SOCIAL AND POLITICAL FACTORS PREDICTING THE PRESENCE OF SYRINGE
EXCHANGE PROGRAMS IN 96 US METROPOLITAN AREAS

Framing Health Matters

About the Authors: Barbara Tempalski, Peter L. Flom, Samuel R.
Friedman, and Don C. Des Jarlais are with the Center for Drug Use and
HIV Research, National Development and Research Institutes, Inc, New
York, NY. Samuel R. Friedman is also with the Department of
Epidemiology, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Md. Don C. Des Jarlais is also with the Baron de
Rothschild Chemical Dependency Institute, Beth Israel Medical Center,
New York. Judith J. Friedman is with the Department of Sociology,
Rutgers University, Piscataway, NJ. Courtney McKnight is with the
Baron de Rothschild Chemical Dependency Institute, Beth Israel
Medical Center, NY. Risa 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 W 23rd St, 8th Floor, New
York, NY 10010. This article was accepted March 13, 2006.

Abstract Community activism can be important in shaping public health policies.

For example, political pressure and direct action from grassroots
activists have been central 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 political, 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 of
the presence of an SEP included percentage of the 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.

In the United States, injection drug users account for about one
third of all AIDS cases 1 and nearly two thirds of new hepatitis C
cases.2 Syringe exchange programs (SEPs), in which injection drug
users exchange used syringes for sterile ones, can address
potentially rapid increases in rates of HIV infection in this
population. If sufficient numbers of sterile syringes are supplied,
users can inject with a new syringe each time, dramatically reducing,
if not eliminating, sharing with others because of an inadequate supply.

This should then reduce HIV transmission among injection drug users.3
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 government has withheld funding for SEPs
contingent on evidence that they reduce the transmission of
blood-borne disease without encouraging injection drug use (IDU).4
Despite the lack of support at the federal level, numbers of
exchanges and numbers of syringes exchanged have increased
considerably over the past 15 years.

As of November 2006, according to the North American Syringe 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.5 Although public health authorities may support SEPs, many
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 6,7 and prevention 8,9 of disease.

Social movements have shaped public health policies in the United
States, France, Great Britain, and Canada.10-13 The "great sanitary
movement" during the mid-19th century in Britain, for example, was
driven chiefly by local activists appalled by the living and working
conditions of the urban poor.8 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.14-17 At present, the controversy over the
formation 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 surface.

Although SEPs remain controversial and continue to face obstacles
from the federal government and state governments, they also continue
to gain support as a method of reducing harm among injection drug
users. Some of the 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 government and
public health programs.

Currently, more than half of the country's SEPs are nongovernmental
programs established by independent local actors.18 Social and
political processes are important determinants of social change and
actions that affect health policy, epidemiology, and prevention services.

We explored the effects of place characteristics, including need for
services, local resources, community opposition, and grassroots
political action, on the geographic availability of SEPs in the
United States.1 We defined "place" as the set of social, 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 geography
literature, we identified place characteristics that affect spatial
variation in SEPs. We hypothesized that the uneven geographic
distribution of SEPs in the United States can be attributed to the
particular political, socioeconomic, and organizational
characteristics that affect local service needs, resources, and
opposition. Using data from the 2000 Beth Israel National Survey of
Syringe Exchange Programs,19 we examined the effects of program need,
political factors, and socioeconomic and organizational
characteristics on the presence of SEPs.

Activism, Politics, And Opposition To Syringe Exchange Programs

A struggle exists in the United States between law enforcement and
medical providers as to whether drug users should be defined as
criminals or medical patients.

One effect of this struggle is that the United States has been the
historical leader in law enforcement and abstinence-based approaches
to illicit drug use,20 which has fueled 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,21,22 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.23 The second form is community opposition,
including opposition organized by clergy and neighborhood 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.24-26 The
third form is negative media portrayals of injection drug users and
services designed to help them (D. Purchase, Point Defiance AIDS
Projects, oral communication, June 2002).27 These forms of opposition
are neither mutually exclusive nor static.

A change in opposition from one source (e.g., local political
leadership) can affect support from others.

Thus, resistance to SEPs does not exist in isolation.

In fact, the most harmful 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.28,29 Illicit drug use-particularly injection drug use-carries
a heavy stigma.

As a result, localized community resistance based on such attitudes
is often mobilized to prevent the opening or expansion of health and
social service facilities.30,31 Many state and local government
bodies have been unwilling or unable to respond effectively to the
HIV epidemic among injection drug users.

