How otherwise dedicated AIDS prevention workers come to support state-sponsored shortage of clean syringes in Vancouver, Canada

Abstract

Vancouver continues to experience an ongoing HIV outbreak among injection drug users despite the presence of North America’s largest needle exchange programme. The present study utilizes ethnographic interviews and observations conducted with fixed site and mobile van ‘exchange agents’ to examine access to sterile syringes by IDUs in Vancouver between May 2000 and March 2001. Point-for-point exchange continues to be the dominant policy. Ethnographic evidence suggests that there is a large demand for sterile syringes (‘rigs’) when users do not have any to return, indicating policy/practice discrepancies. Despite policy, an intricate rig loaning system has evolved out of agreements made between needle exchange agents and their clients. Restrictive syringe exchange policies lead to considerable unmet needs among injection drug users. Policy makers must change their policies to better address issues of syringe access and in consultation with user groups, develop alternative models of needle distribution and recovery that do not necessarily include exchange.

Introduction

The Downtown Eastside of Vancouver is an entrenched inner city neighbourhood, among the most impoverished in Canada, and well known for its public drug use scene and bustling sex trade industry. Combined, the drug hustles and police sweeps create an atmosphere laden with danger, volatility and vulnerability. Overdoses in the alleys, parks and single room occupancy hotels (SRO) are commonplace, and physical violence and sexual assaults against women are prominent and persistent problems. Since the mid-1990s, the Downtown East Side has experienced an explosive and ongoing HIV epidemic among injection drug users (Spittal et al., 2002, Strathdee et al., 1997). The annual HIV incidence rate of 18% among injection drug users observed in 1997 is among the highest ever documented in high income countries (Strathdee et al., 1997), and the prevalence of hepatitis C exceeds 90% (Miller et al., 2002a). HIV incidence rates in recent years remain above 3%, higher than most North American cities (Spittal et al., 2001). At the same time, the neighbourhood is home to one of the largest needle exchange programmes (NEP) in North America. This programme was implemented in 1988 and exchanged more than 2.5 million needles in 2002 (Bardsley, Turvey, & Blatherwick, 1990; Tyndall et al., 2003).

The role of NEPs in disease prevention among IDUs continues to be highly controversial, particularly in the United States (Moss, 2000b). A ban on federal funding of NEPs remains in place in the US (Lurie & Drucker, 1997). When we previously reported that HIV prevalence among those who frequently attended the NEP in Vancouver was higher than among those who attended less frequently (Strathdee et al., 1997), some observers, both Canadian and American, interpreted these observations to suggest that needle exchange programs may promote the spread of HIV (Bellm, 1999, Bennett, 1998). For example, on September 11, 1997, Representative Dennis Hastert proposed an amendment to a yearly appropriations act that would prohibit the use of federal funds for NEPs in the US indefinitely. During debate in the House of Representatives in September 1997, he stated that “what the Vancouver studies have shown is that intravenous drug users who use the needle exchange have a greater chance of becoming HIV positive than intravenous drug users who do not use the needle exchange.” To address such interpretations, we subsequently demonstrated that the association with HIV was entirely due to selection bias (Schechter et al., 1999). We have also demonstrated that acquisition of syringes from the NEP is independently associated with less high-risk syringe sharing (Wood et al., 2002b).

Nevertheless, the fact that one of North America’s most intense HIV epidemics among IDUs occurred in the presence of one of its largest NEP remains unexplained. The Vancouver experience continues to be cited as possible evidence against the effectiveness of NEP’s. The majority of studies have found benefits to making sterile needles accessible to IDU; however, high levels of needle sharing persist in Vancouver despite the presence of fixed sites and mobile exchange. Difficulty in accessing syringes appears to explain much of this risk behaviour (Wood, Tyndall, & Kerr, 2001). Despite the fact that needles are accessible, public health authorities in Canada and in some US jurisdictions are now turning their attention to the more critical questions surrounding the safest and most effective means of providing this service (Coffin, Linas, Factor, & Vlahov, 2000). As Andrew Moss suggested, “I think that [needle exchange programs] need to be shown to work. If they did not work in Canada, I would like to know why not, and what the implications are”(Moss, 2000a). The reasons why IDU have difficulty accessing syringes have not been evaluated through ethnographic research in this setting.

In this article, we report on findings of a qualitative research study addressing questions of policy and practice in Vancouver’s needle exchange programming. We investigate the role of needle exchange personnel in attempting to provide access to sterile equipment. We also study the critical role that “point-for-point” policy (i.e. giving one clean needle or “rig” for every used one returned) and “loaner policy” (“loaners”, i.e. giving out clean needles to those who need them even without used ones to exchange) may have played in the Vancouver epidemic.

