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Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas I Barbara Tempalski, PhD, MPH, Peter L, Flom, PhD, Samuel R, Friedman, PhD, Don C, Des Jariais, PhD, Judith J, Friedman, PhD, Courtney McKnight,

MPH, and Risa Friedman, MPH

Community activism can be important in shaping public health policies. For ex- ample, political pressure and direct action from grassroots activists have been cen- tral to the formation of syringe exchange programs (SEPs) in the United States,

We explored why SEPs are present in some localities but not others, hypothesizing that programs are unevenly distributed across geographic areas as a result of po- litical, socioeconomic, and organizational characteristics of localities, including needs, resources, and local opposition. We examined the effects of these factors on whether SEPs were present in different US metropolitan statistical areas in 2000,

Predictors ofthe presence of an SEP included percentage ofthe population with a college education, the existence of local AIDS Coalition to Unleash Power (ACT UP) chapters, and the percentage of men who have sex with men in the population. Need was not a predictor, {Am J Public Health. 2007;97:437-447, doi:10,2105/AJPH,2005,065961)

In,the United States, injection drug users ac- count for about one third of all AIDS cases' and nearly two thirds of new hepatitis C cases,̂ Syringe exchange programs (SEPs), in which injection drug users exchange used sy- ringes for sterile ones, can address potentially rapid increases in rates of HIV infection in this population. If sufficient numbers of sterile sy- ringes are supplied, users can inject with a new syringe each time, dramatically redudng, if not eliminating, sharing with others because of an inadequate supply. This should then reduce HIV transmission among injection drug users,''

SEPs are accepted as essential components of HIV and hepatitis C prevention in many parts of the world. The United States is a stark exception. Since 1988, the federal gov- emment has withheld funding for SEPs con- tingent on evidence that they reduce the transmission of blood-borne disease without encouraging injection drug use (IDU),"* De- spite the lack of support at the federal level, numbers of exchanges and numbers of sy- ringes exchanged have increased consider- ably over the past 15 years. As of November 2006, according to the North American Sy- ringe Exchange Network, more than 190 SEPs were known to be operating in 36 states, the District of Columbia, and Puerto Rico and on American Indian lands.'

Although public health authorities may support SEPs, meiny states and localities have been reluctant to authorize them. This political situation, however, is not unique. Historically, politics has been a pivotal factor in intensifying both the spread®'̂ and preven- tion '̂̂ of disease. Social movements have shaped public health policies in the United States, France, Great Britain, and Can- ada,'""" The "great sanitary movement" dur- ing the mid-19th century in Britain, for ex- ample, was driven chiefly by local activists appcilled by the living and working condi- tions of the urban poor* Social movements ranging from the feminist health movement to AIDS activism have restructured many health-related issues, including treatment services, health care reform, AIDS policy, and the destigmatization of groups such as injection drug users,'"*""

At present, the controversy over the forma- tion of SEPs in the United States represents a compelling example of the politics of disease and illustrates how struggles over health care access bring underlying conflicts to the sur- face. Although SEPs remain controversial and continue to face obstacles from the federal govemment and state governments, they also continue to gain support as a method of re- ducing hfinn among injection drug users.

Some ofthe first SEPs in the United States were established by activists on their own initiative, and some of these programs later gained legitimacy and funding from local city govemment and public health programs. Cur- rently, more than half of the country's SEPs are nongovemmental programs established by independent local actors,'*

Sodal and political processes are important determinants of sodal change and actions that affect health policy, epidemiology, and preven- tion services. We explored the effects of place characteristics, including need for services, local resources, community opposition, and grassroots politiceil action, on the geographic availability of SEPs in the United States,' We defined "place" as the set of sodal, political, and geographic relations that create a spatial context in which differential responses to IDU- related HIV infection are structured. Drawing on the broader health, social, and political ge- ography literature, we identified place charac- teristics that affect spatial variation in SEPs,

We hypothesized that the uneven geo- graphic distribution of SEPs in the United States can be attributed to the particular polit- ical, sodoeconomic, and organizational char- acteristics that affect local service needs, re- sources, and opposition. Using data from the 2000 Beth Israel National Survey of Syringe Exchange Programs,'^ we examined the ef- fects of program need, political factors, and socioeconomic and organizational characteris- tics on the presence of SEPs,

ACTIVISM, POLITICS, AND OPPOSITION TO SYRINGE EXCHANGE PROGRAMS

A struggle exists in the United States be- tween law enforcement and medical provid- ers as to whether drug users should be de- fined as criminals or medical patients. One effect of this struggle is that the United

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States has been the historical leader in law enforcement and abstinence-based ap- proaches to illicit drug use,^" which has fu- eled stigmatization of services aimed toward injectors. From this perspective, potential or organized opposition to SEPs in the United States assumes several forms.

The first form of opposition is institutional opposition, including opposition from district attorneys, politicians, police officials, and beat officers,̂ ''̂ ^ and legal opposition through the enactment of state and local legislation such as drug paraphernalia laws and laws banning over-the-counter sale of syringes,^^ The sec- ond form is community opposition, including opposition organized by clergy and neighbor- hood or business associations and opposition from within particular sectors of minority communities (e,g,, African American clergy and politicians) to syringe exchange and methadone maintenance programs. '̂'"^^ The third form is negative media portrayals of in- jection drug users and services designed to help them (D, Purchase, Point Defiance AIDS Projects, oral communication, June 2002),^^

These forms of opposition are neither mu- tually exclusive nor static, A change in opposi- tion from one source (e,g., local political lead- ership) can affect support from others. Thus, resistance to SEPs does not exist in isolation. In fact, the most hannfui opposition usually involves a combination of different players,

