Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Tuesday, April 22, 2008

Needle Exchange Programs: An Unrealistic Approach to Decreasing Rates of HIV/AIDS – Elyssa Pesin

The HIV/AIDS Epidemic
Human Immunodeficiency Virus (HIV), the virus that causes AIDS, attacks the immune system, leaving the body vulnerable to a variety of life-threatening infections and cancers [1]. This devastating disease is the focus of many public health interventions in the United States, especially among intravenous drug users (IDUs), a recognized risk group. Nevertheless, current efforts are inadequate to address the complex risks associated with injection drug use, particularly among disadvantaged populations [2]. The nature of intravenous drug use, specifically the process of preparing and injecting drugs, is conducive to the spread of HIV. As the CDC reports, “many opportunities for contamination with and transmission of HIV or other blood-borne viruses” exist among IDUs, due to the mechanics of drug injection [3].

Introduction: A Public Health Intervention
Needle Exchange Programs (NEPs), in which IDUs exchange dirty needles for clean replacement needles, are intended to be a critical strategy for containing the spread of HIV and other blood-borne diseases within this population. However, issues relating to social and behavioral sciences, differences in socioeconomic stratum and sociopolitical issues contribute to the failure of implementation in the United States. Contrary to the 1980’s United States Drug Campaign known as the “war on drugs,” using the slogan “Just say no,” the NEPs’ ideology is based on “Just say yes,” as these programs prioritize HIV/AIDS prevention over reducing drug use.
In a social and behavioral context, the Health Belief Model (HBM) was developed to explain health-related behavior at the individual, decision-maker level. The focus of this model is preventative health behavior of individuals, assuming that human behavior is determined by an objective, logical thought process. HBM includes four concepts: “perceived susceptibility,” “perceived severity,” “perceived barriers to taking that action,” and “perceived benefits of an action” [4]. With regard to NEPs, the former three concepts are skewed and lead to NEP failures. First, instead of realizing that the perceived susceptibility of drug use is the chance IDUs will overdose, develop neurological problems, or acquire multiple chronic and acute illnesses, the perceived susceptibility is the realization that IDUs could only contract HIV/AIDS through dirty needles. Second, IDUs overlook the perceived severity, that is, how severe the effects of transmitted diseases might be, as they continue to use drugs and reject other ways blood borne diseases are transmitted - through sexual contact [5]. Lastly, the perceived barriers and costs of emotionally and financially supporting drug use are overlooked by NEP creators and supports. Interestingly, NEPs use an HBM limitation to their advantage – that is, if drug users have the intent to do a particular behavior, they will do it. Thus, NEPs are structured around the susceptibility to HIV/AIDS and the perceived benefits of preventing the transmission of the disease through shared needles.
By expecting drug-users to seek out these programs on their own using undersupplied and underprovided distribution methods and providing limited geographic locations, needle exchange programs fail to decrease HIV/AIDS through shared needles within the IDU population. More specifically, failures of NEPs can be seen in their inability to reach many drug users due to geographic disparities, broad target populations, and limited distribution strategies.

Reason for Failure #1 – Geographic Disparities
Failures of NEPs are attributed to several different models of social and behavioral science. First, the Stages-of-Change model applies to IDUs who utilize NEPs, who realize they engaged in drug use, who contemplated the risks of intravenous use, and who decided to address those risks by participating in a needle exchange program. Nevertheless, the “action” and “maintenance” stages of change in NEPs, where individuals begin to engage in a new behavior and attempt keep that pattern going or sustain the new behavior respectively, is flawed [6]. This relates to an IDUs use of NEPs, as research shows there are inconsistencies in location, equal distribution of supplies, and accessibility [7]. As a result, IDUs are not able to engage in and maintain this new behavior consistently. Herein lies the first problem: NEP geographic disparities.
Geographic disparities in access to NEPs present clear difficulties to program utilization. Indeed, NEP locations do not always correspond to a demand for such a program in the area. In 1999, a study reported the existence of NEPs in 81 cities and 31 states as well as the District of Columbia. The study concluded that many of these programs were heavily concentrated in four states: California, New York, Washington, and New Mexico. Yet, data suggest that New Jersey – a state with high demand for NEPs –disproportionately lacks in access to these programs [8]. As Barbara Tempalski reports, “injection drug use is the most frequent reported risk behavior among HIV-positive individuals” in New Jersey, and in Jersey City, Newark, and Bergen-Passaic have some of the highest rates of IDU related AIDS in the country [9].
Even within existing NEPs, inequalities in supplies inhibit the efficacy of these programs; twelve of the largest programs, for example, receive 62 percent of available syringes, leaving other NEPs without adequate supplies [10]. The unequal distribution of NEPs and NEP-related resources do not address disparities in HIV prevalence among socially disadvantaged groups or the geographical distribution of IDUs.
One last social and behavioral theory can be attributed to the first reason for NEP failure. The last several stages of the Diffusion of Innovations (DOI) theory are interrupted, as the NEP geographic and inventory shortages prohibit the success, wider implementation, and unrestrained use of this public health intervention. Within the DOI theory, the “adoption process,” is affected by insufficient locations, supplies, and geographic representation, prohibiting the “uptake” of the behavior by IDUs. According to this principle, “uptake” requires movement through knowledge of NEPs, persuasion or attitude development (about adopting behavior), decision (to adopt behavior), implementation, and confirmation, and none of these steps can occur, as NEPs fail to be equally accessible or sufficiently equipped [11].

