Here's a research proposal I wrote for a research methods class based on work I was involved with in the Tenderloin.


Happy Birthday to me! My mom got me HIV and HCV. The HIV ones had "condoms" attached and came in a "sharps" container (she labeled a tupperware with a sharps notice). The HCV also came in the sharps container and had a toenail clipper associated with it. She's a funny lady!)

Intravenous drug use (IDU) is closely associated with the spread of three blood borne viruses (BBVs). These viruses include Hepatitis B (HBV), Hepatitis C (HCV) and the Human Immunodeficiency Virus (HIV) (CDC 2002). While widespread adoption of the HBV vaccine has almost eliminated HBV incidence, there is no such prevention for HIV and HCV. Indeed, 36% of all HIV infected individuals contracted the disease after beginning to inject drugs (Wodak & Crofts 1996). Unfortunately, HCV infection has proved more virulent than HIV in the IDU community; indeed, estimates indicate that 60% of HCV positive individuals contracted the disease after engaging in IDU (CDC 2002).

One successful way of decreasing HIV incidence from IDU has been through Needle Exchange Programs (NEPs). These programs are usually open forums which allow the exchange for clean syringes, sterile equipment, safe sex supplies, vitamins, and risk reduction counseling (Strathdee & Vladhov 2001). Despite a shared mode of infection, NEPs have not been successful in reducing the incidence rate of HCV. This leads us to ask “what features of Needle Exchange Programs are effective in mitigating the spread of HCV in San Francisco?”

This question will be evaluated by using samples from the seventeen weekly needle exchanges in San Francisco. San Francisco is an appropriate venue for evauation due to an ample sample population. These characteristics make the population difficult to serve due to their transient nature and distrust of the system. While presupposing that organizations gear their needle exchanges to their specific communities, one avenue of analysis will evaluate program literature given at each NEP and the underlying philosophies of the organization funding the NEP. Furthermore, attention will be given to the items available at the needle exchange to evaluate the overall social and physical efficacy of the exchange.

 Theory and Framework

There are two social theories surrounding IDU: Reduction and Harm Reduction. Reduction, the current policy held by the United States government, does not provide significant sums of money to drug rehabilitation programs and holds that illicit drug users are breaking the law, and as such we have a moral obligation to penalize these users and dealers through the prison system. Criminalizing these acts may exacerbate their addiction, contributing to further disintegration of society (Drucker et al. 1998).

For Harm Reductionists, abstinence from illegal behaviors, while a desirable end, is not the goal. Instead practitioners focus on lessening the negative impact of the behavior (Riley et al. 1999). Both legal (eg alcohol or tobacco use) and illegal (eg heroin or crack) behaviors are targeted through harm reduction (Des Jarlais 1995). Moral ambiguity is often associated with this perspective, indeed, harm reductionists eschew judgment and support client decision making (Riley et al. 1999).

To diminish the negative outcomes of Injection Drug Behaviors, harm reductionists employ two main courses of action: needle exchange programs (NEPs) and methadone therapy. Needle Exchange Programs are usually more than just places to dispose of used syringes and procure new syringes. Indeed, these NEPs are often gateways to supportive services, including methadone treatment, for IDUs (Strathdee & Vlahov 2001).

NEPs have proved effective in curbing HIV rates. In a study of 29 cities with NEPs there was a 5.8% decrease in HIV incidence each year while in 51 cities without NEPs the rate increased by 5.9% each year. This 11.7% gap is a significant difference in infection rates (Strathdee & Vlahov 2001). Furthermore, the act of continually exchanging needles appears to make individuals more aware of the potential harms of their actions, and individuals who always exchange their needles are 70% less likely to contract HIV than IDUs who never exchange their needles (Des Jarlais 2000). Despite the fact that HIV and HCV are coinfections, indeed, estimates indicate that 50-90% of IDUs are coinfected, this decrease in HIV rates through NEPs has not correlated in a decrease in HCV rates (CDC 2002). If NEPs are going to be utilized as a means to decrease HCV incidence, their features, as well as the overall efficacy of NEPs must be interrogated.

HCV Incidence: A NEP “Failure”

There is a lack of research concerning the effects of NEPs on HCV rates in the United States and Europe (Roy et al. 2002). The following paragraphs provide a broad summary from several cases indicating a lack of prevalence reduction on HCV rates.

