HP420 Photovoice Assignment
Fall 2019
Please complete a brief individual written assignment (5 pages max) reflecting on the
health disparity you covered in this project and a possible solution.
• Your written piece should include the following:
• Title Page (not counted in 5 page total)
• Brief summary of the disparity: briefly summarize the disparity in your community
based on data about the issue and this community, risk factors, prevalence for
this health problem in this population (About 1/2 page.)
• Evidence-based intervention (EBI):
o Find an EBI that uses a community or population based approach to
reduce the health problem you are working on in your photovoice project
(See Cultural Tailoring Lecture Slides 3, 6, 7, 26). Check with group-mates
to make sure you are not duplicating the EBI of another team member.
Bring it to class to discuss on 10/23/19 to review in a small group, and to
make sure it is an EBI. Please note that it does not have to be for the
same population as your photovoice population. That’s why the next part
of the paper is about tailoring it to fit your population.
o In your paper, briefly identify and summarize one evidence-based
(research tested) intervention from the research literature or evaluation
literature that addresses this health problem or a closely similar health
problem and, most important, the key intervention components that make
it work and, briefly, the significant outcomes. (About ½ to one page.)
• Cultural tailoring: suggest how the intervention could be tailored to fit this health
problem, community context and population using course concepts on tailoring.
(About 3 pages)
o First, identify which cultural tailoring model you will use: Framework for
Cultural Tailoring – Surface Structure Deep Structure Adaptation Model,
CBPR, Cancer Control Guidelines, or Van Duyn’s Social Marketing
Approach. (Cultural Tailoring Lecture, slides 17-20). Come to class on
10/23/19 prepared to discuss which tailoring approach you will use and
how you will use it to adapt your EBI.
o Then, in your paper, summarize 3 to 5 known cultural indicators (values,
beliefs, etc., for your population found in the Cultural Tailoring Lecture,
slides 9-11) that you will be using to tailor the intervention. Document
your research sources.
o Finally, explain how you will adapt the key components of the EBI to your
target population/community using your 5 or more components of your
tailoring model and the 3 to 5 known cultural indicators for your population.
• Conclusion: Discuss strengths and limitations of your tailored approach and why
you think this is a good approach. (About ½ page)
• References (additional page, not counted in page total): Please cite your sources
using APA format throughout the text and in a separate reference page at end.
9-15-19
•
Format: 5 pages in length, double-spaced, 12 point font, 1 inch margins, with
title page and references, American Psychological Association (APA) in-text
citation and reference format, and numbered pages.
Individual Paper Grading Rubric
•
Pts
Possible
EBI article submitted
Submitted 10-23-19 in class. Meets criteria of a community or population based EBI:
sound test of intervention effects, showing significant differences in key outcomes, for
health topic that fits the photovoice health topic.
Peer discussion of cultural tailoring model, indicators and tailoring approach in class.
Discussed EBI (journal article), Tailoring Model, and cultural indicators in class on 1023-19 to discuss in small group.
Title Page: required, and not counted in 5 page total
3
Introduction (about ½ page):
• Briefly summarize the health disparity that your group is focusing on
your community, including the prevalence in your population.
• Briefly discuss: what makes it a disparity according to Braveman’s or
Healthy People 2020 definition?
• Cite an appropriate source to document your data about this disparity.
Evidence-based Intervention (EBI) (about 1/2 to 1 page)
• Identify one community or population level evidence-based intervention
from the research or evaluation literature that addresses this health
problem or a health problem that is very similar to your photo-voice
disparity (and cite your source);
• Cite an appropriate source. It can be aimed (and probably should be
aimed) at a different population or location than your photovoice group
presentation.
• Briefly summarize the key components of the intervention (i.e., the
active ingredients)
• Summarize (very briefly) what it was able to change (i.e., the significant
outcomes relevant to your health disparity)
Cultural Tailoring Strategy (about 3 pages)
• State which tailoring framework or model you are using (and cite
source)
• Identify 3 to 5 relevant cultural indicators for this population that you are
going to use to adapt the EBI (cite your sources)
• Note how your intervention will be tailored using at least 5 components
of the tailoring model to fit your specific population and context, based
on your cultural indicators.