Government inaction and active opposition occur at different
bureaucratic levels, 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 involved 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 decision to
legalize SEPs.32 The various forms of political opposition to SEPs
suggest that organized local support for these programs has been
crucial to their formation in the United States. SEPs often are the
result of direct action by grassroots activists.

Bluthenthal 10 suggested that government inaction created a perceived
need for SEPs enabling 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
formation of an activist-oriented SEP in Oakland. Further political
opposition can come from a lack of leadership. In a recent study,
Downing et al.33 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 political opposition were the
biggest barriers to the establishment of SEPs in some localities. In
other situations, strong support by individuals in the community can
lead to wide support for SEPs and produce government 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
recognizing the lack of government response, Purchase 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 number 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 19 000 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, specifically 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, concerned 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 "direct action"
(i.e., political activism strategies such as demonstrations and
workplace occupations) to contest the stigmatization of people with
AIDS by highlighting the underlying stigmatization rooted in
homophobia. Many of the same activists adopted a similar philosophy
and tactics in creating and demanding AIDS prevention services for
injection drug users by distributing clean needles to users
regardless of legality.34 Members of the harm reduction movement-a
unique assemblage of recovering drug users, AIDS activists,
researchers in the areas of substance use and HIV, and community
health educators and workers-continue to volunteer at SEPs, even when
some are repeatedly arrested for distributing syringes.

Place Characteristics

Although social and political factors are important determinants of
public policies and other "community actions" that affect public
health, as argued by Nathanson,35 they have not been adequately studied.

Some comparative and local studies of community actions have
investigated sociopolitical factors that shape the distribution of
programs that address certain public health issues and social problems.

For example, human resource characteristics such as education and
income predict whether and when chapters of anti-drunk-driving
organizations have formed in US counties.36 Chiotti and Joseph's 37
research showed that a community's negative attitudes toward an AIDS
hospice were in part because of the dominant forms of social
stratification (dictated by class and culture) entrenched in the community.

Miller's 38 study of antinuclear activism in the Boston area showed
that socioeconomic variables relating to class, labor, and place were
significantly related to whether a community mobilized against
nuclear development. We adapted a framework developed by Judith J.
Friedman 39,40 to the adoption of SEPs. The framework emphasizes 4
types of local characteristics important to the distribution 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 program.

Two types of local resources are important: general and specialized.
A specialized resource is useful for only a narrow range of programs,
including 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 program.

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 action will increase the
likelihood of an SEP being formed.

Although some studies of health-related programs have shown that
indicators of need are not strong predictors of program
adoption,18,39 we theorized that MSAs with greater levels of
epidemiological need (need for more or better services or health
programs) will be more likely to provide 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 especially needed in areas where
anti-over-the-counter laws prevent the sale of syringes. Second, we
hypothesized that the availability of local resources useful in
creating an SEP will increase the likelihood of the formation of an
SEP. As mentioned, 2 types of resources are important, general and
specialized. MSAs vary in terms of general resources.

Resources useful for public health programs include university
departments of public health and local medical schools, both of which
may affect SEP formation.

For example, localities with a medical school have been found to be
more likely to undertake new community-based interventions for asthma
41 and to develop infant and maternal care programs.39 Research has
shown that specialized resources predict community action with
respect to new approaches to breast cancer treatment.42 Similarly,
concentrations of medical and public health researchers have been
found to predict expansion of local insurance coverage for
children.43 Specialized resources that might facilitate SEP
implementation include ratios of medical and public health
researchers or teaching professionals, and special community services
for HIV/AIDS patients (e.g., hospitals offering specialized care for
HIV/AIDS patients) or injection drug users (e.g., availability of
drug treatment services). These specialized 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 implementing controversial public
health measures.

We categorized opposition into 3 forms: institutional, community, and media.

Studies of the adoption of programs such as urban renewal have shown
that the supply of resources available to opponents and the types of
neighborhood organization in place are predictors of whether
resistance is successful.44 Institutionalized opposition on the part
of local business leaders, party officials, 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 public health intervention
programs for drug users in US cities.26,45 As mentioned,
institutional opposition to SEPs and other harm reduction programs
involves law enforcement activities initiated by district attorneys,
politicians, police officials, and beat officers,46,47 as well as
state and local legislation prohibiting possession of drug
paraphernalia or over-the-counter sales of syringes.23,48 Community
opposition can take several forms, including "not in my backyard"
opposition from neighborhood or business associations 49 and broader
opposition from local clergy and minority interest
organizations.24-26 We used the following as measures of whether
minority communities would be likely to oppose syringe exchange or
methadone maintenance programs: residential segregation according to
Hispanic or Black race/ethnicity (using the residential segregation
dissimilarity index),50 percentage of the population that is Black or
Hispanic, and Black-White and Hispanic-White income differentials.
Finally, opposition can come from negative portrayals of injection
drug users, and services aimed toward them, in the local media and
newspapers.27 These types of opposition typically involve a criminal
viewpoint approach to problems of drug use in communities. We
suspect, then, that the main arguments of those opposed to the
formation 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 formation.