A community's support of or opposition to the establishment of an SEP may depend on its residents' perceptions of drug users and the local context in which they live and use drugs,̂ ®'̂ ^ Illicit drug use—particularly injec- tion drug use—carries a heavy stigma. As a result, localized community resistance based on such attitudes is often mobilized to pre- vent the opening or expansion of health and social service faciUties.'"'̂ '

Many state and local govemment bodies have been unwilling or unable to respond ef- fectively to the HIV epidemic among injection drug users, Govemment inaction and active opposition occur at different bureaucratic lev- els, affecting the distribution and availability of the resources necessary to establish SEPs, The situation in Tacoma, Wash, where the first publicly funded SEP in the United States was established, illustrates the complexity in- volved in setting up an SEP. In 1988, the

county health department had to sue the city to obtain promised funds to set up an SEP when the city withheld funds, arguing that the exchange violated drug paraphernalia laws. In winning that case, the department set a standard for other counties in the state, and the eventual result was a state-level deci- sion to legalize SEPs,'^

The various forms of political opposition to SEPs suggest that organized local support for these programs has been cmcial to tbeir for- mation in the United States. SEPs often are the result of direct action by grassroots activists, Bluthenthal'" suggested that govemment inac- tion created a perceived need for SEPs en- abling harm reduction activists in Oakland, Calif, and elsewhere to set up programs. The efforts of local volunteers and a local political environment that encouraged solidarity were among the conditions that led to the fonnation of an activist-oriented SEP in Oakland.

Purther political opposition can come from a lack of leadership. In a recent study. Down- ing et al.'''' found that a lack of leadership in the political and public health sectors and a fear of implementing or even discussing needle exchange because of perceived politi- cal opposition were the biggest barriers to the establishment of SEPs in some localities.

In other situations, strong support by indi- viduals in the community can lead to wide support for SEPs and produce govemment action, as the Tacoma case illustrates. Tacoma's SEP was established as a result of the actions of Dave Purchase and other local stakeholders. Recognizing that many injection drug users were dying of AIDS and recogniz- ing the lack of govemment response. Pur- chase set up a street-based SEP. He described the pre-SEP situation in Tacoma as follows:

People were going to die. I had some time on my hands. I had some friends that did help out a lot and never got the credit they deserve. We started in the summer of '88, and every couple of years there's another brouhaha with the same old argument. The fact of the matter is that there have been enough local political people with backbone that have supported us and so has the health department, and so we've weathered attacks. And politics is still a num- ber one problem. AIDS is all politics; it's not science and stuff like that (D. Purchase, oral communication, June 2002).

In other areas, local direct action has been less successful. In 1999, New Jersey reported

more than 19000 cumulative IDU-related AIDS cases, and 2.3% of the residents of the Jersey City metropolitan statistical area (MSA) were injecting drugs. However, the governor and city officials opposed distributing sterile syringes to injection drug users, and local police arrested clients and volunteers in an attempt to suppress the state's only publicly visible SEP.

In the United States, development and maintenance of services for injection drug users, spedfically SEPs, are linked to specific activist groups and social movements such as the AIDS Coalition to Unleash Power (ACT UP) and the harm reduction movement. In the late 1980s, concemed activists, usually former or current drug users or members of ACT UP, began setting up SEPs in some localities. In the past, ACT UP had successfully used "di- rect action" (i.e., political activism strategies such as demonstrations and workplace occu- pations) to contest the stigmatization of people with AIDS by highlighting the underlying stigmatization rooted in homophobia.

Many of the same activists adopted a simi- lar philosophy and tactics in creating and de- manding AIDS prevention services for injec- tion dmg users by distributing clean needles to users regardless of legality.'''' Members of the harm reduction movement—a unique as- semblage of recovering drug users, AIDS ac- tivists, researchers in the areas of substance use and HIV, and community health educa- tors and workers—continue to volunteer at SEPs, even when some are repeatedly ar- rested for distributing syringes,

PLACE CHARACTERISTICS

Although social and political factors are im- portant determinants of public policies and other "community actions" that affect public health, as argued by Nathanson,^' they have not been adequately studied. Some compara- tive and local studies of community actions have investigated sociopolitical factors that shape the distribution of programs that ad- dress certain public health issues and social problems. Por example, human resource char- acteristics such as education and income predict whether and when chapters of anti- drunk-driving organizations have formed in US counties.^''

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Chiotti and Joseph's''' research showed that a community's negative attitudes toward an AIDS hospice were in part because of the dominant forms of social stratification (dic- tated by class and culture) entrenched in the community. Miller's''* study of antinuclear activism in the Boston area showed that so- doeconomic variables relating to class, labor, and place were significantly related to whether a community mobilized against nu- clear development.

We adapted a fi-amework developed by Judith J, Friedman""" to the adoption of SEPs, The framework emphasizes 4 types of local characteristics important to the distribu- tion of institutionalized programs in cities or MSAs, The first is the need for the program in the MSA, The second is the extent of local resources useful in implementing the pro- gram. Two types of local resources are impor- tant: general eind specialized, A specialized re- source is useful for only a narrow range of programs, induding SEPs, whereas a more general resource is useful for a wide range of activities. The third characteristic is the strength of organized or potential opposition to the program, and the fourth is the strength of organized or potential support for the pro- gram. Within this framework, we identified appropriate predictors of differences in SEP availability in metropolitan areas,

HYPOTHESES AND SELECTION OF PREDICTORS

Our first hypothesis was that need for ac- tion will increase the likelihood of an SEP being formed. Although some studies of health-related programs have shown that indi- cators of need are not strong predictors of program adoption,'®'̂ ^ we theorized that MSAs with greater levels of epidemiological need (need for more or better services or heEilth programs) will be more likely to pro- vide harm reduction services, including SEPs, Thus, communities with larger populations of injection drug users and higher AIDS case rates among these populations will be more likely than other communities to have SEPs, In addition, states regulate syringe access through over-the-counter syringe laws (anti- over-the-counter laws); these laws work against injection drug users having access to

clean syringes. As a result, SEPs are espe- dally needed in areas where and—over-the- counter laws prevent the sale of syringes.

