In their review of reviews of sterile syringe access interventions, Palmateer and colleagues conclude that the evidence is weak or non-existent for effects on human immunodeficiency virus (HIV) and hepatitis C virus (HCV) incidence among injection drug users (IDUs), but stronger for reductions in injection risk behaviors for needle and syringe exchange program (NSEP) users but not for other sterile syringe access methods . The primary justification for this conclusion is that the vast majority of studies on sterile syringe access have used observational study designs. This justification highlights an important paradox in research on sterile syringe access. Namely, the high face validity of sterile syringe access interventions along with many observational and ecological studies on HIV seroprevalence, incidence and injection risk behaviors have led many researchers to conclude that an experimental design that withholds sterile syringes from an IDU control group would be unethical [2,3]. Because more rigorous research designs are not likely to be conducted on sterile syringe access interventions at this time, there is no rational justification to discount the utility of such interventions.
However, local, regional and federal governments all over the world have failed to protect the health of their peoples by allowing their stigmatization of drug users to justify ignoring common sense syringe access interventions. Recent examples of these failures include the excessive use of force against drug users by the federal government in Thailand , the potential abandonment of harm reduction prevention activities in Russia , the United States ban on federal funding for NSEP until December 2009 and the general low availability of sterile syringes in nearly every region of the world with growing or significant HIV and HCV epidemics [6–8].
Given the ethical barrier to research and the political obstacles to implementation of syringe access interventions, the most pressing question is not whether sterile syringe access prevents HIV and HCV, but rather what research approach will stimulate civil and governmental action to combat the growing epidemics of HIV and HCV among IDUs? We would like to suggest an agenda that includes the following three elements.
First, while commonalities exist among key individual-level risk factors related to HIV transmission in populations of IDUs, local risk environment conditions must be studied closely [9,10]. Researchers are uniquely positioned to describe key local conditions such as IDU social network size and connections, access to syringes and helping services, the impact of law enforcement practices and connections between IDUs and other high-risk populations. Because drug use is both stigmatized and illegal in most locales, multi-method research is required to describe risk patterns and connections and to understand the epidemiological significance of these conditions so that the appropriate prevention strategies can be employed.
Second, quality improvement studies of sterile syringe access are needed desperately. As Palmateer and colleagues have noted, we know little about how to maximize syringe coverage to IDUs. Similarly, not all NSEPs are the same and not all sources of sterile syringes have the same impact [11–17]. Research that considers the effectiveness of increasing sterile syringe access should include making syringes available at more venues, in different settings, as well as using existing IDU drug-using and social networks to distribute syringes to IDUs unwilling or unable to access them at conventional locations.
Third, sexual risk among IDUs has been a persistent problem. Several HIV incidence studies have suggested that sexual risks are more important than injection risk among IDUs [18,19]. The role that sterile syringe access sites might play in preventing sexual risk among IDUs has been largely unexplored. Aside from the distribution of condoms, which while not harmful appears to have very little impact on sexual risk among IDUs, few sexual risk reduction interventions have been situated in sterile syringe access sites. At a minimum, demonstration projects on the feasibility of locating promising sexual risk reduction interventions at NSEP should be considered. Novel sexual risk reduction intervention and other health promotion programs are needed for this population in general.
Sterile syringe access will not prevent every potential HIV or HCV transmission event, but it contributes invariably to lower injection risk, can be a singularly useful venue for providing other recommended health promotion activities and is certainly good enough, given the preponderance of evidence to recommend it widely as a critical element in efforts to prevent blood-borne infection among IDUs. Applied studies that document the various ways in which sterile syringe access strategies might be used to improve health outcomes among IDUs are needed urgently.