These types of support can originate from 2 sources: institutional
sources, such as public health departments, research organizations
and universities, and long-standing programs for injection drug users
(e.g., methadone maintenance programs), and community mobilization sources.

Community mobilization 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 injection drug users.

We theorized that such support would increase the likelihood of the
presence of an SEP and lessen community 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 community 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 distribution of SEPs among MSAs in the United States in
2000: (1) local need for an SEP (and related harm reduction
programs), (2) specialized and general resources, (3) organized and
potential opposition, and (4) organized and potential support.

These place characteristics are interrelated. Presumably, need should
increase concern about underlying health issues and hence increase
the probability 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 SEP. In addition, the
probability of an SEP being established is a function of the
resources available to those involved in implementing the SEP.
Resources useful for any kind of program, those useful for public
health programs and those specifically useful to harm reduction
programs, are all important.

Support and opposition become critical once the idea of an SEP exists
within the community.

Opposition, even assumed opposition, 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, increases the probability of
success. METHODS We used the framework described to construct
logistic regression models exploring how need, support and
opposition, and metropolitan socioeconomic characteristics were
related to whether SEPs were present in 96 MSAs in the United States
in 2000. The US Census Bureau 51 defines an MSA as a set of
contiguous counties that contain a central city of 50 000 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.

First, they allowed continuity with a previous set of estimates
calculated by Holmberg 52-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 municipalities. Third, as a
result of their economic and social unity, MSAs are a reasonable
means of studying drug-related HIV and other epidemics.

Furthermore, 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
measurement times and 2000, the year for which we assessed whether
SEPs were present in the different MSAs assessed (the dependent
variable). Our main concern was that as many predictor variables as
possible had been measured before the period when most SEPs formed
(in the mid-1990s, approximately 1992 to 1998). The study was limited
by the periods for which relevant data were available 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, including
"need" variables such as the estimated number of injection drug users
and the percentage 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 SEP 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
conjunction with the North American Syringe Exchange Network. As of
2000, 47 of the 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 socioeconomic and demographic variables that
others have suggested are related to different program-presence
variables,53,54 including percentage of the population that is Black
or Hispanic, residential segregation dissimilarity index,
unemployment level and breakdown of unemployment according to
race/ethnicity, median family income ratio (e.g., ratio of Black
median income to White median income), and percentage of the
population below the poverty level.

We also included data on other structural variables provided by the
Lewis Mumford Center for Comparative Urban and Regional Research.50
Table 1 presents statistics on the independent variables.

Indicators of the need for an SEP included AIDS prevalence rate among
injection drug users (derived from the AIDS Public Information Data
Set 55), number of injection drug users in an MSA (derived from
estimates provided by Holmberg 52), and laws prohibiting
over-the-counter sales of syringes (details on these laws were
derived from Burris et al.23 and Friedman et al.48).
Anti-over-the-counter legislation was a dichotomous variable (1=yes,
0=no). Thirty-six of the 96 MSAs were located in states that had
passed anti-over-the-counter syringe laws as of 1993.

TABLE 1-Distribution of Independent Variables Among 96 MSAs, by
Category: 1989-993 We measured 2 variables pertaining to general
resource availability: number of public 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.56 In addition, we assessed the availability of 2
specialized resources: number of drug treatment slots per 10 000
population, a measure of the services available to substance users
(derived from the 1992 Treatment Episode Data Set 57), and number of
hospitals with specialized HIV/AIDS care units per 10 000 population
(derived from the Bureau of Health Professions Area Resource File 56).

Institutional opposition can be manifested through police harassment
of injection drug users via drug arrests, arrests of SEP participants
for carrying syringes, and harassment and arrests of SEP staff.21,22
We viewed these variables as symbolizing a "criminal justice"
approach to social problems, an approach consistent 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
Reporting Program county-level arrest data 58) and number of police
employees per 10 000 population (derived from Uniform Crime Reporting
Program data on police force employees).59

We categorized 2 types of organized or institutional support.