Second, we hypothesized that the availabil- ity of local resources useful in creating an SEP will increase the likelihood of the forma- tion of an SEP, As mentioned, 2 types of re- sources are important, general and spedal- ized, MSAs vary in terms of general resources. Resources useful for public health programs indude university departments of public health and local medical schools, both of which may affect SEP formation. For ex- ample, localities with a medical school have been found to be more likely to undertake new community-based interventions for asthma"' and to develop infant and maternal care programs,^^

Research has shown that specialized re- sources predict community action with re- spect to new approaches to breast cancer treatment,"^ Similarly, concentrations of med- ical and public health researchers have been found to predid expansion of local insurance coverage for children,"^ Spedalized resources that might fadlitate SEP implementation in- clude ratios of medical and public health re- searchers or teaching professionals, and special community services for HIV/AIDS patients (e,g,, hospitals offering spedalized care for HIV/AIDS patients) or injection drug users (e,g,, availability of drug treatment ser- vices). These spedalized resources suggest a concentration of people likely to organize and support a movement for an SEP,

Our third hypothesis was that organized or potential opposition to SEPs will reduce the likelihood of SEP formation. The various forms of opposition to SEPs in the United States illustrate the politics involved in imple- menting controversial public health measures. We categorized opposition into 3 forms: insti- tutional, community, and media. Studies of the adoption of programs such as urban renewal have shown that the supply of resources avail- able to opponents and the types of neighbor- hood organization in place are predictors of whether resistance is successful,"" Institution- alized opposition on the part of local business leaders, party offidals, and government actors is a key determinant of successful resistance against urban renewal. In the area of public health, strongly organized opposition has often

resulted in delays in the establishment of pub- lic health intervention programs for drug users in US cities,''*"^

As mentioned, institutional opposition to SEPs and other harm reduction programs in- volves law enforcement activities initiated by district attorneys, politicians, police officials, and beat officers,"""^ as well as state and local legislation prohibiting possession of drug paraphernalia or over-the-counter sales of syringes,^''"* Community opposition can take several forms, including "not in my backyard" opposition from neighborhood or business associations"^ and broader opposi- tion from local clergy and minority interest organizations,^""^^ We used the following as measures of whether minority communities would be likely to oppose syringe exchange or methadone maintenance programs: resi- dential segregation according to Hispanic or Black race/ethnicity (using the residential segregation dissimilarity index),^^ percentage of the population that is Black or Hispanic, and Black-White and Hispanic-White in- come differentials.

Finally, opposition can come irom negative portrayals of injection drug users, and ser- vices aimed toward them, in the local media and newspapers,^' These types of opposition typically involve a criminal viewpoint ap- proach to problems of drug use in communi- ties. We suspect, then, that the main argu- ments of those opposed to the fonnation of SEPs focus on the idea that these programs encourage drug use.

Our fourth and final hypothesis was that organized or potential support for programs will increase the probability of SEP forma- tion. These types of support can,originate from 2 sources: institutional sources, such as public health departments, research organiza- tions and universities, and long-standing pro- grams for injection drug users (e,g,, metha- done maintenance programs), and community mobilization sources. Community mobiliza- tion refers to efforts mounted through social movements to shape public health.

We organized variables for institutional support as the early presence in a community of federally funded outreach programs for in- jection dmg users. We theorized that such support would increase the likelihood of the presence of an SEP and lessen community

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opposition to SEPs or other services targeted toward injection drug users, A variety of local organizations such as ACT UP, other AIDS advocacy groups, drug user advocacy groups, and political groups can be involved in com- munity mobilization. We included data on local ACT UP chapters, and we used men who had sex with men (MSM) as a proxy measure for community support from AIDS advocacy groups.

We hypothesized that 4 kinds of "place" characteristics would help us predict the dis- tribution of SEPs among MSAs in the United States in 2000: (1) local need for an SEP (and related harm reduction programs), (2) spedalized and general resources, (3) orga- nized and potenticil opposition, and (4) orga- nized and potential support. These place characteristics are interrelated. Presumably, need should increase concern about underly- ing health issues and hence increase the prob- ability of support for an SEP as well as the probability that an organization or individual will begin the process of setting up an SEP. Need is not the only factor, however, and some communities with a relatively low level of need will develop an SER

In addition, the probability of an SEP being established is a function of the re- sources available to those involved in imple- menting the SEP, Resources useful for any kind of program, those useful for public health programs and those specifically useftil to harm reduction programs, are all impor- tant. Support and opposition become critical once the idea of an SEP exists within the community. Opposition, even assumed oppo- sition, can hinder steps toward forming an SEP, Strong organized opposition can kill a proposal or result in an SEP operating only for a short time. Support for those organizing and then running the SEP, in contrast, in- creases the probability of success,

METHODS

We used the framework described to con- struct logistic regression models exploring how need, support and opposition, and met- ropolitan socioeconomic characteristics were related to whether SEPs were present in 96 MSAs in the United States in 2000. The US Census Bureau^' defines an MSA as a set of

contiguous counties that contain a centred city of 50000 people or more and form a socioeconomic unit determined according to commuting patterns and social and economic integration within the constituent counties. We included data on the 96 largest MSAs as of 1993.