Summary/Discussion (about 1/2 page)
• Discuss the strengths and limitations of this tailored approach and why
you think it’s a good approach.
4
9-15-19
3
8
20
4
Comments
Individual Paper Grading Rubric
References (separate page at end, not counted in 5 page limit)
• Appropriately cite sources throughout the text
• Appropriately cite sources in a reference section at the end of the paper
• Use American Psychological Association (APA) citation and reference
guidelines (e.g., references are cited by authors not by number)
Overall Organization (note this may also be reflected in grades for sections above)
• Clearly written
• Well-argued and integrated
• Depth of discussion in each section rather than a simple listing of
features.
• Formatted appropriately (1 inch margins, 12 point font, 4-5 page double
spaced text, separate title page and reference page not counted in 5
page limit)
Total
9-15-19
Pts
Possible
5
3
50
Comments
Health Policy 45 (1998) 209 – 220
Syringe and needle exchange as HIV/AIDS
prevention for injection drug users in Puerto Rico
Rafaela R. Robles a,b,*, Héctor M. Colón a,b, Tomás D. Matos a,b,
H. Ann Finlinson a, Aileen Muñoz b, C. Amalia Marrero a,b,
Myriam Garcı́a a, Juan C. Reyes a
a
Center for Addiction Studies, School of Medicine, Uni6ersidad Central del Caribe, Call Box 60 -327,
00960 -6032 Bayamón, Puerto Rico
b
Research Institute, Mental Health and Anti-Addiction Ser6ices Administration,
Puerto Rico Department of Health, Box 21414, 00928 -1414 San Juan, Puerto Rico
Received 15 April 1998; accepted 27 August 1998
Abstract
This study evaluated the effectiveness of the first needle exchange program (NEP)
established in Puerto Rico. The data for this study were collected during the first months of
the NEP from July 1995 to March 1996 in 13 communities of the San Juan metropolitan
area. Subjects were the participants of two modalities of the NEP: a mobile team and a
community-based drug treatment program. During the 3-week evaluation period, 2401
injection drug users (IDUs) were recruited, resulting in a total of 19195 exchange contacts
and 146323 syringes exchanged. No significant change in drug injection was observed.
However, the program was effective in reducing sharing of syringes and cookers. The study
suggests that the NEP did help in reducing needle sharing in Puerto Rico. However, the HIV
seropositivity in returned syringes suggests the need to continue aggressive prevention
programs to arrest the epidemic among IDUs. However, factors related to the socio-cultural
environment as well as cultural norms and traditions need to be considered when planning
and expanding NEPs. © 1998 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Puerto Rico; HIV/AIDS prevention; Injection drug users; Syringe exchange
program; Needle exchange program
* Corresponding author. Tel.: +787 7854211; fax: +787 7854222; e-mail: ucccea@caribe.net
0168-8510/98/$ - see front matter © 1998 Elsevier Science Ireland Ltd. All rights reserved.
PII S0168-8510(98)00046-3
210
R.R. Robles et al. / Health Policy 45 (1998) 209–220
1. Introduction
Puerto Rico shares with various large metropolitan areas in the US mainland the
epicenter of the acquired immunodeficiency virus (AIDS) epidemic (58.4 AIDS
cases per 100000 population) [1]. Injection drug use is the most frequently reported
risk for AIDS on the island [2]. Puerto Rican drug users, whether residents of
Puerto Rico or residents of the United States, have been disproportionately affected
by the AIDS epidemic.
A study among Hispanics in the continental United States found that, among
men born in Mexico or Central and South America, 65% of AIDS cases were
attributable to male-male sex. Fewer than 10% of AIDS cases in this group were
associated with injection drug use. In contrast, 61% of AIDS cases among Puerto
Rican born men were attributable to injection drug use, and only 22% to male–
male sex [3]. Moreover, in Puerto Rico as in the United States, transmission of
human immunodeficiency virus (HIV) infection has had a cascading effect; infections have spread from injection drug users (IDUs) to their sexual and needlesharing partners and from HIV-infected mothers to their children. Since 1993,
sexual transmission has accounted for the majority of AIDS cases among female
Puerto Ricans [2].