The first was the presence of an outreach program for injection drug
users and, in certain instances, their partners (compiled from data
reported by Brown and Beschner 60 and the National Institute on Drug
Abuse 61). The second was the number of methadone maintenance
programs in a given MSA as of 1989 (as reported in the 1989 National
Drug and Alcoholism Treatment Unit Survey 62). Finally, we classified
potential or actual community mobilization as efforts by grassroots
organizations and local activists to develop and sustain programs for
stigmatized groups.

General gay political influence and concern regarding HIV/AIDS
prevention and the direct involvement of gay and lesbian activists in
ACT UP may have influenced the establishment of SEPs and perhaps
deterred the efforts of political authorities to prevent their formation.

The following variables were used in assessing community mobilization
in support of SEPs: (1) the presence of an ACT UP chapter, many of
which initiated SEPs or expanded local drug treatment and other HIV
prevention service capacities (as cited in records maintained by
members of New York ACT UP and in various literature reviews 63-65;
19 MSAs had local ACT UP chapters as of 2000); (2) estimates of MSM
populations as a measure of potential AIDS-interested constituencies
52; 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 Information Data Set 55).

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
process to reduce the number of independent variables.

First, we conducted bivariate analyses to determine the independent
variables that exhibited a statistically significant association with
SEP presence (P(.20 was used as the screening criterion to avoid
deleting potentially significant predictors). Second, we grouped
variables found to be significant into 5 categories for domain
analysis.66,67 Next, within each domain, we used logistic regression
techniques to identify variables that were significant independent
predictors at P(.05. Finally, we applied logistic techniques to the
pooled set of independent variables significant at P(.05 to determine
the final model predictors.

Results

Within each overall category of indicators, there were significant
(P(.20) associations between independent variables and the presence
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 availability
category, number of public health and medical researchers and number
of drug treatment slots per 10 000 population were significant. In
the institutional opposition category, number of hard drug arrests
per 10 000 population was significant.

TABLE 2-Domain-Specific Bivariate Relations Between Independent
Variables and Presence of a Syringe Exchange Program (SEP): 96
Metropolitan Statistical Areas, 2000 (MSAs), 2000

In the organized or potential support category, 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 domain analyses (Table 3) at P(.05 (and their respective
domains) were (1) number of AIDS cases per 1000 injection drug users
(need); (2) number of public health and medical researchers per 10
000 population (resource availability); (3) percentage of MSM in the
population, presence of an ACT UP chapter, and number of methadone
maintenance programs in 1989 (organized or potential support); and
(4) number of hard drug arrests per 10 000 population (institutional
opposition). In addition, 2 socioeconomic indicators, percentage of
the population with a college education and MSA population, were significant.

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

In the final, fully adjusted model (Table 4), significant independent
predictors of the presence of an SEP as of 2000 were ACT UP presence
(adjusted odds ratio [OR].367; 95% confidence interval [CI]=1.111,
116.250) and percentage of the population with a college education
(adjusted OR=1.173; 95% CI=1.003, 1.372). Percentage of MSM in the
general population (adjusted OR=1.213; 95% CI=0.987, 1.490) was of
borderline significance.

TABLE 4-Significant Predictors in Multivariate Logistic Regression Analyses

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
multivariate analyses using this variable.

Approximately 40% of the MSAs in our study had SEPs despite not
having an ACT UP chapter. We conducted 2 additional analyses to
assess 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.

Significant predictors of the presence of an ACT UP chapter were
number of AIDS cases among MSM (adjusted OR=1.105; 95% CI=1.015,
1.202) and MSA population (adjusted OR=1.090; 95% CI=1.018, 1.167)
(Hosmer-Lemeshow goodness-of-fit test P=.6768). Predictors of ACT UP
presence were quite different from predictors of SEP presence. To
further explore the interaction between SEP presence and ACT UP
presence, we analyzed SEP presence among 77 MSAs without 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
chapters were percentage of the population with a college education
(adjusted OR=1.229; 95% CI=1.040, 1.452; P=.0156) and percentage of
MSM in the population (adjusted OR=1.250; 95% CI=0.997, 1.567;
P=.0520). Research has shown that, in many cities, SEPs have been
initiated by ACT UP members.17,63-65 Here this very direct form of
causation resulted in a large predictive value 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 research regarding this topic is needed to
understand the factors associated with the correlation 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 residents.

In the absence of ACT UP chapters, percentages of college-educated
residents and percentages of MSM in the population remained the
important predictors.

Discussion

Limitations Despite our efforts to gather variables that best
captured our theoretical 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.

For example, 1993 arrest data for Kansas, the District of Columbia,
and Florida were not available in the public use files.