We used MSAs as the unit of analysis for 3 reasons, Eirst, they allowed continuity with a previous set of estimates calculated by Holmberg^^—estimates of HIV prevalence rates, numbers of injection drug users, and numbers of MSM within 96 MSAs—that we used as a basis for the variables included in our analysis. Second, more published health data are available for the county units that make up MSAs than for individual municipal- ities. Third, as a result of their economic and social unity, MSAs are a reasonable means of studying drug-related HIV and other epi- demics, Eurthermore, they are meaningful units for assessing drug users and services given that many injection drug users who live in the suburbs buy drugs (and perhaps obtain drug-related services) in the central city.

It is important to address the concern about when our independent variables were measured and thus the lag between measure- ment times and 2000, the year for which we assessed whether SEPs were present in the different MSAs assessed (the dependent vari- able). Our main concern was that as many predictor variables as possible had been mea- sured before the period when most SEPs formed (in the mid-1990s, approximately 1992 to 1998). The stiidy was limited by the periods for which relevant data were avail- able for MSAs; for example, estimates of per capita numbers of injection drug users were available only for 1993 and 1998, and MSM estimates were available only for 1993. Data on these and other predictor variables, includ- ing "need" variables such as the estimated number of injection drug users and the per- centage of injection drug users among AIDS patients, were relatively stable over this time period and indeed remained relatively stable after SEPs had been implemented.

Dependent Variable The dependent variable was the presence

of an SER in an MSA as of 2000. Data on the dependent variable were derived from

the Beth Israel National Survey of Syringe Exchange Programs, conducted in conjunc- tion with the North American Syringe Ex- change Network. As of 2000, 47 ofthe 96 MSAs assessed had at least 1 SEP

Independent Variables

Data at the MSA level were available on a range of social, demographic, and structural variables. We included a number of socioeco- nomic and demographic variables that others have suggested are related to different pro- gram-presence variables,''''^'' including per- centage of the population that is Black or Hispanic, residential segregation dissimilarity index, unemployment level and breakdown of unemployment according to race/ethnic- ity, median family income ratio (e.g,, ratio of Black median income to White median in- come), and percentage of the population below the poverty level. We also included data on other structural variables provided by the Lewis Mumford Center for Compara- tive Urban and Regional Research,^" Table 1 presents statistics on the independent vari- ables. Indicators of the need for an SEP in- cluded AIDS prevalence rate among injection drug users (derived from the AIDS Public In- formation Data Set^'), number of injection drug users in an MSA (derived from esti- mates provided by Holmberg^^), and laws prohibiting over-the-counter sales of syringes (details on these laws were derived from Burris et al,̂ ^ and Eriedman et al.''*). Anti-over-the-counter legislation was a dichotomous variable (1 =yes, 0 = no). Thirty-six ofthe 96 MSAs were located in states that had passed anti-over-the-counter syringe laws as of 1993.

We measured 2 variables pertaining to general resource availability: number of pub- lic health and medical researchers per 10 000 population and number of public health and medical teaching professionals per 10 000 population. Data for both variables were derived from the 1990 Bureau of Health Professions Area Resource File.^'' In addition, we assessed the availability of 2 specialized resources: number of drug treat- ment slots per 10 000 population, a measure of the services available to substance users (derived from the 1992 Treatment Episode Data Set̂ ^), and number of hospitals with

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TABLE 1-Dlstribution of Independent Variables Among 96 MSAs, by Category: 1989-1993

Categoiy and Variable

Need

No, of injection drug users per 1000 popuiation (1993)

No, of AiDS cases among injection drug users per

1000 users (1993)

Presence of anti-OTC laws

Resource availabiiity

No, of drug treatment slots' (1992)

No, of hospitals with specialized HIV/AIDS services'

(1992)

No, of medical and public health researchers' (1990)

No, of medical and public health teaching professionals'

(1990)

Institutional opposition

No, of hard drug arrests' (1993)

No, of police employees' (1993)

Organized or potential support

No, of MSM per 1000 population (1993)

No, of AIDS cases among MSM per 1000 MSM (1993)

Presence of outreach efforts

Presence ofACT UP chapter

No, of methadone maintenance programs' (1989)

Socioeconomic and demographic factors (1990)

MSA population (in 100000s)

Black, %

Black residential segregation dissimilarity index'

Black-White median income ratio

Black-White unemployment ratio

Hispanic, %

Hispanic residential segregation dissimilarity index'

Hispanic-White median income ratio

Hispanic-White unemployment ratio

Unemployment rate, %

Population below poverty level, %

Population with college education, %

Mean (SD)

8,631 (4,335)

12,071 (9,381)

0,375 (0,486)

0,810 (0,862)

14,081 (3,371)

0,778 (0,940)

1,046 (0,605)

15.059 (14,175)

27,946 (9,544)

10,360 (3,781)

16,693 (8,402)

0,417 (0,495)

0,198 (0,400)

2,406 (2,406)

16,578 (15,782)

11,786(8,224)

64,684 (11.584)

0,676 (0.218)

2.819 (1.486)

9.525 (12,589)

41.509 (12,081)

0.822 (0.303)

2.106(0.977)

5.869 (1.459)

11,345 (3.597)

22.195 (5,184)

Minimum

2.512

1.428

0,000

0.000

3.518

0.032

0.110

0.532

11.104

4.163

3.275

0.000

0.000

0,000

5.011

0.897

37.516

0,309

0,018

0,448

21,487

0.321

0.591

3.065

4.200

12,044

Maximum

23.118

41,000

1.000

4.701

22.249

5.198

4,117

71.870

77.332

32.906

42,307

1,000

1.000

20.87

90.922

40,589

89.945

1.318

7.463

69.576

66.764

1.356

5.833

10.036

26,803

37.006

Note. OTC=over-the-counter; MSM = men who have sex with men; ACT UP=AIDS Coalition to Unleash Power; MSA=metropolitan

statistical area; the actual number of MSAs in the analysis ranged from 93-96, according to availability of data. Years in

parentheses are the years of the data.'^'^*

'Per 10000 population.

