International Journal of Drug Policy 14 (2003) 361–363

Response
What is it about needle and syringe programmes that make
them effective for preventing HIV transmission?
Alex H. Kral a,∗ , Ricky N. Bluthenthal b
a Urban Health Studies, Department of Family and Community Medicine, University of California, San Francisco,
3180 18th Street Suite 302, San Francisco, CA 94110, USA
b Drug Policy Research Center, Health Program at RAND, and Drew Center on AIDS Research,

Education, and Service, Department of Psychiatry, Charles R. Drew University, USA

Received 1 December 2002; received in revised form 15 March 2003; accepted 24 July 2003

In this issue of the International Journal of Drug Policy,
MacDonald, Law, Kaldor, Hales, and Dore (2003) present
data from an ecological study of the effectiveness of sy-
ringe exchange programmes (SEPs) in preventing HIV
transmission among injection drug users (IDUs) globally
(MacDonald et al., 2003). Their study found that within
99 cities internationally, HIV prevalence among IDUs de-
creased significantly in cities with SEPs as compared to
cities without SEPs. This confirms findings from similar
ecological studies conducted in the past decade (Friedman,
Perlis, & Des Jarlais, 2001; Hurley, Jolley, & Kaldor, 1997;
Lurie & Drucker, 1997). Ecological studies of the impact
of SEPs and syringe access are amongst the most pow-
erful research tools available as they allow us to assess
community-level effectiveness of interventions. However,
there are also several limitations to the use of ecological
studies. Most noteworthy is that they often rely on data col-
lected for purposes other than studying the specific research
question being posed (Kleinbaum, Kupper, & Morgenstern,
1982). This often prohibits the use of key confounding
and effect modifying variables, making it difficult to assess
whether the observed relationship between exposure and
outcome is spurious. For example, MacDonald et al. (2003)
study does not control for community or SEP operational
factors.
While numerous studies have examined SEP effective-
ness in preventing HIV transmission, few have studied how
community context and SEP operational factors have an im-
pact on effectiveness. Several community contextual factors
are likely to affect SEP effectiveness (Table 1). It may be
that SEPs are more effective in certain types of communi-
∗Corresponding author.
E-mail address: alkral@itsa.ucsf.edu (A.H. Kral).
ties than others, or that SEPs with certain operational char-
acteristics are more effective in certain communities. It is
important for researchers to study what types of SEPs are
most conducive to stemming HIV transmission in different
community contexts. Thus, it is crucial that studies of SEPs
collect community contextual factors and report and control
for them in analyses.
Recent reviews of SEP studies suggest that inattention to
SEP operational characteristics have biased interpretations
of programme effectiveness (Bastos & Strathdee, 2000;
Heimer, 1998). Indeed, the current literature on SEPs does
not identify operational characteristics associated with opti-
mal HIV risk reduction among clients (Bastos & Strathdee,
2000; Des Jarlais, 2000). There are numerous operational
characteristics of SEPs that may affect their ability to prevent
HIV transmission (Table 2). According to the 1998 Beth
Israel/North American Syringe Exchange Network Annual
Programme Survey, U.S. SEPs differ on nearly every as-
pect of their operations except supplies (over 90% of SEPs
provide condoms, alcohol pads, bleach) (Center for Disease
Control, 2001). For instance, location of SEP sites includes
health vans, health clinics, shooting galleries, cars, side-
walk tables, and staff on foot. Most SEPs operate fixed
site exchange with between 6 and 18% of programmes
providing mobile syringe exchange or some other site
types not listed by the authors. In terms of syringe distri-
bution protocols, 27% of SEPs are strict one-for-one pro-
grammes while 73% provide either one-for-one plus extra
syringes or conduct distribution based on need (Centers for
Disease Control, 2001). Also, 16% of SEPs limit the num-
ber of syringes exchanged per visit. On-site HIV testing was
reported by 70% of programmes, but HBV, HCV testing
and counselling was provided by only 21 and 24% of SEPs,
respectively. Further, only 19% of SEPs provided on-site
medical care, 18% provided HBV vaccination, 15% pro-

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362 A.H. Kral, R.N. Bluthenthal / International Journal of Drug Policy 14 (2003) 361–363

Table 1
Community contextual factors likely to affect effectiveness of SEPs
Background HIV prevalence and incidence among IDUs (Kaplan and Heimer, 1994)
Sexual mixing patterns between IDUs and other groups with high HIV prevalence (e.g. men who have sex with men) (Friedman et al., 2001)
Drug (e.g. heroin, cocaine) (Bourgois, 1999) and form of drug being injected (e.g. black tar vs. white powder heroin) (Ciccarone & Bourgois, in press)
Syringe prescription and possession laws (Bluthenthal, Kral, Erringer, & Edlin, 1998; Burris, Finucane, Gallagher, & Grace, 1996)
Pharmacy sale of syringes (Taussig, Junge, Burris, Jones, & Sterk, 2002)
Law enforcement practices (Bluthenthal, Kral, Lorvick, & Watters, 1997)
Urban/suburban/rural location (Anderson et al., 2002)
Syringe coverage of programme (Bastos & Strathdee, 2000)

Table 2
Operational characteristics of SEPs likely to affect effectiveness of SEPs
Syringe distribution policy (e.g. one-for-one, one-for-one plus some extra, need-based distribution) (Kral et al., 2002)
Syringe limits (e.g. no more than 30 syringes can be exchange at one time)
Geographical coverage
Fixed vs. mobile and delivery service (Kral et al., 2002)
Inside vs. outside fixed sites
Number of hours open
Days of the week and time of day of operation
Ancillary services offered (e.g. medical care, methadone treatment, HIV testing and counselling)
“Harm reduction” philosophy of staff (Bluthenthal, Anderson, Flynn, et al., 2002)
Cultural appropriateness of staff
Type and variety of syringes/needles offered
Non-syringe drug paraphernalia offered

vided TB screening, and 13% provided sexually transmitted Acknowledgements

disease screening. On-site services varied by programme
size with very large programmes reporting a median of seven
services as compared to two to three services being offered
by large, medium, and small programmes. Despite this vari-
ety, very little research has been conducted on the impact of
differences in operational characteristics on client HIV risk
behaviours. Researchers should study which operational
characteristics are optimal for which types of communities.
Ecological approaches have been used to address a num-
ber of other issues related to SEPs, including their impact on
drug use among youth (Marx, Brahmbhatt, Beilenson, et al.,
2001), criminal activity (Marx, Crape, Brookmeyer, et al.,
2000), and biohazardous waste disposal (i.e. used syringes)
(Doherty, Garfein, & Vlahov, 1997). While few existing data
sources provide relevant information on community context
or SEP operational factors, researchers can improve on ex-
isting ecological studies by combining secondary analysis of
data (e.g. HIV prevalence) with primary data collection. For
example, Friedman and colleagues are currently conduct-
ing an ecological study combining data from Holmberg’s
study of HIV prevalence and incidence in 96 U.S. metropoli-
tan areas (Holmberg, 1996) with primary collection of vari-
ous community contextual and SEP operational informations
(Tempalski et al., 2003). Likewise, we are currently in the
last phases of data collection of SEP operational character-
istics and individual-level HIV risk and prevalence among
clients of all SEPs in California. Now that there is little
question of the effectiveness of such programmes, hopefully
new research efforts will help guide public health workers
in their decisions about where and what type of SEPs to
implement in their communities.
Writing of this editorial was supported by the Centers
for Disease Control (Grant # R06/CCR918667) and NIDA
(Grant # R01 DA14210).
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