To the Editor:
Scientific evaluations have shown that providing injection drug users (IDUs) with access to sterile needles substantially reduces the transmission of HIV-1 and HIV risk behaviors while providing a place where contaminated syringes can be safely discarded. 1–3 As a result, needle exchange programs (NEPs) have been endorsed by numerous independent scientific bodies, including the U.S. National Institutes of Health Consensus Panel, U.S. National Research Council, and American Public Health Association among others. 4
Nevertheless, limited funding for NEPs and restrictive service design remain constraints to optimal service delivery in many settings. 5,6 For instance, in Vancouver, difficulty in accessing syringes has been repeatedly identified as the main risk factor for syringe sharing among the city's IDUs, 7,8 a concern that was later shown to be primarily attributable to the operating hours of the city's large fixed-site exchange, which closes at 8:00 p.m. each evening. 9
Due to the ongoing problem of difficulty in accessing syringes at night, 7–9 on September 1, 2001, the Vancouver Area Network of Drug Users (VANDU), a peer-based organization of drug users that is funded by the local health authority, 10 initiated a nighttime syringe exchange program. Syringes were exchanged from a small tent located in the heart of the city's Downtown Eastside, where most injection drug use is concentrated. 8 We have recently demonstrated that the VANDU exchange has played a critical public health function by reaching those users, such as frequent cocaine injectors, 11 who may be at the highest risk of HIV infection. 12
In recent years, Vancouver police have stepped up their efforts to address the city's illicit drug use problem. 13,14 Among these strategies was a plan to place a constant and highly visible police presence on the street corner in front of the VANDU NEP in an effort later referred to as “Operation 24/7.” Although the displacement of drug users was subsequently described as “an example of the benefits to a neighborhood that can occur when there are adequate and properly deployed police resources,” the health impact of this strategy was never evaluated. 15 Therefore, the present study was conducted to evaluate potential changes in sterile syringe acquisition prior to and after Operation 24/7.
Since the VANDU exchange program was initiated, persons working at the exchange have been required to tabulate the number of syringes being exchanged each evening as well as the number of syringes being provided as “loaners” (ie, syringes being provided when an IDU has no used syringes to return). As such, detailed figures were available on the number of sterile syringes going out and the number of used syringes being returned for each day the exchange was operating.
We defined 2 arbitrary time points for assessing the impact of the police effort on the number of syringes being provided. Because we assumed that the number of syringes being provided may be associated with the day of the week as well as with the day of the month, we selected periods of interest that considered 4 7-day periods prior to and after the start of Operation 24/7. In addition, to evaluate the potential for confounding due to seasonal trends in syringe demand, we evaluated the same dates during the year prior.
The average number of syringes distributed in each of the 4-week periods before and after the initiation of Operation 24/7 is shown in Figure 1. As shown, there were a total of 35,539 syringes distributed from the exchange in the 4 weeks prior to the enforcement effort and 26,053 syringes distributed in the 4 weeks after. This amounts to a 26.7% decline in sterile syringes reaching IDUs through this source. When we considered only syringe exchange, excluding loaners, a total of 21,786 syringes were distributed from the exchange in the 4 weeks prior to the enforcement effort and 15,765 syringes were distributed in the 4 weeks after, a 28% decline. In both cases, this decline was statistically significant (both P > 0.001 by paired t test). When we evaluated these same periods 1 year prior, there was no evidence of a similar decline in syringe demand in the relevant periods (P = 0.6 by t test).
Although the ecologic nature of our study is a limitation, our findings are consistent with those of several previous studies suggesting that law enforcement efforts may create a barrier to sterile syringe acquisition when placed in proximity to NEPs. 9,16–18 These findings suggest that policy makers must strive to balance enforcement and public health interventions so as to avoid unintended consequences of police activities, such as increasing HIV risk.
In summary, we have found that the number of syringes reaching IDUs from the only nighttime fixed source of sterile syringes declined by more than 26% during a police operation that was publicly reported to be a success. 15 This may be of particular concern in our setting, given the extensive evidence demonstrating the markedly elevated risk of syringe sharing among IDUs who have difficulty in accessing sterile syringes at night. 7–9 Given that the cost of each case of HIV to the Canadian taxpayer is estimated to be $150,000, 19 it may be that police interventions that reduce access to sterile syringes have major implications for future health care expenditures as well as disease transmission.
Evan Wood, PhD
Thomas Kerr, PhD
Will Small, MSc
Martin T. Schechter, MD, PhD
Mark W. Tyndall, MD, ScD
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