'Per 1 million population.

'Measures residential segregation according to minority race/ethnicity, that is, whether one particular group is distributed

across census tracts in the metropolitan area in the same way as another group.A high value indicates that the 2 groups tend

to live in different tracts.Values range from 0 to lOO.A value of 60 or above, considered very high, indicates that 60% (or more)

of the members of one group would need to move to a different tract in order for the 2 groups to be equally distributed. Values

of 40 or 50 are usually considered moderate, and values of 30 or below are considered to be relatively low.

specialized HIV/AIDS care units per 10000 population (derived from the Bureau of Health Professions Area Resource File^^).

Institutioneil opposition can be manifested through police harassment of injection drug users via drug arrests, arrests of SEP partici- pants for carrying syringes, and harassment

and arrests of SEP staff,̂ ''̂ ^ We viewed these variables as symbolizing a "criminal justice" approach to sodcil problems, an approach con- sistent with hostility toward SEPs. We assessed a pair of institutional opposition variables: number of arrests for possession of cocaine or heroin per 10 000 population ("hard drug

arrests"; derived from Uniform Crime Report- ing Program county-level arrest data*") and number of police employees per 10 000 popu- lation (derived from Uniform Crime Reporting Program data on police force employees).̂ '"̂

We categorized 2 types of organized or institutional support. The first was the pres- ence of cin outreach program for injection dmg users and, in certain instances, their partners (compiled from data reported by Brown cind Beschner^" and the National Insti- tute on Dmg Abuse^'). The second was the number of methadone maintenance programs in a given MSA as of 1989 (as reported in the 1989 National Dmg and Alcoholism Treatment Unit Survey^^),

Finally, we classified potential or actual com- munity mobilization as efforts by grassroots or- ganizations and local activists to develop and sustain programs for stigmatized groups. Gen- eral gay political influence and concem regard- ing HfV/AIDS prevention cind the direct in- volvement of gay and lesbian activists in ACT UP may have influenced the establishment of SEPs and perhaps deterred the efforts of politi- cal authorities to prevent their fonnation. The following variables were used in assessing com- munity mobilization in support of SEPs: (1) the presence of an ACT UP chapter, many of which initiated SEPs or expanded local dmg treatment and other HIV prevention service ca- pacities (as cited in records maintained by members of New York ACT UP and in various literature reviews"^"" ;̂ 19 MSAs had local ACT UP chapters as of 2000); (2) estimates of MSM poptilations as a measure of potential AIDS- interested constituencies^^; and (3) percentage of MSM with AIDS in a given MSA (included as a measure of impetus to gain gay support for SEPs; derived from the AIDS Public Informa- tion Data Set̂ )̂.

Data Analysis

As a result of the large number of potential independent variables and the relatively small number of MSAs, we developed a 4-step pro- cess to reduce the number of independent variables. First, we conducted bivariate analy- ses to determine the independent variables that exhibited a statistically significant associa- tion with SEP presence {P<.20 was used as the screening criterion to avoid deleting po- tentially significant predictors). Second, we

March 2007, Vol 97, No, 3 | American Journal of Public Health Tempalski et al. \ Peer Reviewed | Framing Health Matters | 4 4 1

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TABLE 2-Ooniain-Specific Bivariate Reiations Between Independent Variabies and Presence of a Syringe Exciiange Program (SEP): 96 iVIetropoiitan Statistical Areas (iVISAs), 2000

Category and Variable'

Mean in

MSA

Need

No, of injection drug users per 1000 population (1993)

With SEP 9,24

Without SEP 8,04

No, of AiDS cases among injection drug users per 1000

users (1993)

With SEP 14,73

Without SEP 9,51

Presence of anti-OTC syringe laws

With SEP 0,46

Without SEP 0,28

Resource availability

No, of drug treatment slots per 10000 population (1992)

With SEP 0,78

Without SEP 0,76

No, of hospitals per 10 000 population with specialized

HIV/AIDS seivices (1992)

With SEP 14,36

Without SEP 13,81

No, of medicai and public heaith researchers per 10 000

population (1990)

With SEP 1.03

Without SEP 0,53

No, of medical and public health teaching professionals

per 10000 population (1990)

With SEP 1,10

Without SEP 0,99

institutional opposition

No, of hard drug arrests per 10000 population (1993)

With SEP 18,24

Without SEP 12,01

No, of police employees per 10000 population (1993)

With SEP 29,18

Without SEP 26,76

Organized or potentiai support

No, Of MSM per 1000 population (1993)

With SEP 11.62

Without SEP 9,15

No. of AIDS cases among MSM per 1000 MSM (1993)

With SEP 17,92

Without SEP 15,51

Presence of outreach efforts

With SEP 0.59

Without SEP 0.24

Odds Ratio (95%

Confidence Interval)

1,07 (0.970,1.175)

1,07(1,017,1.124)

2,20(0.946,5,117)

1,09(0,440,2,709)

1,05 (0.930,1.185)

2.13(1.116,4,082)

1,36(0.683,2.717)

.180

,093

.067

,850

.433

,022

.380

1,04 (1,001,1.070) .040

1.03 (0,983,1.076) ,226

1,31 (1.100,1,550) .002

1.04(0.986,1,088) .162

4,54 (1.897,10,886) .007

Continued

grouped variables found to be significant into 5 categories for domain analysis,̂ '̂®' Next, within each domain, we used logistic regres- sion techniques to identify variables that were significant independent predictors at P<,05, Finally, we applied logistic techniques to the pooled set of independent variables signifi- cant at P<.05 to determine the final model predictors.