A comparative study of drug users in Puerto Rico and the US mainland showed
that Puerto Rican drug users are more likely to inject speedball (a mixture of
cocaine and heroin) and to inject drugs in shooting galleries than their drug
injecting peers in the US. Moreover, drug users residing on the island reported a
significantly higher number of daily injections and use of previously used drug
injection paraphernalia; 39% on the island reported any use in the previous 30 days
compared with 22% in New York. Also significantly, more drug users residing on
the island reported sharing used cookers, cotton or rinse water compared with their
peers residing in New York (30% vs 22%) [4,5].
Although in Puerto Rico, up until 19971, there were no laws restricting the sale,
distribution or possession of syringes, drug users have reported considerable
impediments to obtaining sterile syringes. Some pharmacies require documentation
that a client has a condition (e.g. diabetes) that justifies the purchase of a syringe.
Other pharmacies sell syringes without documentation but limit purchases to large
quantities (e.g. ten or more). The restrictive policies of some pharmacies present a
barrier to drug injectors who prefer to buy one or two syringes at a time. Drug
users’ access to sterile syringes has also been limited due to harassment by police
who destroy the syringes drug users carry [6].
1
In November 1997 law no. 4 of June 23, 1971 was amended with article 412 entitled — Paraphernalia
Related to Controlled Substances; definitive, criteria, penalties. This new article of the law prohibits the
production, distribution, transportation and possession of any article defined in the law as controlled
substances paraphernalia. However this article excludes from the law the Department of Health and non
profit Community Base Organizations authorized by the Department of Health which are permitted
distribute syringes, equipment and educational materials to prevent the transmission of contagious
diseases.
R.R. Robles et al. / Health Policy 45 (1998) 209–220
211
Recent studies have shown the benefits of needle exchange programs (NEPs) in
reducing syringe sharing and HIV transmission. These studies have also demonstrated the NEPs are not associated with an increase in the number of injectors or
increased frequency of injecting [7–11]. On the basis of this evidence, many
communities in the US have established NEPs [12].
In Puerto Rico, there were no data which could provide an understanding of the
circumstances under which a NEP would be effective in reducing HIV needle risk
behavior among drug users. This paper extends needle exchange prevention research by evaluating the effectiveness of the first NEP established in Puerto Rico,
a different sociocultural and geographic site from those where previous programs
were developed.
2. Methods
The NEP was initiated in July of 1995 in 13 communities of the San Juan
metropolitan area, in the municipalities of San Juan, Cataño, Bayamón and Trujillo
Alto (Fig. 1). The data for this study were collected during the first eight months
of the program from July, 1995 to March, 1996.
Communities were selected for their high density of IDUs in relation to other
communities in the San Juan metropolitan area, as determined by previous epidemiological studies [13], drug treatment program admissions data [14] and drug
arrest data [15]. Outreach workers from two drug treatment community based
organizations (CBOs) were responsible for the intervention. The design of the
evaluation was developed by researchers at the Center for Addiction Studies in the
School of Medicine of the Universidad Central del Caribe (UCC).
Fig. 1. Municipalities in which the Puerto Rico NEP provided services.
212
R.R. Robles et al. / Health Policy 45 (1998) 209–220
Each respondent who exchanged at least one needle was interviewed using a
short questionnaire (contact form) dealing with the characteristics of the participant
(i.e. sex, age, employment status), number of syringes exchanged, years injecting,
number of injections per day, and whether the participant was engaging in syringe
sharing. Data to measure changes in sharing drug injection paraphernalia and
length of participation in the program were obtained from a structured interview
completed by a sample of 325 IDUs who were participants in a HIV prevention
study (Cooperative Agreement for AIDS Community-Based Outreach/Intervention
Research, Grant 5U01DA07287) funded by the National Institute on Drug Abuse
(NIDA). These participants were assigned to two study groups. One group comprised 133 subjects who had their follow-up interview before the program was in
operation, the second group comprised those subjects who were interviewed while
the program was operating. The Risk Behavior Assessment (RBA) and Risk
Behavior Follow-up Assessment (RBFA), structured interview protocols designed
by NIDA and adapted to the island’s vernacular, were used to collect information
related to drug use, injection and sex risk behaviors, health care, as well as drug
treatment and incarceration history previous to the NEP and after the program had
been established. The specific behavior change measures were reduction in sharing
of syringes and cookers, and reduction in drug injection.