Reason for Failure #2 – Broad Focus
Two additional social and behavioral principles can be applied to a second reason for NEP failure. On one hand, the success of NEPs relies largely on selecting a target population, where IDUs among different socioeconomic strata are the targets. The widespread use of the intervention relies on these social groups or networks to communicate the benefits of the program. On the other hand, failure to account for the “political economy,” which has an important bearing on why and how people do what they do, and consequently, how people change what they do, affects the efficacy of NEPs [12]. Both political economy and behavior are factors that must be addressed when assessing the inadequate and very broad focus of NEP interventions as it contributes to the crisis of HIV/AIDS in poor, urban communities. Because HIV/AIDS has such a disproportionate effect on poor, minority, and urban communities, NEPs are suffering because they frame HIV/AIDS as just a health problem, rather than the product of a larger set of social relationships, particularly relationships of socioeconomic structure, class, ethnicity, and gender [13]. Consequently, the NEP failure is rooted in its very broad focus, as they do not take into account the aforesaid larger set of social and political relationships.
Despite drug regulation, illegal drug use continues among the underserved and the needs of those who seek prevention or treatment have not been met. As Dr. Adewale Troutman states in his on-line tutorial Creating Health Equity Through Social Justice, “the existence of social injustice typified by the continued growth of the gap between the have and the have-nots, lack of access to services and care, preventive and curative is unethical and immoral” [14]. This inequality is ever-present among IDUs. According to Richard Hofricter, although overall life expectancy has increased and mortality rates have decreased in the twentieth century, “an increasing level of inequality in the health status and mortality of those with less material resources in relation to their social class, particularly in ‘communities of color’ persists” [15]. Moreover, disadvantaged groups do not benefit equally from advances in HIV and AIDS intervention, treatment and prevention.
While the HIV/AIDS epidemic has had a disproportionate impact on certain populations, particularly racial and gender minorities, NEPs do not effectively narrow their focus among these groups. Within the IDU population, disadvantaged groups are especially vulnerable to HIV infection. In certain racial and ethnic groups, half of the deaths due to HIV in both African American and Latino populations can be attributed to injections with contaminated needles. Furthermore, African American IDUs are 5 times as likely, and Latinos are 1.5 times as likely as white IDUs to develop AIDS [16]. These statistics highlight the limitations in the breadth of NEP, as programs do not have specific strategic plans to reach each group.
The African American experience portrays an obstacle that NEPs do not address or overcome with regard to ethnicity. African Americans are increasingly vulnerable to the transmission of HIV/AIDS. With this, another social and behavioral principle accounts for the larger HIV/AIDS cases in this group: the Social/Environmental Context, and more specifically within this context, the Historical Context. Historically, African American communities have greatly opposed NEPs as a consequence of their distrust of the government and medical trials in general. According to Stephen Thomas, African Americans’ adverse response to NEPs is connected to the “persistent neglect of the drug abuse epidemic, mistrust of public health authorities, and fear that the broader society may consider large segments of the black population expendable consumers of scarce human and economic resources” [17]. Many of these opponents worry that needle exchange programs will ultimately lead to Tuskegee-like abuse of research subjects [18]. Within many African American communities, NEP initiatives are held in high suspicion due to historic exploitation and discrimination [19]. With these factors, one can observe that throughout various segments of the American public, NEPs prove controversial. This Social/Environmental Context is relevant, as the Tuskegee-mentality is shared across this group, contributing to an African American experience made up of historical influence and personal experience interacting with the environment that inhibits this group from utilizing NEPs [20]. The failure of NEPs in this group is rooted in the history of the African American experience for which NEPs do not account.