RESULTS

Within each overall category of indicators, there were significant (P<,20) assodations between independent variables and the pres- ence of an SEP (Table 2), In the category of need, significant variables were percentage of injection drug users in the general population, number of AIDS cases per 1000 injection drug users, and presence of anti-over-the- counter syringe laws. In the resource avail- ability category, number of public health and medical researchers and number of drug treatment slots per 10 000 population were significant. In the institutional opposition cate- gory, number of hard drug arrests per 10 000 population was significant.

In the organized or potential support cate- gory, significant variables were percentage of MSM in the general population, number of AIDS cases per 1000 MSM, presence of an ACT UP chapter, early program outreach to injection drug users, and number of methadone maintenance programs. Finally, the following socioeconomic indicators were significant: MSA population. Black—White and Hispanic-White median income ratios, Hispanic residential segregation index, and percentage of the population with a college education.

Variables that were significant in the do- main analyses (Table 3) at P < , 0 5 (and their respective domains) were (1) number of AIDS cases per 1000 injection drug users (need); (2) number of public health and med- ical researchers per 10 000 population (re- source availability); (3) percentage of MSM in the population, presence of an ACT UP chap- ter, and number of methadone maintenance programs in 1989 (organized or potential support); and (4) number of hard drug arrests per 10 000 population (institutional opposi- tion). In addition, 2 socioeconomic indicators.

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TABLE 2-Contlnued

Presence ofACT UP chapter

With SEP

Without SEP

No, of methadone maintenance programs'' per 1 million

population (1989)

With SEP

Without SEP

0,38

0,02

3,10

1,73

29,80(3,775,235,106)

1,66 (1,189,2,343)

Socloecanomic and demographic factors (1990)

MSA population in 100 000s

With SEP

Without SEP

Black, %

With SEP

Without SEP

Blacl< residential segregation dissimilarity index

With SEP

Without SEP

Black-White median income ratio

With SEP

Without SEP

Black-White unemployment ratio

With SEP

Without SEP

Hispanic, %

With SEP

Without SEP

Hispanic residential segregation dissimilarity index

With SEP

Without SEP

Hispanic-White median income ratio

With SEP

Without SEP

Hispanic-White unemployment ratio

With SEP

Without SEP

Unemployment rate, %

With SEP

Without SEP

Population below poverty level, %

With SEP

Without SEP

Population with college education, %

With SEP

Without SEP

22.21

11,17

11,55

12,05

65,75

63,67

0,63

0,71

2,78

2,85

10,67

8,45 •

45,20

38,04

0,73

0,90

2,09

2,11

5,98

5,75

11,06

11,60

24,44

20,08

1,09 (1.031,1.155)

0.99 (0.945,1.04)

1.02 (0.981,1.052)

0.14 (0.019,1.029)

0.97 (0.736,1.277)

1.02 (0.982,1.049)

1,05 (1.016,1.094)

0.19(0.033,0.578)

0.97 (0.639,1,477)

1.12 (0.845,1.478)

0.96 (0.854,1.074)

1.22 (1.100,1.361)

.001

.003

.003

,788

.382

.053

.825

.392

.005

.067

.893

.437

.459

.001

Note. OTC-over-the-counter; MSM=men who have sex with men. Years in parentheses are the years of the data.

'With SEP, n-47; Without SEP, n - 4 9 .

"Based on likelihood ratio test.

percentage of the population with a college education and MSA population, were significant.

In the final, fully adjusted model (Table 4), significant independent predictoi-s of the presence of an SEP as of 2000 were ACT UP presence (adjusted odds ratio [OR] = 11,367; 9 5 % confidence interval [CI] = 1.111, 116.250) and percentage of the population with a col- lege education (adjusted 0 R = 1.173; 9 5 % CI= 1.003, 1.372).'Percentage of MSM in the general population (adjusted 0 R = 1.213; 9 5 % CI=0.987, 1.490) was of borderline significance.

Of the 96 MSAs, 19 had ACT UP chapters; of these chapters, all but 1 (Houston) had at least 1 SEP, Because of the small number of MSAs with ACT UP chapters but no SEP, it was difficult to conduct multivaiiate analy- ses using this variable. Approximately 4 0 % of the MSAs in our study had SEPs despite not having an ACT UP chapter.

We conducted 2 additional analyses to as- sess whether SEP presence was simply a product of ACT UP presence. First, we ran the same model described earlier with ACT UP presence as the dependent variable. Sig- nificant predictors of the presence of an ACT UP chapter were number of AIDS cases among MSM (adjusted 0 R = 1.105; 9 5 % CI= 1.015, 1.202) and MSA population (ad- justed 0 R = 1.090; 9 5 % Cl= 1,018, 1,167) (Hosmer-Lemeshow goodness-of-fit test P=,6768). Predictors ofACT UP presence were quite different from predictors of SEP presence.