As in most North American cities, the goal of needle exchanges is to provide access to sterile syringes to those people who use injection drugs in order to prevent the sharing of contaminated equipment. Exchanges commonly exchange syringes on a “one for one” basis and maintain a count of the number of syringes given out and the number of syringes returned. At any one time, one or two rigs are given out without expecting the users to have one or two rigs available to exchange, and any requests beyond that number should in theory be denied. Some exchanges in both the United States and Canada also maintain trading limits (a limit on the number of needles a person may exchange at any given time).

Vancouver’s first needle exchange was initiated informally by the Downtown Eastside Youth Activities Society (DEYAS) in August of 1988 and was formally funded by the City of Vancouver and the Federal Ministry of Health by March of the next year. Two staff members were hired, and initial trading limits were two rigs per day or fourteen rigs per week. In 1989, the total volume traded and returned was 127,806. At that time, the estimated HIV prevalence among the city’s active injection drug using population was approximately 1–2% (Bardsley et al., 1990).

Between 1990 and 1992, the needle exchange put a van on the road and a policy of exchanging two new rigs for one used rig was adopted to increase needle availability. In addition, anyone presenting with a health condition that predisposed them to injection risk, e.g. a person with hepatitis, was allowed to exchange at twice the stated limits. They were monitored to ensure that they received the social and medical referrals they needed.

Responsibility for funding the NEP shifted from the City of Vancouver to the British Columbia provincial government of British Columbia by the end of 1992. In that year, the exchange traded 607,385 rigs. However, in 1993 the quality and quantity of cocaine available to users in the Downtown Eastside changed. With greater availability of powder cocaine, injection cocaine use rose dramatically, leading to greater client demand for needles. As a result, the exchange limits were changed from 2 to 4 rigs per day, or 28 per week (up to 14 at one time) and 3 per mobile van visit. In 1993, a second van was put on the road and the total volume traded was just over 600,000 rigs.

In 1994, with escalating costs and limited budget the exchange was forced to take one van out of service. When public health officials began to note increases in the proportions of IDUs testing HIV positive in BC between 1993 and 1995, an outbreak investigation of just over 1000 IDUs was initiated by the BC Centre for Disease Control and the BC Centre for Excellence in HIV/AIDS. Prevalence rates of approximately 23% were observed at baseline with a subsequent annual incidence rate of 5.3% (Patrick et al., 1997). In addition to the noticeable presence of quality powder cocaine on the streets of Vancouver, these findings indicated the urgent need for programme expansion and policy re-examination.

In October of 1994 DEYAS’ budget was increased by the BC Ministry of Health. Exchange limits were doubled and plans were made to increase mobile exchange operations. In 1995, DEYAS added another evening route and, early in the year, another overnight van. A total of 1,815,480 rigs were exchanged in 1995, triple the number exchanged in the previous 2 years. By 1997, after incidence rates as high as 19% were detected within the Vancouver Injection Drug User Study cohort (Strathdee et al., 1997), the epidemic in the Downtown Eastside was declared a medical emergency by the regional Health Board. In February of 1997, DEYAS adjusted exchange maximums to 14 per day and 98 per week.

Since that time, the DEYAS needle exchange programme has expanded into a 24-h operation in the Downtown Eastside with a complementary system of fixed site, mobile vans and foot patrols reaching clients around the clock. In addition to the formal needle exchange apparatus, secondary exchanges also operate. In-house hotel exchanges exist to service clients in close proximity to where they live and use, and DEYAS continues to provide drug paraphernalia to two peer-driven (user-centred) exchange initiatives. Limits on bulk exchange were lifted prior to the initiation of this study.

Needle exchange policy in British Columbia, Canada is determined and evaluated by the Office of the Provincial Health Officer. NEP policy recommendations at the provincial level are heavily informed by the needle exchange politics of the Downtown Eastside community and the Vancouver Coastal Health Authority. Unlike the shift toward more liberal needle exchange policy demonstrated in the Province of Quebec, the policies in Vancouver during the study period emphasised the importance of ‘point-for-point’ exchange.

There are two main reasons given for this policy. First, it has been argued that exchanging rather than distributing rigs facilitates more contact between clients and needle exchange agents. Many users are homeless and living perilous lives on the streets, and the exchange agents are sometimes their only regular contact with service providers. Therefore, it is argued that the needle exchange, through contact with exchange agents, can offer its clients medical and social services that they may never otherwise access. Second, focus on exchange as opposed to distribution addresses community concerns regarding stray rigs in alleyways, schoolyards, public washrooms and parks. Funders and Health Boards definitely want to know how many rigs go out and ensure that they come back in. The policy adopted by DEYAS is clearly linked to the concerns expressed by their funding agencies about needle recapture.

Prior to the initiation of this study, there were reports of an informal system of distributing one or two ‘loaners’ to clients who had none to exchange. Restrictive trading policies, if followed, could clearly have a significant negative impact on the availability of sterile needles. The present study was conducted to explore what, despite policy, is the practice of needle exchange and/or distribution among exchange agents who are responsible for the distribution and collection of needles and drug paraphernalia.