This is the first systematic survey addressing specifically the prevalence of and program characteristics associated with police practices targeting SEPs and their clients. The analysis supports our hypothesis that SEP authorization and laws governing syringe possession do not influence substantially the frequency of police interference. Gaps in street-level implementation of laws designed to improve syringe access [39
] help to explain this finding and suggest that, without targeted efforts to change police policies and practices on the local level, formal legal reform alone may be insufficient to maximize the impact of SEPs and other interventions targeting IDUs.
Our findings also support the hypothesis that SEPs operated by health departments experience frequencies of police interference similar to other SEPs. This suggests that lateral communication between government agencies is not realized fully. Further, the results support the hypothesis that more visible programs—those serving more sites/week—are more likely to experience police interference. This may result from the larger geographic footprint of the programs, their visibility and their general ‘exposure’ to police activity.
That stationary exchanges experienced less frequent uninvited police appearances suggests that officers may be less likely to make unannounced visits if they know when and where SEPs are in operation. Consequently, programs may benefit from educating police about SEP locations and scheduling. Overall, communication and coordination between police and SEPs may reduce police interference, yielding improvements in overall effectiveness and cost-effectiveness [34
]. This finding adds urgency to efforts to improve harmonization of effort between police and public health professionals. Closer analysis of SEPs at the extremes of the distribution continuum—those reporting very frequent or no problems with police (see )—can help to identify additional factors that shape such alignment. The latter group is especially notable, as it may represent SEPs already working in harmony with law enforcement agencies.
The greater risk of client arrest and unauthorized confiscation of injection equipment reported by SEPs serving primarily people of color underscores a pernicious disparity. This finding hints at a mechanism by which racial disparities in police interactions—such as stop-and-frisk searches, questioning and arrests—can deter participation in SEPs, and ultimately translate into elevated incidence of HIV infection in minority communities [49
]. Further research is needed to examine how IDUs’ experience of these interactions and attitudes about police and criminal justice system influence the psychological, social, economic and other costs of participating in HIV prevention programs. In addition to the public health imperative to reduce HIV incidence, social justice concerns dictate increased emphasis upon and funding for empirical inquiry in this domain of health and human rights research. In view of mounting evidence that criminal justice involvement and adverse police events can influence HIV risk behavior [25
], we advocate for the inclusion of items addressing this domain in behavioral surveillance surveys such as the US National HIV Behavioral Surveillance System, as well as in analogous international instruments.
Our finding that having a system for monitoring police events was associated with perceptions of more frequent interference may have a number of explanatory mechanisms. Some programs may institute a formal documentation policy as an institutional response to past adverse events and continue to experience higher levels of such events. Alternatively, these surveillance systems may be instituted on recommendations from oversight agencies or through horizontal knowledge exchange between SEPs. With data collection policies and systems in place, clients may be more likely to be prompted to report adverse events. In turn, these reports may be more likely to be captured, aggregated and discussed regularly than in settings without documentation systems. Collecting and tabulating adverse event data systematically may equip SEPs to engage in advocacy, litigation or other responsive activities that can help curb incidence, but the cross-sectional nature of this survey does not afford an opportunity to evaluate this effect. Future research should examine if, when and how programs use these data and whether having documentation systems influences adverse event incidence over time. Understanding what distinguishes programs that already collect this information and how these data are gathered and utilized can inform technical assistance efforts and funding priorities.
This research also dictates building a knowledge base about SEPs’ other responses to police interference and their ability to effectively prevent or address it. Measuring the influence of police-related experiential and attitudinal factors on SEP utilization necessitates triangulation. Such inquiry should include research with SEP clients, non-client IDUs and program staff, as well as police. Better understanding of these factors is antecedent to efforts to harmonize public health and criminal justice efforts [50
This study has a number of limitations. Although our sample covers roughly two-thirds of all US SEPs, it is possible that some unaddressed factors distinguish responding programs, introducing sample bias and limiting generalizability. Despite the broad coverage, our sample size is relatively small; a larger sample, or a research design that directly captured individual clients’ experiences, could add statistical power to our multinomial regression analysis.
Our conclusions about the lack of association between the SEP’s legal environment and the perceived frequency of adverse police events should be interpreted in the context of a caveat: we utilized respondents’ report of the law, which may deviate from the jurisdictions’ actual laws. We identified minor discrepancies between states’ legal stance on syringe possession and responses given. It is beyond our capacity to determine such discrepancies on the local level. Policies regarding syringe possession are often conflicting and confusing, but these data suggest that SEP managers are not always optimally informed about the regulatory environment in which they operate.
Other limitations include definitional shortcomings within our instrument. For example, the term ‘police harassment’ may capture a broad range of subjective experience. Similarly, we assumed that uninvited police appearances at SEPs represent adverse events, but it is conceivable that such appearances may also represent neutral or positive interactions. Despite satisfactory piloting, the wording of some items may have been interpreted differentially by respondents. Another limitation is that three of the four outcomes reflect the SEP managers’ perceptions of client experience, which may underestimate the true levels for several reasons: (i) most programs report not collecting such data systematically; (ii) SEP managers do not always have direct, regular client contact; and (iii) client and staff attrition may mask the true incidence of adverse events, especially because only the experiences of those clients who continue to visit the SEP are captured. Although SEP managers are likely to be the ones to assess aggregate levels of police interference most accurately, assessing respondents’ years of service and connection to daily operations might have informed determination of potential biases. In the absence of a systematic nation-wide IDU survey on this topic, however, program managers’ reports serve as an important source of preliminary data.