To further explore the interaction between SEP presence and ACT UP presence, we an- alyzed SEP presence among 77 MSAs with- out ACT UP chapters. The bivariate results were similar to our original analysis. In the fully adjusted model, significant independent predictors of the presence of an SEP as of 2000 for those areas without ACT UP chap- ters were percentage of the population with a college education (adjusted 0 R = 1.229; 9 5 % CI= 1.040, 1.452;/'= .0156) and per- centage of MSM in the population (adjusted 0 R = 1.250; 9 5 % C l = 0 . 9 9 7 , 1,567; P=.O52O).

Research has shown that, in many cities, SEPs have been initiated by ACT UP mem- bers,'^''''~'^' Here this very direct form of

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TABLE 3-Significant Predictors In Domain-Specific Multiple Logistic Regression Analysis

Category and Variable Adjusted Odds Ratio

(95% Confidence Interval)

Need

No, of injection drug users with AIDS per 1000 users

Resource availability

No, of medical and public health researchers per

10000 population

Institutional opposition

No, of hard drug arrests per 10000 population

Organized/potential support

Presence ofACT UP chapter

No, of MSM per 1000 population

No, of methadone maintenance programs per

1 million population

Socioeconomic/structural factors

Percentage of population with college education

MSA population

1,07 (1,017,1,124)

2,13(1,116,4,082)

1,04 (1,001,1,070)

20,331 (2,476,166,966)

1,206 (1,005,1,447)

1,522(1,038,2,231)

1,19 (1,064,1,320)

1,067 (1,009,1,128)

,009

,022

,04

,005

,044

,031

,002

,023

Note. ACT UP=AIDS Coalition to Unleash Power; MSM=men wlio have sex with men; MSA "metropolitan statistical area.

TABLE 4-Significant Predictors in iVIuitivariate Logistic Regression Anaiyses

Adjusted Odds Ratio (95% Confidence Interval)

Presence ofACT UP chapter

Percentage of population with college education

No, of MSM per 1000 population

11,367 (1,111,116,250)

1,173 (1,003,1,372)

1,213 (0,987,1,490)

,041

,046

,067

Note. ACT UP=AiDS Coalition to Unieash Power; MSM-men who have sex with men.

causation resulted in a large predictive Vcilue between the presence of ACT UP chapters and the formation of SEPs, The results of our analysis indicate that the presence of an ACT UP chapter is almost a sufficient condition for the presence of an SEP but that it is not a necessary condition. However, continued re- search regarding this topic is needed to un- derstand the factors associated with the cor- relation of ACT UP presence to SEP presence,

MSAs were more likely to have SEPs in 2000 if they had ACT UP chapters, higher percentages of MSM in their population, and higher percentages of college-educated resi- dents. In the absence of ACT UP chapters, percentages of college-educated residents and percentages of MSM in the population re- mained the important predictors.

DISCUSSION

Limitations Despite our efforts to gather variables that

best captured our theoreticed framework, we were limited by the information,available in the secondary data sets and public use files we used. Furthermore, some of these data sets involved missing values when information was aggregated to the MSA unit of analysis, Eor example, 1993 arrest data for Kansas, the District of Columbia, and Elorida were not available in the public use files. However, we were able to compile Elorida drug arrest data from county-level data (state of Elorida crime reports). However, we were unable to account for missing values for the Wichita, Kan, and District of Columbia MSAs, Moreover, given our difficulty in obtaining data relating to

opposition, we were not able to measure po- tential community opposition, including oppo- sition from local media and newspapers.

In addition, in the case of our dependent variable, SEP presence, we included only those programs that responded to the Beth Is- rael National Survey of Syringe Exchange Pro- grams, Twenty-seven ofthe 154 programs did not respond to the survey in 2000, despite re- peated follow-ups, Fortunately, only 1 of these 27 programs was located in a study MSA, We reanalyzed the data to account for the missing SEP using the same methods described ear- lier, and the results did not differ,

Finally, our analysis was limited to MSA boundaries, leading to the omission of 8 SEPs located within 10 mi (16 km) ofthe MSAs as- sessed, Euture research might indude a spa- tial buffering component so that such SEPs can be incorporated into the analyses, Euture studies should also include analyses of SEPs as a time-dependent variable, which would help provide an understanding of the geo- graphic diffusion of programs in the United States over time and across space,

Conciusions

Our results are consistent with current the- ory positing that SEPs are oiten established as a result of political pressure or direct action by grassroots activists and organizations such as ACT UP, We identified 3 independent predic- tors ofthe presence of an SEP, Overall, MSAs with Mgh percentages of MSM in their popula- tion were more likely to have SEPs, as were those with ACT UP chapters. As mentioned, 19 of the 96 MSAs assessed had an ACT UP chapter, and all but 1 of these 19 had at least 1 SER This indicates a strong association be- tween the presence of local ACT UP chapters and the presence of an SEP and implies that activism influences provision of services.

We found that both active solidarity (ACT UP presence) and potential solidarity (higher percentages of MSM in the population, sug- gesting more concem vnth HIV/AIDS issues and education) are positive factors in forming and, possibly, sustaining SEPs in the United States, Eurthermore, when we did not ac- count for ACT UP presence in the model, percentage of MSM in an MSA was signifi- cant. Thus, SEPs are more likely to be located in areas with high percentages of MSM, even

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after control for ACT UP presence. This find- ing provides further evidence that efforts by grassroots and AIDS activists have made a significant contribution to helping to curb the HIV epidemic among injection dnig users.

The relationship between the percentage of college-educated individuals in an MSA and the presence of an SEP in that MSA was also significant; MSAs with higher percent- ages of college-educated residents were more likely to have SEPs, Although education may be a proxy for volunteerism, research sug- gests that individuals with a college diploma are more likely than those who have not at- tended college to he politically involved,^* to engage in civic activities,̂ ^™ and to be re- ceptive to new scientific technologies,^''^^ It is likely that this individual-level demo- graphic factor translates into increased sup- port for SEPs at the MSA level.

