From the *Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD; and †Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Baltimore, MD.
Received for publication June 9, 2003; accepted June 2, 2004.
Funded by the National Institute on Drug Abuse (grant DA09951).
Reprints: Carl A. Latkin, Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management, 624 North Broadway, Baltimore, MD 21205 (e-mail: firstname.lastname@example.org).
Needle exchange programs (NEPs) play a critical role in reducing the spread of HIV infection in injection drug users (IDUs) by providing sterile needles and removing contaminated syringes from the community.1 In addition, many NEPs provide social and medical services and referrals that may improve the health of drug users and result in risk reduction.2 Although NEPs are available in a number of cities throughout the United States, many IDUs refrain from accessing NEPs due to a variety of factors such as geographic distance, policies of the NEP, and law-enforcement policies.3,4
NEPs may compete with or complement other suppliers of needles, including needle sellers. Some of these sellers are secondary exchangers who obtain their needles from NEPs and distribute them in the community.5 Latkin and Forman6 examined needle sources among IDUs in Baltimore, Maryland. In this sample, 51% of injectors reported obtaining needles from the NEP, while only 4% of them reported that the NEP was their only source of needles. Furthermore, the largest source of needles was needle sellers (85%).
Although many IDUs rely on needle sellers for their needles, rather than directly obtaining them at NEPs, research on needle sellers is scarce. In one study, secondary exchangers were indirectly identified by the large quantities of needles from an NEP.7 These satellite exchangers were found to be similar to other needle exchange users in terms of drug use and injection risk behaviors. This study, however, did not examine individuals who give or sell needles that are not obtained at an NEP.
The goal of the current study was to explore the role of needle selling in a drug-using community. Specifically, this study examined how needle sellers differ from others in the drug-using community and assessed the original sources of needles sold by needle sellers, the volume of needles distributed, and the proportion of used syringes distributed. In addition, this study explored factors associated with needle selling.
Data from the Self-help in Eliminating Life-Threatening Disease Study (SHIELD), an HIV prevention intervention, were used for the current project. These data were collected from April 2000 through June 2002. Participants were recruited through targeted outreach in areas with high levels of drug activity in Baltimore. Detailed descriptions of recruitment methodology have been reported previously on the baseline findings.6 The eligibility criteria for this study were as follows: age of 18 years or older; having any type of contact (ie, social, sexual, or drug related) with drug users on at least a weekly basis; willingness to conduct HIV/AIDS outreach education; willingness to bring 2 risk network members (ie, individuals linked directly to the participant by a particular behavior or role) into the clinic; and not currently enrolled in other HIV interventions or network studies. After a brief screening, individuals participated in a baseline interview. Before participation in the study, all eligible individuals provided informed consent, which was approved by the Johns Hopkins School of Public Health's Institutional Review Board.
All data used in the current study were from the second follow-up survey (18 months from baseline), with the exception of race and education (which were collected at baseline). The data presented were collected between April 2000 and June 2002. Source of needles was measured by the question, "Where did you most often get your needles?" Bivariate χ2 tests examined differences in demographic characteristics and drug-related behaviors between needle sellers and nonsellers. Logistic regression was conducted to assess factors associated with selling needles for IDUs.
Comparison of Needle Sellers With Nonsellers
The total sample of SHIELD Study participants used for the current investigation was 991 individuals. Of this sample, ∼8% reported needle selling in the past 6 months. Of the 76 needle sellers, 62 were injectors. Demographic data for needle sellers and nonsellers are shown in Table 1. Data are presented for the total sample as well as injectors only. Compared with participants who did not sell needles, needle sellers were more economically disadvantaged as assessed by homelessness and employment status. In addition, needle sellers were more likely to be infected with HIV than were nonsellers. However, there were not significant differences in demographics between needle sellers and nonsellers in the injectors only analysis.
Needle sellers engaged in drug use behaviors more frequently than did nonsellers (Table 1). Needle sellers were significantly more likely than nonsellers to report using any drug (95% vs. 60%, respectively), inject drugs (82% vs. 29%, respectively), and inject cocaine/speedball daily (53% vs. 25%, respectively) in the past 6 months. In addition, compared with nonsellers, a greater proportion of needle sellers who were injectors reported using drugs at a shooting gallery (34% vs. 18%, respectively) and were more likely to share their needles with their sex partners (34% vs. 24%, respectively) and casual friends (31% vs. 21%, respectively).
