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

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

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 approachCan syringe sellers fill an important harm reduction

niche?

MethodsIn-depth Interviews (N=25):

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 (N=878)Ethnographic Observations

Syringe Source Used Most ) Often, Past 30 Days (N=878)

0

10

20

30

40

50

60

70

Hartford(n=328)

Springfield(n=300)

New Haven(n=250)

SEPPharmacySyringe SellerDiabetic

Categorization of syringe sellers and diabetics is based on perceptions of IDUs who were interviewed.

Rationale for Selling SyringesEasy 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 don’t 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 source…wouldn’t have to go steal…”“Less worries” with police Harm Reduction -- “So I got hepatitis C. That is why I am

selling [sterile syringes] now…I don’t want nobody to catch that.” (Hartford Seller)

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 street…The more you sell, the more money you make. I give you 30, you give me $20 and you keep ten…”

ClienteleIDUs who...

Don’t want to be seen at SEP or pharmacy (Hartford)Want to maintain a low profileFind seller’s schedule and location more convenient

Male (74%) and female (26%) IDUs

Regulars vs. “weekend junkies” (Hartford)

Buyers of Underground Syringes, by Race/Ethnicity (n=121)

0

10

20

30

40

50

60

70

80

Hartford Springfield New Haven

African AmericanWhiteLatino

IDU Perceptions of Syringe SellersHierarchy 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 I’m clean. But you know, they ain’t gonna tell you, yeah I’ve got HIV, wanna buy these?” (Hartford IDU)

“...it’s just medicine, it’s not like they shooting drugs or anything...” (Springfield IDU)

“Alcoholics” next most trusted

Fellow IDUs least trusted as syringe sellers

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 draw’r, 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)

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

Economy of Syringes II

Street sales vs. house sales

Syringes as currency

Syringe Prices, by Source and City

$1.501.471.42

3.67

2.68

$0.87

1.72

1.22

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

Hartford Springfield New Haven

PharmacySyringe SellerDiabetic

Syringe Sources for Syringe Sellers

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

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

Sales Challenges

Police: “That (possession of syringes) will get you a year in

Jail” (Springfield)

New facesSyringe inventory depleted quickly

(especially around 1st of month in Springfield)

Gangs (Hartford)Competition

Sterility of Syringes Purchased from Syringe Sellers

Hartford: 0 of 59 syringes tested positive for human DNA (new syringes)37.9% originally from SEP8.4% 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)

New HavenMost 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.

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

•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.