Contrary to our hypotheses, neither re- source availability nor institutional opposi- tion predicted the presence of an SEP Need, as measured by the prevalence of AIDS cases among injection drug users or the per- centage of users in the MSA population, also did not predict SEP presence, indicating a lack of association between need and ser- vices aimed toward populations of injection drug users. Attempts to set up SEPs in New Jersey and Massachusetts serve as illustra- tions of the political processes leading to this lack of relationship.

In New Jersey, injection drug use is the most fi^quently reported risk behavior among HIV-positive individuals,'^ Three of the state's MSAs Oersey City, Newark, and Bergen- Passaic) have among the highest rates of IDU- related AIDS in the country (more than 32% among injectors as of 2001), and research has shown that the percentages of injection drug users in Jersey City and Newark are very high (2,3% and 1,6%, respectively, in 1993)," The number of IDU-related AIDS cases in the state peaked in 1993, accounting for 4 9 % of the AIDS cases that year. Despite that alarm- ing situation, in April 1996 then Covemor Christine Whitman rejected the recommenda- tions of her advisory council on AIDS to dis- tribute clean needles to injection drug users and allow the sale of syringes in pharmades. By 2000, the only publicly visihle SEP in the state had been suppressed.

The current situation in New Jersey is un- predictable and shaped by politics. Under an executive order signed by former Covemor Jim McCreevey in November 2004, up to 3 of the state's cities were slated to be approved to establish SEPs. The Camden and Atlantic City SEPs were expected to be operating by May of 2005, but on June 20, 2005, the Mercer County Superior Court issued cin in- junction staying the govemor's executive order As a result, Atlantic City and Camden were not able to proceed (R. Scotti, Drug Pol- icy Alliance New Jersey, oral communication, December 2005), Two years after this study study was undertaken. New Jersey Govemor Job Corzine signed the Bloodbome Disease Harm Reduction Act, which allows up to 6 cities in the state to establish SEPs.

In Massachusetts in 1993, then Covemor WnHam Weld passed a law allowing 10 pilot SEPs in the state, witb a clause leaving final approval for implementing progrsims to each locality. Since 1993, several Massachusetts SEPs have been established, including programs in Boston, Cambridge, Provincetown, and Northampton. The most positive political di- mate for implementing an SEP was in Northampton, where the exchange was initiated by the mayor and the health commissioner; bowever, Northampton did not have the great- est need as measured by AIDS prevalence rates.

By contrast, Springfield had a dire need for a program; an estimated 54% of all AIDS cases in Springfield were attributed to injection drug use.''' Although the dty's mayor, health commissioner, public health coundl, and board of health all had supported establishment of an SEP since 1998, Springfield's dty council ve- toed the much-needed program because of ongoing political pressure by a local dtizen group. The lack of correlation between pro- gram presence and need and the continued reluctcince of policymakers to implement con- troversial initiatives such as methadone main- tenance programs and SEPs can thwart efforts to reduce HIV transmission among injection drug users and their sexual partners.

The lack of an association between pro- gram presence and need implies that current US political systems are not responding adequately to an important public health problem. This is not unique: previous studies have shown that the presence of programs

aimed at drunk driving,'"' matemal and infant health,^^ and smoking''^ is not related to the need for such programs. When community needs are at odds with national policy, ac- tivism and mobilization at the local level are essential in implementing public health pro- grams such as SEPs. •

About the Authors Barbara Tempalski, Peter L Elom, Samuel R. Friedman, and Don C. Desfarlais are with the Center for Drug Use and HIV Research, National Development and Research Institutes, lnc. New York, NY. Samuel R. Friedman is also with the Department of Epidemiology, fohns Hopkins Bloomberg School of Public Health, Baltimore, Md. Don C. Desfarlais is abo with the Baron de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, fudithf. Friedman is with the Department of Sociology, Rutgers University, Piscataway, Nf. Courtney McKnight is with the Baron de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, NY. RLsa Friedman is with the Department of Public Health, Universidad San Francisco de Quito, Quito, Ecuador.

Requests for reprints should be sent to Barbara Tempalski, PhD, MPH, National Development and Research Institutes, 71 W23rd St, 8th Floor, New York, NY 10010 (e-mail: [email protected]}.

This article was accepted March 13, 2006.

Contributors B. Tempalski was responsible for theory concept; data acquisition, analysis, and interpretation; and the writing of the article. P. L. Flom contributed to the analysis and interpretation of the data. S. R. Friedman contributed to the conception and design of tlie analysis. D.C. Des Jarlais contributed to the conception and interpretation of the data. J.J. Friedman contributed to theory concept. C. McKnight contributed to data acquisition. R. Friedman contributed to the writing of the article.

Acknowledgments This research was part of a collaboration between the Community Vulnerability Response to IDU-Related HIV project at the National Development and Re- search Institutes, lnc (supported by the National Insti- tute of Drug Abuse; grant ROI DA 13336) and the Na- tional Survey of Syringe Exchange Programs at Beth Israel Medical Center (funded by the American Foun- dation for AIDS Research [grant 106611-38-PASA], the Elton John AIDS Foundation, and the Irene Diamond Foundation-Tides Foundation).

Special thanks to Peter. L. Flom, Peter Hoff, and Sara McLafferty for their statistical advice; Judith Friedman for feedback on the theory framework; and Courtney McKnight for her help and avice regarding the Beth Israel Syringe Exchange Survey.

Human Participant Protection No protocol approval was needed for this study.

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