CASE STUDIES OF PUBLIC HEALTH RESEARCH THAT HAVE ALTERED PUBLIC POLICY THE NEW HAVEN SEP EVALUATION

HIV-1 TRANSMISSION AMONG IDUs l Behavioral risk factors include:  Syringe sharing  Shooting gallery attendance  Sharing drugs l Behavioral risks are driven by societal factors.  Fear of arrest  Aversion to withdrawal  Scarcity of syringes

HISTORY OF SYRINGE EXCHANGE l Syringe exchange began in Holland in response to a hepatitis outbreak. l It is impossible to say when syringe exchange first began in the US. l The first openly operating initiative began in Tacoma in 1988.

WHY A SYRINGE EXCHANGE PROGRAM IN NEW HAVEN l In contrast to national data, 70% of AIDS cases in New Haven could be attributed to injection drug use.

ESTABLISHING THE SEP IN NEW HAVEN, CONNECTICUT l The city established a task force to seek solutions to the AIDS epidemic that lobbied for three years ( ) to change the laws to start a SEP.  By statute, customers could exchange no more than five syringes in a strict one-for-one fashion.  A evaluation report had to be produced and issued within one year. l The SEP, operated by the city health department, opened on November 13, 1990.

EVALUATING THE NEW HAVEN SEP l Minimize reliance on self-reported data. l Investigate the link between the operations of the program and its effects. l Maintain the anonymity of the participants. l Provide a timely analysis that measures the program's effectiveness.

SYRINGE TRACKING AND TESTING l All outgoing syringes coded and exchanges recorded. l All returned syringes recorded in second database. l Nearly 50,000 syringes exchanged in first three years of the SEP. l Approximately one-tenth of all returned syringes tested for presence of blood from HIV-1 infected individual.

SEP FOUND TO PREVENT NEW HIV INFECTIONS l The testing data were used to generate two models to estimate the HIV incidence rate. l The first, an ecological model, assumed that in the absence of exchange previously used syringes will be used at random. l The second, a changepoint model, assumed that sequential testing of syringes returned by individuals yields reliable longitudinal data.

MODEL 1: TRANSMISSION OF SYRINGE-BORNE INFECTIONS  x  x   Incidence is equal to the rate at which an uninfected injector uses a potentially infectious syringe without first disinfecting it times the rate which the exposure results in infection.

THE TWO MODELS INCIDENCE ESTIMATES BASED ON THE TWO MODELS l Using model 2, the most likely incidence rate was estimated at 1.6% per year, less than half the estimate from model 1.

EFFECT OF SEP EVALUATION ON POLICY IN CONNECTICUT l In 1992, the state government reviewed the findings and  Removed the “demonstration” status.  Increased syringe exchange limit from 5 to 10 syringes per visit.  Added five new SEPs in other cities.  Allowed syringes to be purchased from pharmacies. l In 1999, the state again increased the limit on syringes from 10 to 30 per visit.

EFFECT OF SEP EVALUATION ON POLICY IN OTHER STATES l Neighboring states of New York and Massachusetts legalize SEPs. l California legislation cites New Haven studies. l Only three states continue to keep SEPs illegal. HIV Prevalence among IDUs in New York City following SEP Legalization

EFFECT OF SEP EVALUATION ON FEDERAL GOVERNMENT POLICY l U. S. government reports repeatedly certify that New Haven evaluation clearly demonstrated that SEPs can reduce HIV transmission among IDUs. l Nevertheless, Congress refuses to change law that makes federal funding of SEPs illegal. l U. S. continues to seek international disapproval of syringe exchange.