Reason for Failure #3 – Methods of Distribution and Legal Implications
A third reason for the failure of NEPs lies in their distribution strategies, which are neither private nor anonymous. When using NEPs, IDUs must make themselves publicly available to the needle “exchanger” and must make behavioral changes through regular needle exchanges. For this reason, there is a great deal of social and personal responsibility, motivation and social and personal acceptance of help. The two primary methods of delivery are fixed NEPs located in pharmacies or health and community centers and NEP vans that drive through areas with known groups of IDUs [21][22]. Both of these methods of delivering exchange services require IDUs to seek out needle-exchange programs, which deter many from utilizing them. For this reason, drug-users typically refrain from using NEPs, consequently transmitting disease.
Many states have opted to utilize pharmacies in addition to local community centers to allow IDUs to obtain sterile syringes if businesses choose to participate. Nevertheless, while the pharmacy model has been shown to dramatically reduce the risk associated with IDU, not all geographic areas have benefited from these programs. For example, in New York, it is legal for pharmacies and other organizations to register and to provide up to ten syringes to individuals over the age of eighteen without prescriptions [23]. However, many pharmacists have refrained from participating in such services due to personal beliefs of fear that the presence of IDUs are detrimental to their businesses [24]. Moreover, the exchange of syringes in this model is not necessarily free, so many IDUs are unwilling or unable to participate [25]. For this reason, implementation of the pharmacy exchange model has been piecemeal and inadequate, contributing to the failure of NEPs in pharmacies.
Mobile exchange services are the second method of distribution which intend to reach more drug users. These mobile programs, which have predetermined van routes, are interventions for including hard-to-reach individuals and those who do not typically access mainstream services. For instance, an analysis of a 1997 Baltimore program revealed that mobile services attracted twice as many high-frequency injectors as pharmacy programs [26]. Furthermore, a study of the Vancouver program, which consisted of a variety of different facilities, reported that 65 percent of participants obtained some of their needles from the van and 17 percent used the van as their main needle source. Typically, users of this mobile exchange injected more frequently, were younger, more likely to engage in prostitution, and less likely to enroll in a drug treatment plan [27].
The mobile exchange model, whose intention is to reach those who are unable to access participating pharmacies, has several limitations [28]. First, the mobile programs offer fewer opportunities for counseling and other educational service, as the mobile programs do not afford lengthy time intervals during which the staff and clients can interact. Second, in the case of the San Diego, California NEP, IDUs refrained from visiting this site because legislation fails to protect IDUs from state laws prohibiting the transport of drug paraphernalia. In fact, reports confirm that law enforcement officers wait outside NEPs and arrest individuals suspected of carrying syringes [29]. Two social and behavioral theories, the Social Cognitive Theory and more specifically the Social/Environmental Context applies to the existing laws pertaining to drug paraphernalia in each state [30]. Drug paraphernalia laws, which exist in all states except Alaska, hinder the sale, distribution, purchase, and possession of syringes. In fact, 20 states have drug paraphernalia laws that are used against IDUs who possess a syringe [31]. Additionally, pharmacies may implement their own requirements and regulations that inhibit access [32]. The fear that this regulatory environment and existingpolicies instill in IDUs prevents them from accessing either method of distribution, even though the presence of these programs is acceptable. A third theory known as Political-Economic Space - a space that is governed by a specific political system, with regulations, values, and procedures –applies to the existing regulations and laws that affect health [33]. In this framework, many states, even those that support NEPs, continue to restrict the sale of syringes to pharmacies and require IDUs to have a prescription, provide valid identification, or disclose their reasons for purchasing the syringe [34]. This barrier to access is associated with the Political Economy, as NEPs encompass a wide range of theory and history about the links between politics and behavior, and their functions in society [35]. While NEPs focus on reducing disease transmission through sharing needles among IDUs, NEPs have failed to address the legal implications of the program such that the legal framework and Political Economy deter users for fear of identification and police harassment.
The lack of anonymity in these two methods of distribution makes IDUs vulnerable to the ever-present legal and regulatory barriers to access and to possess sterile syringes. Barriers include: drug paraphernalia laws, syringe prescription laws (both of which place restrictions on syringe exchange programs), pharmacy regulations and practice guidelines, fear of identification and police harassment - presenting obstacles to participation and decreased disease transmission. Further, the fear instilled in IDUs is largely derived from a Social Cognitive Theory known as Reciprocal Determinism, in which a person acts based on individual factors and social environment cues, receiving a response from that environment, and adjusting behavior accordingly [36]. In this fashion, IDUs act based on their personal responsibility and motivation to use NEPs, but ultimately react to the negative “cues,” that is regulation and punishment for attempting to use this intervention. Lastly, the concept of Self-Efficacy applies, as IDUs’ past experiences with NEPs will affect whether they are motivated to use this intervention. IDUs with low Self-Efficacy regarding NEP use may feel more hesitation, and when they actually use the program, may be reluctant to use it for fear of being punished. Once IDUs feel comfortable and confident in their chosen NEPs, this sense of Self-Efficacy may help the IDU continue this intervention and spread the word about NEPs in their networks [37].