However, we were able to compile Florida drug arrest data from
county-level data (state of Florida 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
potential community opposition, including opposition 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 Israel National Survey of Syringe Exchange Programs.
Twenty-seven of the 154 programs did not respond to the survey in
2000, despite repeated 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 earlier,
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) of the MSAs assessed.

Future research might include a spatial buffering component so that
such SEPs can be incorporated into the analyses.

Future studies should also include analyses of SEPs as a
time-dependent variable, which would help provide an understanding of
the geographic diffusion of programs in the United States over time
and across space. Conclusions Our results are consistent with current
theory positing that SEPs are often established as a result of
political pressure or direct action by grassroots activists and
organizations such as ACT UP. We identified 3 independent predictors
of the presence of an SEP. Overall, MSAs with high percentages of MSM
in their population 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 SEP. This indicates a strong
association between 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,
suggesting more concern with HIV/AIDS issues and education) are
positive factors in forming and, possibly, sustaining SEPs in the
United States. Furthermore, when we did not account for ACT UP
presence in the model, percentage of MSM in an MSA was significant.
Thus, SEPs are more likely to be located in areas with high
percentages of MSM, even after control for ACT UP presence.

This finding provides further evidence that efforts by grassroots and
AIDS activists have made a significant contribution to helping to
curb the HIV epidemic among injection drug 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 percentages of college-educated residents were more likely to
have SEPs. Although education may be a proxy for volunteerism,
research suggests that individuals with a college diploma are more
likely than those who have not attended college to be politically
involved,68 to engage in civic activities,69,70 and to be receptive
to new scientific technologies.71,72 It is likely that this
individual-level demographic factor translates into increased support
for SEPs at the MSA level. Contrary to our hypotheses, neither
resource availability nor institutional opposition predicted the
presence of an SEP. Need, as measured by the prevalence of AIDS cases
among injection drug users or the percentage of users in the MSA
population, also did not predict SEP presence, indicating a lack of
association between need and services aimed toward populations of
injection drug users.

Attempts to set up SEPs in New Jersey and Massachusetts serve as
illustrations of the political processes leading to this lack of
relationship. In New Jersey, injection drug use is the most
frequently reported risk behavior among HIV-positive individuals.73
Three of the state's MSAs (Jersey 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).52 The number of
IDU-related AIDS cases in the state peaked in 1993, accounting for
49% of the AIDS cases that year. Despite that alarming situation, in
April 1996 then Governor Christine Whitman rejected the
recommendations of her advisory council on AIDS to distribute clean
needles to injection drug users and allow the sale of syringes in
pharmacies. By 2000, the only publicly visible SEP in the state had
been suppressed. The current situation in New Jersey is unpredictable
and shaped by politics.

Under an executive order signed by former Governor Jim McGreevey 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 an injunction staying the
governor's executive order.

As a result, Atlantic City and Camden were not able to proceed (R.
Scotti, Drug Policy Alliance New Jersey, oral communication, December
2005). Two years after this study study was undertaken, New Jersey
Governor Job Corzine signed the Bloodborne Disease Harm Reduction
Act, which allows up to 6 cities in the state to establish SEPs. In
Massachusetts in 1993, then Governor William Weld passed a law
allowing 10 pilot SEPs in the state, with a clause leaving final
approval for implementing programs to each locality.

Since 1993, several Massachusetts SEPs have been established,
including programs in Boston, Cambridge, Provincetown, and
Northampton. The most positive political climate for implementing an
SEP was in Northampton, where the exchange was initiated by the mayor
and the health commissioner, however, Northampton did not have the
greatest 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.74
Although the city's mayor, health commissioner, public health
council, and board of health all had supported establishment of an
SEP since 1998, Springfield's city council vetoed the much-needed
program because of ongoing political pressure by a local citizen group.

The lack of correlation between program presence and need and the
continued reluctance of policymakers to implement controversial
initiatives such as methadone maintenance programs and SEPs can
thwart efforts to reduce HIV transmission among injection drug users
and their sexual partners. The lack of an association between program
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,36 maternal and infant health,39 and
smoking 35 is not related to the need for such programs.

When community needs are at odds with national policy, activism and
mobilization at the local level are essential in implementing public
health programs such as SEPs. 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 the 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 Research Institutes, Inc (supported by the National
Institute of Drug Abuse; grant R01 DA13336) and the National Survey
of Syringe Exchange Programs at Beth Israel Medical Center (funded by
the American Foundation 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 advice regarding
the Beth Israel Syringe Exchange Survey.

Human Participant Protection

No protocol approval was needed for this study.

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