Human immunodeficiency virus (HIV) and other bloodborne pathogens are transmitted among injecting-drug users (IDUs) through the reuse and sharing of contaminated needles and syringes (NSs) (1). Of the 689 acquired immunodeficiency syndrome (AIDS) cases reported in Connecticut in 1992, 413 (60%) were associated with injecting-drug use. To help reduce IDUs' use of contaminated NSs, Connecticut enacted laws effective July 1, 1992, that allow the purchase without a prescription of up to 10 NSs at one time in pharmacies and the possession of up to 10 clean NSs.* Before this date, purchase and possession of NSs without a prescription had been illegal in Connecticut. This report presents preliminary information from the first 5 months of an ongoing evaluation to determine whether the new laws affected pharmacy-based NS sales, IDUs' reported knowledge of the laws and places to obtain NSs, and law enforcement officers' risk for needlestick injuries.

Investigation of Pharmacy-Based NS Sales

In June 1992, eight pharmacies in Hartford, a city of 139,739 (1990 U.S. Census), were enrolled in a sentinel surveillance system to monitor pharmacy-based NS sales. For 1992, the annual incidence of AIDS in Hartford was 86 cases per 100,000 residents. All sentinel pharmacies were located in neighborhoods where injecting-drug use was reported to be prevalent. Monthly prescription and nonprescription NS sales for each participating pharmacy were monitored beginning July 1992.

By November 1992, six (75%) of the eight pharmacies were selling nonprescription NSs. The number of nonprescription NSs sold by these pharmacies increased steadily each month through October 1992 (480 in July; 856, August; 1143, September; and 1560, October).

In the two pharmacies not selling nonprescription NSs in November, pharmacists reported they had sold nonprescription NSs when the law went into effect, but cited IDU-related incidents (i.e., a used syringe was found on a shelf and an IDU disrupted business) in their pharmacy as the reason for now refusing to sell. IDUs' Knowledge of Laws and Places to Obtain NSs

During August-November 1992, staff members at three HIV counseling and testing sites, two correctional facilities, and two drug-treatment centers in Connecticut interviewed active IDUs using a standard questionnaire. Active IDUs were defined as persons who reported using a needle or syringe to inject drugs into their veins, into their muscles, or under their skin during June 1992 and who reported using injected drugs during the 30 days preceding the interview. IDUs were asked about their knowledge of the new laws and NS-purchasing practices during the 30 days preceding the interview and during the 30 days before the laws became effective.

Of 124 active IDUs, 68 (55%) reported they were aware they could both purchase and possess clean NSs. An additional 26 (21%) IDUs were aware they could legally purchase NSs but did not know they could legally possess them. Thirteen (59%) of the 22 IDUs who were not aware of either law were men interviewed in correctional facilities.

More IDUs reported purchasing NSs from a pharmacy during August- October (51 {41%}) than during June (23 {19%}). This change included 27 IDUs who began purchasing from a pharmacy and two IDUs who reported not purchasing from a pharmacy after the new laws went into effect (p<0.001, sign test, matched-pair analysis). Those purchasing NSs during June may have been IDUs with diabetes, made illegal pharmacy purchases, or recalled inaccurately their purchasing during that time. Fewer IDUs reported purchasing NSs on the street during August-October (73 {59%}) than during June (92 {74%}); four IDUs reported they began purchasing and 24 reported they did not purchase on the street (p<0.001, sign test). However, of all methods to obtain NSs, purchases on the street (59%) were reported more often than purchases from pharmacies (41%). The prevalence of NS sharing was unchanged during both periods, approximately 36% of IDUs reported at least one episode of NS sharing.

In November 1992, four focus groups were held in Hartford with a total of 34 active IDUs to address issues regarding NS use and purchasing practices. Participants reported that many IDUs changed their NS-purchasing practices in July and began purchasing from pharmacies. Approximately two thirds of the IDUs attending the meetings were aware that clean NS possession was legal and reported they were now more likely to carry NSs with them on the street. Focus group participants reported that NS-sharing episodes were less frequent after the new laws went into effect.

Law Enforcement Officers' Risk for Needlestick Injuries

To determine whether Hartford police officers were at greater risk for needlestick injuries after the new laws went into effect -- because IDUs reported that they were more likely to carry NSs on the street -- Occupational Safety and Health Administration-mandated reports of occupational injuries and illnesses were reviewed for reports of needlestick injury among police officers. Needlestick injury rates among officers were similar during the 3 months before and after July 1 (two needlestick injuries in 423 arrests for opium, cocaine, or NS possession versus one in 478 arrests, respectively).

