Syringe Access, Use

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Syringe Access, Use Discard Context in AIDS
Risk Study (NIDA Grant RO1 DA12569, PI
Merrill Singer, PhD)

• Hispanic Health Council, Htfd., CT Tom Stopka,
  MHS, Merrill Singer, PhD, Claudia Santelices,
  ABD, Wei Teng, PhD, Glenn Scott, Susan Shaw, PhD,
  Anna Marie Nicolaysen, MA, Julie Eiserman, M.A.
• Yale Univ. Dept. of EPH Robert Heimer, PhD,
  Kaveh Khoshnood, PhD, Mark Kinzly, Anthony
  Givens, Kevin Irwin, BS
• UMass SPH David Buchanan, DrPH
• New North Citizens Council, Spfd. Antonio
  Arzola
• Spfd. SW Comm. Hlth. Ctr., MA Sabrina Simmons

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Public Health Interventionists, Successful
Capitalists, Harbingers of Risk? Syringe Sellers
in Connecticut and Massachusetts

• Tom Stopka1, Merrill Singer1, Claudia
  Santelices1, Wei Teng1, Robert Heimer2, Susan
  Shaw1, Anna Marie Nicolaysen1, Mark Kinzly2,
  Kaveh Khoshnood2, David Buchanan3, and Glenn
  Scott1
• 1) Hispanic Health Council, Hartford, CT 2) Yale
  University, New Haven, CT 3) University of
  Massachusetts, Amherst, MA

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Need for a New Intervention

• 10 years since any new public health
  interventions have been attempted to reduce HIV
  and Hepatitis transmission among IDUs
• SEP
• OTC sales of pharmacy syringes
• Outreach efforts
• Bridge to treatment programs
• Need a new approach
• Can syringe sellers fill an important harm
  reduction niche?

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Methods

• In-depth Interviews (N25)
• Hartford 20 IDIs with 18 syringe sellers
  Springfield 7 total
• Hartford 13 Latino, 3 AA, 1 white, 1 M.E.
• Springfield 4 PR, 2 AA, 1 white
• Hartford 15 male, 3 female mean age 37
• Springfield 3 male, 4 female mean age
  39
• Syringe sellers difficult to locate in New
  Haven
• Structured surveys with IDUs (N878)
• Ethnographic Observations

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Syringe Source Used Most ) Often, Past 30 Days
(N878)
Categorization of syringe sellers and diabetics
is based on perceptions of IDUs who were
interviewed.
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Rationale for Selling Syringes

• Easy Labor -- I started hanging around on the
  corner right over here ..., and I saw some people
  selling syringes, and selling drugs. I had no
  choice. I dont do no drugs. And the syringes
  were easy to sell. So, I said, hell, that is
  what I am going to do. (Hartford)
• Easy money
• Insurance sourcewouldnt have to go steal
• Less worries with police
• Harm Reduction -- So I got hepatitis C. That is
  why I am selling sterile syringes nowI dont
  want nobody to catch that. (Hartford Seller)

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Typology of Syringe Sellers in Hartford and
Springfield

• Opportunistic Sellers -- I got a box of syringes
  from a friend for a couple of bucks and I sold
  them.
• Bulk Sellers -- I sell about 40-50 syringes a
  day.
• Subcontractors (Hartford) -- I give you 30
  syringes, and what you do is you work this end of
  the street and I work this end of the streetThe
  more you sell, the more money you make. I give
  you 30, you give me 20 and you keep ten

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Clientele

• IDUs who...
• Dont want to be seen at SEP or pharmacy
  (Hartford)
• Want to maintain a low profile
• Find sellers schedule and location more
  convenient
• Male (74) and female (26) IDUs
• Regulars vs. weekend junkies (Hartford)

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Buyers of Underground Syringes, by Race/Ethnicity
(n121)
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IDU Perceptions of Syringe Sellers

• Hierarchy of Risk
• Diabetics (non-IDUs) most trusted sellers.
• I know that she is not a drug user. The other
  sources are drug users and you know, when you are
  a drug user, you say, no I never touched them and
  Im clean. But you know, they aint gonna tell
  you, yeah Ive got HIV, wanna buy these?
  (Hartford IDU)
• ...its just medicine, its not like they
  shooting drugs or anything... (Springfield IDU)
• Alcoholics next most trusted
• Fellow IDUs least trusted as syringe sellers

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Risky Sales

• One time a dude asked me, and I had no
  syringes, and he said he had to get off, I said
  I got a couple of used ones in the drawr, but I
  got Hepatitis, so whatever, I said if I give it
  to you, I am telling you now, you got to clean
  it. (Hartford Seller)

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Economy of Syringes I

• Variations in price
• Sliding scale 1.00 to 5.00 new and used
  pricing variation in Springfield
• Good days vs. bad days -- Sundays are my good
  days. I sell syringes for 2.00. During the
  week I sell for 1.00. (Hartford Seller)
• Beginning of the month is good for sales.
• Availability determines price
• Syringes sold on credit at higher prices

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Economy of Syringes II

• Street sales vs. house sales
• Syringes as currency

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Syringe Prices, by Source and City
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Syringe Sources for Syringe Sellers

• Diabetics self, relative
• Syringe Exchange Program (SEP)
• Pharmacy OTC (Hartford), Rx (Spfd.)
• Injection locales
• Hospital (stealing)
• Underground bulk source?

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Street Selling Strategies

• New Sellers Tengo ganchos
• Experienced sellers word of mouth
• Sales 2 for 1, five for two dollars.
• Referral system with drug dealers
• One stop deal
• Shelter business

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Sales Challenges

• Police
• That (possession of syringes) will get you a
  year in Jail (Springfield)
• New faces
• Syringe inventory depleted quickly
• (especially around 1st of month in Springfield)
• Gangs (Hartford)
• Competition

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Sterility of Syringes Purchased from Syringe
Sellers

• Hartford 0 of 59 syringes tested positive for
  human DNA (new syringes)
• 37.9 originally from SEP
• 8.4 individually wrapped
• Springfield 9 of 76 syringes (11.8) tested
  positive for DNA positive (9 used syringes).
• New Haven 0 of 2 syringes positive
  (outlier-syringe selling seems very rare)

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New Haven

• Most participants were reluctant to talk about
  street sellers.
• IDUs shocked by the thought of repackaged
  syringes.
• 10 years of increased syringe availability
  through SEP and pharmacies.
• Conscious effort by police to shut down syringe
  sellers.
• No Street Peddler tradition.

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Conclusions Syringe Sellers...

• can improve harm reduction efforts by increasing
  access to sterile syringes, filling a gap in
  supply
• may decrease the possibility of IDUs experiencing
  crisis events with syringes
• sell more sterile syringes in Hartford than in
  New Haven and Springfield
• can play an integral part in future HIV and
  hepatitis interventions

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Operationalizing Syringe Sellers as Public Health
Advocates

• Conduct further research about public health
  risks and benefits of street sellers.
• Educate sellers on safe sales practices.
• Advise IDUs on purchase precautions.
• Encourage street sellers to sell/hand out harm
  reduction materials (e.g., water, cookers, etc.).
• Consider creating a formal relationship between
  DPH and street syringe sellers.