The analyses suggest that needle sellers, both the total sample and injectors only, had much greater involvement in the drug economy than nonsellers (Table 1). Significantly higher proportions of needle sellers engaged in selling drugs, steering or touting, holding drugs or money, providing security, injecting others, "copping" drugs for others, and letting people use drugs in their homes (total sample only). In addition, a greater number of needle sellers reported being a proprietor of a shooting gallery and cutting, packaging, or cooking drugs in both total sample and injectors only analyses.
Sources of Needles (Injectors Only)
For both needle sellers and nonsellers, the most common sources of needles were the NEP (92% and 41%, respectively), needle sellers (84% and 83%, respectively), friends or neighbors (47% and 49%, respectively), and people with diabetes (42% and 37%, respectively). Although most needle sellers (61%) reported selling needles they had obtained from the needle exchange, a variety of sources were cited including pharmacy/drug stores (20%), hospitals (3%), patients with diabetes (not self) (12%), and other sources (17%) such as spouses or friends. On average, needle sellers reported selling 45 needles per week. Approximately 95% of needle sellers reported that none of the needles sold in the past 3 months had been previously used. However, 5% of needle sellers acknowledged that some of the needles they distributed were used. It is unclear whether these used needles had been cleaned before distribution (data not shown).
Multivariate Factors Associated With Needle Selling
Multivariate analysis was conducted to identify factors associated with selling needles in the past 6 months. For the whole sample, needle sellers were more likely to have injected drugs in the past 6 months (odds ratio [OR], 6.45; 95% confidence interval [CI], 3.44-12.08). In addition, the likelihood of needle selling increased by 50% with every additional role they played in the drug economy (OR, 1.50; 95% CI, 1.33-1.70). The influence of homelessness, employment status, and HIV status was attenuated after controlling for injection drug use. For injectors only, factors associated with selling needles included obtaining needles from the NEP (OR, 14.30; 95% CI, 5.32-38.48) and having >1 role in the drug economy (OR, 1.28; 95% CI, 1.08-1.15). Needle selling was marginally associated with obtaining needles from a pharmacy/drug store or hospital (OR, 1.93; 95% CI, 0.91-4.09) and using needles at a shooting gallery in the past year (OR, 2.06; 95% CI, 0.91-4.63).
The findings from the current study suggest that needle sellers are more disadvantaged than other drug users. Their lack of resources may be a motivator for their selling needles. Through needle selling, as well as other roles in the drug economy (such as steering and touting), needle sellers frequently interact with IDUs. Thus, needle sellers play a prominent role in the drug-using community and may have a pivotal role in HIV prevention strategies. This study found that most needle sellers do obtain their needles from the NEP. Therefore, needle sellers, as well as other secondary exchangers, could be identified by NEPs and trained in HIV prevention activities, such as promoting safe injection practices. In addition, needle sellers could be provided with risk reduction materials like alcohol pads and sharps containers that could be distributed to injectors. Research has shown that the use of peer educators is an effective strategy for HIV prevention.8
Although almost all of the needle sellers reported that none of the needles they distributed were used, it is important to note that a few individuals did disseminate used needles that may not have been cleaned. Distribution of used needles that have not been appropriately cleaned may lead to transmission of HIV. This finding demonstrates the need for safety seals on needles to ensure that they are sterile. In addition, both needle sellers and nonsellers need to be trained in the proper techniques of needle disposal. Promoting methods of disposal, such as the Red Box Program in Baltimore, or providing injectors with sharps containers are important methods of reducing contaminated needles in the community.9
This study is limited by self-reports and sampling biases. We do not know if the sampling in the present study over- or undercounted the proportion of needle sellers in the drug-using community. Moreover, these analyses did not provide information on needles that needle sellers give away. Many participants reported that they obtained needles from friends or neighbors, rather than needle sellers. This finding suggests that a substantial number of needles originating from the NEP are given away rather than sold by secondary exchangers.
The results from this study suggest that the Baltimore NEP, which operates 6 days a week through 12 sites, is effectively diffusing needles into the community through a range of sources including spouses, friends, neighbors, and needle sellers. Because the demand for needles is so high, the NEP cannot directly provide needles to all injectors but reaches them through secondary exchangers. Needle sellers who obtain their needles from the NEP must bring in used needles to obtain new ones; hence, sellers are reducing HIV transmission by collecting and returning contaminated syringes. Encouraging secondary exchange and training exchangers, including needle sellers, in risk reduction techniques may be effective strategies for promoting safer injection practices among injectors.
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