Two years after the implementation of California’s DPDP, and in a city where 81% of pharmacists report selling syringes without a prescription,19
results from this small study suggest that SEPs still provide the majority of syringe distribution and disposal services to San Francisco IDUs. However, 39% of IDUs who participated in this study now also access sterile syringes from pharmacies in a jurisdiction where both sources are available. After adjusting for SEP use, unsuccessful attempts to purchase syringes at a pharmacy were significantly associated with using and giving away previously used needles. These data suggest public health benefits from reducing barriers to syringe access at pharmacies.
The association between an inability to obtain syringes from a pharmacy and giving away used syringes is noteworthy. Whether this association is confounded or mediated by an unmeasured factor, or whether it is indeed a true effect, is currently unclear. While the current study is unable to determine the mechanism through which barriers to pharmacy-sold syringes would influence giving away used syringes, several possibilities exist. For instance, an inability to purchase syringes at a pharmacy may be correlated with an inability to dispose. If the closest pharmacy to which an individual lives does not dispose of syringes, s/he may have more syringes on hand to lend. Additionally, if the closest pharmacy to which an individual lives does not sell syringes, s/he may keep the few owned in her/his possession, making these syringes more accessible and thus more likely to be loaned.
Due to the cross-sectional nature of the current study, results presented herein cannot be directly compared to several longitudinal studies regarding the impact of syringe access through pharmacies on IDU risk behavior. However, given that an inability to access syringes through a pharmacy was correlated with using and giving away previously used syringes, these results are consistent with the longitudinal evidence to date, indicating that increased options for syringe access predict lower risk behaviors. For instance, Cleland et al. found that safe syringe disposal increased following New York’s expanded syringe demonstration program;15
Singer et al. reported that pharmacies were an important source of sterile syringes 4 years after policy changes that allowed sales in Connecticut,21
and results reported by Des Jarlais et al. suggested that a comprehensive public health approach, using multiple strategies across systems, could enhance the prevention of blood-borne pathogens.22
Taken together, these studies suggest that pharmacies can be an effective and sustainable mode of reducing injection-related HIV risk by augmenting syringe access established at programs such as SEPs.
Potential discrepancies within and between studies regarding pharmacy access to syringes should be noted. First, an unsuccessful attempt to purchase syringes through a pharmacy was a significant correlate of high-risk behavior in the current study; however, successfully purchasing a syringe through a pharmacy was not a protective factor. This suggests differences between persons who are able and those who are unable to purchase syringes at a pharmacy, and emphasizes a need to focus prevention efforts on persons who are unable to access resources. Given the cross-sectional nature of the current study, it is possible that persons who unsuccessfully attempted to purchase syringes at a pharmacy may have had higher baseline risk profiles, not that unsuccessful attempts to purchase a syringe prompted high-risk behavior. In addition, given the nature of the available data, an inability to purchase syringes may have stemmed from unusual purchasing times/locations12
or an inability to pay rather than reluctance on the part of the pharmacists. However, using the example of giving away used syringes, variables that have been traditionally associated with baseline risk behavior, such as injection frequency, income, and age, were not strong correlates. Thus, the results suggest that barriers to accessing syringes through a pharmacy may have potential detrimental effects on the risk behavior of IDUs. In addition, even though Cotton-Oldenburg et al. reported increases in pharmacy use and decreases in syringe sharing following changes in Minnesota legislation that permitted non-prescription syringe sales,16
there were no reported differences in safe syringe disposal. The current study also found no significant association between purchasing syringes at a pharmacy and safe syringe disposal, which is inconsistent with results from New York City. Whether differences are due to study design or geographical differences in legislation implementation or IDU behavior are unclear. Legislation is often passed more quickly than research funding can be obtained to evaluate it; however, future individual-level longitudinal data collected before and after policy change would provide important data to address these potential differences. While a better understanding of the differences within and between studies is needed, as well as a more detailed understanding of how and why the studies presented herein influenced IDU risk behavior, each study cited has found significant associations between non-prescription syringe access and decreases in injection-related risk behavior, consistently indicating a role for pharmacies in the reduction of blood-borne pathogens.
These results, in combination with others cited herein, have implications for further reductions in syringe-related risk that may be possible in the context of legal syringe access through pharmacies. First, increasing the number of pharmacies that sell syringes without a prescription may decrease the number of persons who unsuccessfully attempt to purchase syringes at a pharmacy. In addition, as reported in New York, an increase in the use of pharmacies over time would be expected among IDUs who have not yet accessed them.23
Increased availability through pharmacies and increased uptake by IDUs could decrease the risk of injecting with a used syringe and giving away used syringes. Second, efforts to develop more accessible systems of accepting and disposing used syringes at pharmacies, and efforts to encourage IDUs to dispose of used syringes at pharmacies, may increase pharmacy-based syringe disposal. Third, developing bridges between pharmacies and SEPs would increase options for safe acquisition and disposal. In this environment, educating SEP staff and IDUs about pharmacy options and locations, as well as educating pharmacists about SEP options and locations, would be important. The education and coordinated efforts of pharmacists, health care providers, and public health practitioners to improve access to sterile syringes through pharmacy sales is a long-standing goal24,25
that has been substantiated by more recent findings19
as well as the current study.
While this study’s strengths lie in its community-based approach, some limitations should be considered. Even though interviewers did not collect identifying information, data were self-reported, thus socially desirable responding as well as recall bias were possible. However, no evidence exists to suggest that either response or recall bias would differ by persons who do or do not use pharmacies or SEPs. Data were also cross-sectional, making it impossible to establish incidence or change over time. Additionally, the small number of respondents resulted in wide CIs for some associations. Finally, in the context of California’s current implementation of expanded syringe access, these results may only be representative of California Jurisdictions with the highest levels of syringe access. This is because the county of San Francisco enacted the DPDP, and the proportion of participating pharmacies was high (81%) relative to other approving California Local Health Jurisdictions.19
In this environment, accepting and giving away used syringes were more likely among individuals who had unsuccessfully tried to purchase syringes at a pharmacy.
In an environment where SEPs are available, pharmacy syringe sales are legal, and a high proportion of pharmacies register to sell syringes; over one third of IDUs draw on both syringe sources, and measures of success in accessing each are associated with safe syringe-related behavior, while few IDUs utilize pharmacies for disposal. This and earlier studies suggest that increasing the number of options for syringe access and disposal in other California Local Health Jurisdictions would facilitate lower risk behaviors, thereby decreasing the risk of infections with blood-borne pathogens.