Reported by: Hartford Dispensary; Regional Network of Programs; Chemical Dependency Unit, Community Health Svcs; Hartford Police Dept; AIDS Program, Hartford Health Dept. AIDS Program, Bridgeport Health Dept. AIDS Program, Waterbury Health Dept. Health Svcs Div, Connecticut Dept of Correction. B Weinstein, MPH, AIDS Section, JL Hadler, MD, State Epidemiologist, Connecticut Dept of Health Svcs. Div of Field Epidemiology, Epidemiology Program Office; Clinical Research Br, and Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Office of HIV/AIDS, Office of the Director, CDC.

Editorial Note

Editorial Note: In July 1991, the National Commission on AIDS recommended removing legal barriers to the purchase and possession of NSs as part of a strategy for reducing the spread of HIV among IDUs unable or unwilling to enter drug treatment (2 ). Statutes in 44 states and the District of Columbia place criminal penalties on the possession and distribution of NSs (drug paraphernalia laws), and the sale of NSs without a medical prescription are prohibited in 10 states and the District of Columbia (needle prescription laws) (3). Although IDUs in some localities have begun to clean their NSs and to decrease NS sharing in response to the AIDS epidemic (4,5), NS sharing continues, reflecting the limited availability of NSs and the established practices of injecting-drug use (5-7).

Because the number and proportion of HIV infections related to injecting-drug use in Connecticut are high, efforts to prevent HIV infection among IDUs and their sex partners have been broad and include street outreach and drug-treatment-based education to encourage safer sex and injection practices, comprehensive drug treatment, HIV counseling and testing, and legalizing the availability of sterile NSs. In July 1990, the Connecticut legislature legalized needle exchange in New Haven, and in May 1992, the legislature approved and funded additional needle-exchange programs in Hartford and Bridgeport. Connecticut legislators also amended the state's needle prescription and drug paraphernalia statutes. Legalizing over-the-counter purchase of up to 10 NSs potentially expanded IDUs' access to sterile needles to include pharmacies in Connecticut that might choose to sell nonprescription NSs. Allowing possession of up to 10 clean NSs might encourage IDUs to carry their own NSs, thereby decreasing the likelihood of unsafe NS sharing.

A follow-up questionnaire survey of active IDUs is being conducted to determine whether the behaviors reported in these preliminary findings have changed and to better characterize NS-purchasing practices, NS ownership, and patterns of NS usage as IDUs' knowledge of the new laws becomes more widespread. One issue being explored is the discrepancy between questionnaire results indicating that no change occurred in NS-sharing practices while focus groups indicated that NS-sharing episodes decreased. The increase in the number of nonprescription NSs sold by sentinel pharmacies in Hartford probably reflects NS purchasing by IDUs but might also represent a shift from prescription to nonprescription sales to persons with diabetes or those who use NSs for medical purposes. To better define pharmacists' knowledge, attitudes, and practices regarding nonprescription NS sales, pharmacists will be interviewed in person and be surveyed by mail during 1993.

References

1. Schoenbaum EE, Hartel D, Selwyn PA, et al. Risk factors for human immunodeficiency virus infection in intravenous drug users. N Engl J Med 1989;321:874-9.

2. National Commission on Acquired Immune Deficiency Syndrome. The twin epidemics of substance use and HIV. Washington, DC: National Commission on Acquired Immune Deficiency Syndrome, July 1991:10-1.

3. Gostin L. The needle-borne epidemic: causes and public health responses. Behavioral Sciences and the Law 1991;9:287-304.

4. CDC. Coordinated community programs for HIV prevention among intravenous-drug users -- California, Massachusetts. MMWR 1989;38: 369-74.

5. Selwyn PA, Feiner C, Cox CP, Lipshutz C, Cohen RL. Knowledge about AIDS and high-risk behavior among intravenous drug users in New York City. AIDS 1987;1:247-54.

6. DesJarlais DC, Friedman SR, Sotheran JL, Stoneburner R. The sharing of drug injection equipment and the AIDS epidemic in New York City: the first decade. In: Battjes RJ, Pickens RW, eds. Needle sharing among intravenous drug abusers: national and international perspectives. Washington, DC: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1988. (NIDA research monograph no. 80).

7. Grund JPC, Kaplan CD, Adriaans NFP. Needle sharing in the Netherlands: an ethnographic analysis. Am J Public Health 1991;81:1602-7.

• Connecticut General Statutes, Sections 21a-65, 21a-240, 21a-267, 1992. Under the new laws, pharmacies are permitted, but not required, to sell NSs without a prescription.

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