Within the United States, selections were taken from New Mexico, Washington, California, and Illinois. Samuel et al.’s (2001) article concerning urban exchange in New Mexico supports a link between NEPs and lower rates of HCV. From Tacoma, Washington, Hagan et al.’s 1995 study concluded that incidence rates of HCV could be lowered by a factor of seven via the utilization of NEPs. Unfortunately, Hagan et al.’s 1999 follow-up article indicated that HCV rates did not continue to decrease with the continued use of NEPs. Bluthenthal et al.’s (1999) report on Oakland, California focused on methods to reduce BBV in high risk individuals. The focus of their analysis, concerning sexual partners and the habits of young users, indicated two possible target communities while showing no measurable change in HCV rates with NEP access. In two articles, Thorpe et al. (2000 &2001) showed that no measurable change in HCV rates in Chicago as a result of traditional NEPs.

The Canadian articles include cases from Montreal and Vancouver. Bruneau et al.’s 1997 study of Montreal indicates a 6.5 times infection rate correlation to continued utilization of NEPs (Drucker et al. 1998). A follow up study to the 1994 outbreak of HIV in Vancouver, found that while rates of HIV dropped between 1996-1999, HCV infection rates remained high (Patrick et al. 2001; Schechter et al. 1999; Wodak & Cooney 2006; Patrick et al. 2001).

European examples include ambivalent findings from Sweden, France, and Spain (Mansson et al. 2000; Emmanuelli & Desenclos 2005; Hernandez-Aguado et al. 2001). While success in England is attributed to the aging English population, an overestimation of previous prevalence rates, and universal health care (Hope et. al. 2001; Hunter et al. 2000; Judd et al. 2005).

In sum, journal reports from two continents and six countries did not show a measurable reduction in HCV prevalence despite continued NEP access; hence the overall efficacy of NEPs must be evaluated and improved upon.

Specializing in HCV Prevention

This lack of universally applicable trends indicates that, unlike NEP HIV strategies, a universal NEP strategy will not work to decrease HCV rates. Indeed, HCV is closely linked to cultural behaviors and prevention strategies must be tailored to specific IDU populations. While the literature does not show a best practice for HCV prevention, it does indicate that significant differences exist in the vectors of infection and demographics of incidence. These factors should be monitored and programs tailored to provide maximum HCV reduction (VanBeek et al. 1998).

Vectors of Infection

Traditionally bleach is utilized to sanitize syringes and other drug paraphernalia given its ability to kill the HIV virus (Hagan & Des Jarlais 2000). Unfortunately this approach is not useful in preventing HCV as HCV is immune to the exhuming properties of bleach (Wright & Tompkins 2006). Thorpe et al. (2002) found that indirectly sharing injection supplies, primarily the “cooker” leads to an increase in HCV infections while Bluthenthal et al. (2000) reports that young users consistently share their syringes and “works;” a trend which holds in Oakland, San Francisco, and New York. Furthermore, the concept that paraphernalia is as risky as needles is cognitively dissonant to many IDU users, as most HIV safety notices emphasize the dangers associated with the syringe (Edlin 2004).  Because of these differences, this study will examine the misconceptions and behaviors of users to better target health promotion strategies.

Age and Duration of Use

After analyzing these articles it is clear that the number one predictor of HCV infection incidence is duration of use. A 2001 Maryland statistic puts the incidence rate of HCV at 65% in all users who have been injecting for a year or less (Hope et al. 2001). While this statistic is skewed due to a large inner-city sample population, the average HCV infection rates of long term users is between 60-80% (Des Jarlais & Schuchat 2001). Due to the ease at which IDUs contract HCV, Samuel et al.’s (2001) observations note that HCV infection rate leveled at 89.4% by the age of 30 in continued drug users. Thorpe’s study from Chicago indicates that the first four years of  IDU use where the majority of infections occur, indeed, the incidence rate for HCV is exponential through the first four years of drug use, and at year four an individual is ten times as likely to have HCV as at year one (Thorpe et al. 2000).  If these trends hold in the San Francisco population, it would be wise to target populations at young and emerging drug users.

Race, Gender, and Sexual Practices

While this literature review analyzed many case studies which included full demographic profiles, the literature found via Google Scholar and PubMed did not offer a meta-analysis of the articles.  An attempt to manually compare data points proved futile as some articles concluded that increased rates represented racial disparities while others assumed that they stemmed from racial homogeny (Thorpe 2001; Hagan 1999). The author theorizes that this lack of comprehensive ethnographic data is partially due to the geographic variety across the United States and Europe.

Like race, an analysis of gender proved inconsistent. Spittal & Schechter (2001) report a 1.5 times rate of HCV in women to men. This correlation appears dependent on geographic and socioeconomic region as a contemporary study of Montreal by Bruneau et al. showed that men were more likely to be HCV positive. Recent sexual contact was correlated to an increase in HCV incidence (Hagan et al. 1999; Thorpe 2001). Sexual behaviors should be looked at in depth as sexual partners often share syringes, both contaminated and sterile (Bluthenthal et al. 2000). Hence, to better understand the racial and gender related differences in NEP users, a population specific breakdown should be completed of the San Francisco population.