Syringe Access, Use & Discard: Context in AIDS Risk Study (NIDA Grant # RO1 DA12569, PI: Merrill Singer, PhD)

1. Syringe Access, Use & Discard: Context in AIDS Risk Study (NIDA Grant # RO1 DA12569, PI: Merrill Singer, PhD) • Hispanic Health Council, Htfd., CT: Tom Stopka, MHS, Merrill Singer, PhD, Claudia Santelices, ABD, Wei Teng, PhD, Glenn Scott, Susan Shaw, PhD, Anna Marie Nicolaysen, MA, Julie Eiserman, M.A. • Yale Univ. Dept. of EPH: Robert Heimer, PhD, Kaveh Khoshnood, PhD, Mark Kinzly, Anthony Givens, Kevin Irwin, BS • UMass SPH: David Buchanan, DrPH • New North Citizens’ Council, Spfd.: Antonio Arzola • Spfd. SW Comm. Hlth. Ctr., MA: Sabrina Simmons

3. Public Health Interventionists, Successful Capitalists, Harbingers of Risk? Syringe Sellers in Connecticut and Massachusetts Tom Stopka1, Merrill Singer1, Claudia Santelices1, Wei Teng1, Robert Heimer2, Susan Shaw1, Anna Marie Nicolaysen1, Mark Kinzly2, Kaveh Khoshnood2, David Buchanan3, and Glenn Scott1 1) Hispanic Health Council, Hartford, CT; 2) Yale University, New Haven, CT; 3) University of Massachusetts, Amherst, MA

4. Need for a New Intervention • 10 years since any new public health interventions have been attempted to reduce HIV and Hepatitis transmission among IDUs • SEP • OTC sales of pharmacy syringes • Outreach efforts • Bridge to treatment programs • Need a new approach • Can syringe sellers fill an important harm reduction niche?

5. Methods • In-depth Interviews (N=25): • Hartford: 20 IDIs with 18 syringe sellers Springfield: 7 total • Hartford: 13 Latino, 3 AA, 1 white, 1 M.E. Springfield: 4 PR, 2 AA, 1 white • Hartford: 15 male, 3 female; mean age = 37 Springfield: 3 male, 4 female; mean age = 39 *Syringe sellers difficult to locate in New Haven* • Structured surveys with IDUs (N=878) • Ethnographic Observations

6. Syringe Source Used Most ) Often, Past 30 Days (N=878) Categorization of syringe sellers and diabetics is based on perceptions of IDUs who were interviewed.

9. Rationale for Selling Syringes • Easy Labor -- “I started hanging around on the corner right over here ..., and I saw some people selling syringes, and selling drugs. I had no choice. I don’t do no drugs. And the syringes were easy to sell. So, I said, ‘hell, that is what I am going to do.’” (Hartford) • “Easy money” • “Insurance source…wouldn’t have to go steal…” • “Less worries” with police • Harm Reduction -- “So I got hepatitis C. That is why I am selling [sterile syringes] now…I don’t want nobody to catch that.” (Hartford Seller)

10. Typology of Syringe Sellers in Hartford and Springfield • Opportunistic Sellers -- “I got a box of syringes from a friend for a couple of bucks and I sold them.” • Bulk Sellers -- “I sell about 40-50 syringes a day.” • Subcontractors (Hartford) -- “I give you 30 syringes, and what you do is you work this end of the street and I work this end of the street…The more you sell, the more money you make. I give you 30, you give me $20 and you keep ten…”

11. Clientele • IDUs who... • Don’t want to be seen at SEP or pharmacy (Hartford) • Want to maintain a low profile • Find seller’s schedule and location more convenient • Male (74%) and female (26%) IDUs • Regulars vs. “weekend junkies” (Hartford)

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

13. IDU Perceptions of Syringe Sellers • Hierarchy of Risk • Diabetics (non-IDUs) most trusted sellers. “… I know that she is not a drug user. The other sources are drug users and you know, when you are a drug user, you say, no I never touched them and I’m clean. But you know, they ain’t gonna tell you, yeah I’ve got HIV, wanna buy these?” (Hartford IDU) “...it’s just medicine, it’s not like they shooting drugs or anything...” (Springfield IDU) • “Alcoholics” next most trusted • Fellow IDUs least trusted as syringe sellers

14. Risky Sales “One time a dude asked me, and I had no syringes, and he said he had to get off, I said ‘I got a couple of used ones in the draw’r, but I got Hepatitis,’ so whatever, I said ‘if I give it to you, I am telling you now, you got to clean it.’” (Hartford Seller)

15. Economy of Syringes I • Variations in price: • Sliding scale = $1.00 to $5.00; new and used pricing variation in Springfield • Good days vs. bad days -- “Sundays are my good days. I sell syringes for $2.00. During the week I sell for $1.00.” (Hartford Seller) “Beginning of the month is good for sales.” • Availability determines price • Syringes sold on credit at higher prices

16. Economy of Syringes II • Street sales vs. house sales • Syringes as currency

17. Syringe Prices, by Source and City

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

20. Street Selling Strategies • New Sellers: “Tengo ganchos” • Experienced sellers: word of mouth • “Sales”: 2 for 1, “…five for two dollars.” • “Referral system” with drug dealers • “One stop deal” • Shelter business

21. Sales Challenges • Police: “That (possession of syringes) will get you a year in Jail” (Springfield) • New faces • Syringe inventory depleted quickly (especially around 1st of month in Springfield) • Gangs (Hartford) • Competition

24. Sterility of Syringes Purchased from Syringe Sellers • Hartford: 0 of 59 syringes tested positive for human DNA (new syringes) • 37.9% originally from SEP • 8.4% individually wrapped • Springfield: 9 of 76 syringes (11.8%) tested positive for DNA positive (9 used syringes). • New Haven: 0 of 2 syringes positive (outlier-syringe selling seems very rare)

25. New Haven • Most participants were reluctant to talk about street sellers. • IDUs shocked by the thought of repackaged syringes. • 10 years of increased syringe availability through SEP and pharmacies. • Conscious effort by police to shut down syringe sellers. • No “Street Peddler” tradition.

26. Conclusions: Syringe Sellers... • can improve harm reduction efforts by increasing access to sterile syringes, filling a gap in supply • may decrease the possibility of IDUs experiencing crisis events with syringes • sell more sterile syringes in Hartford than in New Haven and Springfield • can play an integral part in future HIV and hepatitis interventions

27. Operationalizing Syringe Sellers as Public Health Advocates • Conduct further research about public health risks and benefits of street sellers. • Educate sellers on safe sales practices. • Advise IDUs on purchase precautions. • Encourage street sellers to sell/hand out harm reduction materials (e.g., water, cookers, etc.). • Consider creating a formal relationship between DPH and street syringe sellers.