scientific review has now proven that needle- exchange programs can reduce the transmission of HIV and save lives without losing ground in the battle against illegal drugs." The Secretary was responding to a 34-member Presidential Advisory Council's review of scores of empirical studies on the effectiveness of needle exchange programs on reducing the risk behaviors of injection drug- using clients.
The study released by Broadhead et al. looks at the effectiveness of such programs from a different angle: It is the first empirical study of the impact of an established needle exchange's closure on injection drug users' risk behaviors, and on the community. The study was conducted in Windham, a small city in northeastern Connecticut where a state-sponsored needle exchange operated for several years serving several hundred injection drug users. The exchange was closed in March, 1997 following ten months of tumultuous public debate and controversy. The program's opponents succeeded in placing blame on the needle exchange program for virtually all of Windham's drug-related problems, and even the economic decline of the city itself. While not a perfect program, the exchange became a convenient and ready scapegoat by its opponents. Thus, like a storm, as the controversy began, gained in strength, peaked, and then blew itself and the needle exchange away, virtually all of the problems blamed on the exchange still remain in Windham, including a very large and active illicit drug scene.
Design of the Study
For three years prior to the closure of the Windham needle- exchange, the Eastern Connecticut Health Outreach (ECHO) project, directed by the researchers, conducted 330 initial and 173 follow-up interviews on HIV risk-related behavior of Windham drug injectors. Following the closure of the exchange in March 1997, the ECHO project began re-recruiting former respondents who remained in the area and continued as active injectors. This resulted in 111 "post-closure initial" interviews and 78 three-month "post-closure follow- up" interviews focusing on any changes in their risk behavior status.
The ECHO project also continued the practice, begun many months before the closure of the needle exchange, of systematically surveying several public outdoor areas in Windham where high levels of drug use occur. During these surveys, the project recorded the number of discarded syringes found, as well as dope bags, syringe wrappers and caps, and other injection-related debris. Both as a public service, and to avoid recounting such items during subsequent surveys, the ECHO project collected these materials.
The results indicate that the closure of the needle exchange profoundly and negatively impacted drug injectors' access to clean syringes, which proportionately increased their risk of using syringes infected with HIV. Before the closure of the exchange, only 14% of Windham drug injectors reported that their primary source of "new" syringes was from family or friends, diabetics or street sources. These are unsafe sources because drug users cannot be sure that such syringes are unused and sterile. At the post-closure initial interview, respondents' rate of obtaining syringes from unsafe sources increased to 36% -- a 165 percent increase, and to 51% at the post-closure follow-up interview -- mostly from street sources -- which nearly quadrupled the pre- closure baseline rate. This change in the number of respondents who obtained syringes from street dealers -- the least safe source -- was more alarming. Whereas before the closure of the exchange, only 4% of respondents obtained their syringes from the street, after the closure the rate increased to 38%.
Further, before the closure of the exchange, the respondents reported that they reused syringes 3.52 times on average. This increased to 7.68 times at the post-closure initial interview -- a 118% increase. This findings is especially dramatic because a relationship has been scientifically documented between the amount of time syringes remain in circulation and rates of HIV infection among drug injectors. As reported by Charles Kaplan and Robert Heimer in their highly respected "needle circulation" study of the New Haven needle exchange, a needle exchange reduces the circulation time of syringes, which reduces the probability that they will become infected. After the closure of the Windham needle exchange, there was a sharp increase in the amount of time that dirty syringes remain in circulation, creating a proportional increase in the probability that Windham drug injectors are likely to re-use and share infected syringes.
The closure of the needle exchange also significantly increased drug injectors' self-reported syringe sharing. At their last interview before the closure of the exchange, only 16% of Windham drug injectors' reported sharing a syringe within the last 30 days. After the exchange's closure, 34% of the respondents reported in their first interview that they had shared a syringe within the last 30 days, a 100 percent increase. The respondents also reported increases in the sharing of other HIV-related injection materials following the closure of the exchange, such as the sharing of cookers and water used in the preparation of drugs.
Lastly, the surveys of public outdoor areas in Windham where high levels of drug use occur found that the closure of the needle exchange had no effect either on the number of improperly discarded syringes and other drug-injection debris, or on the robustness of the Windham illicit drug scene.
All of the problems blamed on the needle exchange remain in Windham following its closure. In fact, Windham now faces even more problems. First, because of the controversy surrounding the exchange, almost all of Windham's pharmacies no longer sell syringes over-the-counter for fear of being blamed for the city's "needle problem." This forces drug injectors further into re-using and sharing dirty syringes. Second, virtually all of the progress the city made over the last several years in reducing drug injectors' HIV risk behaviors has been lost. Finally, with the closure of the exchange and the campaign against it -- much of it based on assertions now disproved about the exchange causing the city's drug problem and economic decline -- Windham has seriously crippled its ability to protect the community against HIV and other drug-related diseases.