Consequences of a restrictive syringe exchange policy on utilisation patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk

Introduction and Aims: Syringe distribution policies continue to be debated in many jurisdictions throughout the USA. The Baltimore Needle and Syringe Exchange Program (NSP) operated under a 1-for-1 syringe exchange policy from its inception in 1994 through 1999, when it implemented a restrictive policy (2000-2004) that dictated less than 1-for-1 exchange for non-program syringes. Design and Methods: Data were derived from the Baltimore NSP, which prospectively collected data on all client visits. We examined the impact of this restrictive policy on program-level output measures (i.e. distributed:returned syringe ratio, client volume) before, during and after the restrictive exchange policy. Through multiple logistic regression, we examined correlates of less than 1-for-1 exchange ratios at the client level before and during the restrictive exchange policy periods. Results: During the restrictive policy period, the average annual program-level ratio of total syringes distributed:returned dropped from 0.99 to 0.88, with a low point of 0.85 in 2000. There were substantial decreases in the average number of syringes distributed, syringes returned, the total number of clients and new clients enrolling during the restrictive compared to the preceding period. During the restrictive period, 33508 more syringes were returned to the needle exchange than were distributed. In the presence of other variables, correlates of less than 1-for-1 exchange ratio were being white, female and less than 30 years old. Discussion and Conclusions: With fewer clean syringes in circulation, restrictive policies could increase the risk of exposure to HIV among Injection Drug Users (IDUs) and the broader community. The study provides evidence to the potentially harmful effects of such policies.