NEP programs, meant to decrease HIV/AIDS transmission, are unsuccessful not only structurally, but also for reasons surrounding social and behavioral sciences, socioeconomic strata, and sociopolitical issues. More specifically, NEPs fail to address their geographic disparities, political patterns, and relationships of ethnicity that contribute to the efficacy of this intervention. This intervention fails to identify groups of IDUs on which to focus their strategies, as the target population is much too large to see positive results, that is, a decrease in HIV/AIDS transmission. After this assessment, it is clear that HIV/AIDS affects a wide-ranging population of potential NEP users who, in one form or another experience barriers to access.

1. Centers for Disease Control and Prevention. Prevention Among Injection Drug Users. US Department of Health and Human Services, January 2007. Date accessed: 27 Mar 2008
2. Ibid.
3. Ibid.
4. Rosenstock, Irwin M. Ph.D. Historical Origins of the Health Belief Model. Health Education Monographs 2 (4): 328-335, 1974.
5. Centers for Disease Control. op.cit.
6. Prochaska JO, Reding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education, 3rd ed. San Francisco, CA: John Wiley & Sons; 2002.
7. Centers for Disease Control and Prevention. Epidemiology of HIV/AIDS—Unites States, 1981- 2005. Morbidity and Mortality Weekly, 55(21):589–592, June 2006.
8. Robert E. Fullilove and Mindy Thompson Fullilove. HIV/AIDS in the African American Community: The Legacy of Urban Abandonment.
9. B. Tempalski, P.L. Flom, S.R. Friedman, D.C. Des Jarlais, J.J. Friedman, C. McKnight, and R. Friedman. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. American Journal of Public Health, 97(3):437, 2007.
10. M.P. Singh, C.A. McKnight, D. Paone, S. Titus, D.C. Des Jarlais, M. Krim, D. Purchase, J. Rustad, and A. Solberg. Update: Syringe Exchange Programs–United States, 1998. Morbidity and Mortality Weekly Report, May, 18:384–87, 2001.
11. Rogers EM. Diffusion of Innovations, 4th ed. New York: Free Press; 1995.
12. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 72.
13. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall;
14. Adewale Troutman. Creating Health Equity Through Social Justice. Satellite broadcast originally aired February 20, 2003.
15. R. Hofrichter. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease. Jossey-Bass, 2003.
16. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US Department of Health and Human Services, 2004.
17. S.B. Thomas and S.C. Quinn. The Burdens of Race and History on Black Americans’ Attitudes toward Needle Exchange Policy to Prevent HIV Disease. Journal of Public Health Policy, 14(3):320–347, 1993.
18. Ibid., p337
19. Ibid., p343
20. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 52.
21. Institute of Medicine of the National Academies. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. The National Academies Press, 2006.
22. Riley E.D., M. Safaeian, S.A. Strathdee, M.A. Marx, S. Huettner, P. Beilenson, and D. Vlahov. Comparing New Participants of a Mobile Versus a Pharmacy-Based Needle Exchange Program. JAIDS Journal of Acquired Immune Deficiency Syndromes, 24(1):57–61, 2000.
23. Institute of Medicine of the National Academis. op.cit.
24. Institute of Medicine of the National Academis. op.cit.
25. Institute of Medicine of the National Academis. op.cit.
26. Riley, E.D. op.cit. p59.
27. M.W. Tyndall, J. Bruneau, S. Brogly, P. Sptal, M.V. O’Shaughnessy, and M.T. Schechter. Satellite Needle Distribution Among Injection Drug Users: Policy and Practice in Two Canadian Cities. JAIDS Journal of Acquired Immune Deficiency Syndromes, 31(1):98–105, 2002.
28. Riley, E.D. op.cit. p60.
29. Kaiser Family Foundation. Syringe Exchange and AB 136: The Dynamics of Consideration in Six California Communities, February 2002. Pub 6018.
30. Bandura A. Social Cognitive Theory: an agentic perspective. Ann Rev
Psychol. 2001;52:1-26.
31. T.S. Jones and P.O. Coffin. Preventing Blood-Borne Infections Through Pharmacy Syringe Sales and Safe Community Syringe Disposal. Journal of the American Pharmacists Association, 43:6–9, 2002.
32. Ibid., p 6-9.
33. Edberg, Mark. op. cit. p52.
34. Ibid., p52.
35. Ibid., 72.
36. Bandura A. The Self System in Reciprocal Determinism. Am Psychol. 1978; 33:344-358.
37. Bandura A. Social Learning Theory. op. cit.

Labels: , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home