The amount of time syringes were in circulation was measured by the following
procedure: a sample of 1075 syringes was enumerated; a calendar was kept for each
site indicating when the syringes were to be distributed as well as documenting the
date when the distribution actually took place. The date was also documented in
the contact form when the enumerated syringes were returned. The enumerated
syringes were subsequently tested for HIV seropositivity in the laboratory of the
School of Medicine, UCC, using the following methods: the traces of blood
contained in the syringes were submitted to the ELISA test, using the commercial
immunoassay Genetic Systems LAV EIA, which is manufactured using the virus
propagated in the CEM cellular line and purified through centrifugation. It is worth
mentioning that this test was developed and optimized by the manufacturer for the
detection of HIV antibodies in serum/plasma, recommending a determined dilution
of these antibodies to reach a sensitivity of 100% and a specificity of 99.8%. This
control over the dilution of the sample is impossible with respect to the syringes, as
the quantity of blood that might have adhered to the walls of the syringes is
unknown. Understanding that for the purposes of this study, we had to focus on
generating the highest sensitivity possible given the characteristics of the sample, we
proceeded to dilute the contents of the syringes in the minimal volume that would
permit its evaluation in duplicate. The remainder of the test was carried out,
following strictly the recommendations of the manufacturer.
We assumed that a reduction in needle-sharing would result in a decrease in
related seropositivity; the lesser the number of individuals who use the same
syringe, the lesser the probability that the syringe will contain antibodies. We
understood that whatever limitation of the test with respect to its sensitivity would
equally affect the study across the board, permitting the evaluation of tendencies
through statistical methodology.
R.R. Robles et al. / Health Policy 45 (1998) 209–220
213
3. The NEP
The NEP comprised two modalities: a mobile team that visited assigned communities two to three times a week for a period of 45 min to 1 h, and a store-front
office maintained by a community based drug treatment program that was open
week-days from 08:00 to 17:00 h. Both modalities offered their services during the
daytime on weekdays. The intervention team in each modality was comprised of
three individuals: a male outreach worker, a male case manager and a female nurse.
There was an official one-to-one exchange rule but both CBOs placed restrictions
on the number of syringes participants were allowed to exchange.
4. Outcome Measures
The effectiveness of the NEP was assessed with the following indicators:
1. the number of client contacts and syringes exchanged as recorded on the contact
form;
2. the frequency of visits to the syringe exchange as reported by participants and
recorded on the contact form;
3. the potential negative impact of the syringe exchange program was examined
using the following indicators recorded on the contact form:
3.1. changes in the self-reported frequency of injection since the first time
syringes were exchanged,
3.2. changes in the age distribution of participants,
3.3. proportion of respondents reporting first injection since the program
started,
3.4. syringe sharing was examined by assessing the relationship between reported syringe exchange used during the first 32 weeks of the program and
reported syringe sharing partners in the 30 days prior to the interview. We
analyzed the self reports of syringe sharing and the HIV seropositivity
among enumerated exchanged syringes. Our analysis shows that those
syringes exchanged by participants who reported sharing syringes were
more likely to be seropositive than those exchanged by participants reporting not sharing syringes. This analysis seems to indicate that self reports of
syringe sharing seem valid.
5. Statistical analysis
x 2 tests were used to determine differences in the proportion of male and female
IDUs who shared syringes. To identify differences in the mean years of injecting
and the reported frequency of daily injections, a t-test analysis was performed. A
multiple regression analysis was used to determine the impact of the exchange
program on syringe sharing and frequency of drug injection. All statistical analyses
were performed using the Statistical Package for the Social Sciences (SPSS) version
7.5 for Windows.
214
R.R. Robles et al. / Health Policy 45 (1998) 209–220
Table 1
Number of new participants, exchange events and needles exchanged by NEP modality in the first 8
months of implementation
NEP modality
New participants
Exchange events
Needles exchanged
On-site unit
Mobile unit
Total
743
1658
2401
8425
10 770
19 195
53 257
93 066
146 323
6. Results
During the 31-week evaluation phase of the program, some 2401 IDUs were
recruited, resulting in a total of 19195 exchange contacts and 146323 syringes
exchanged.
Table 1 shows the distribution of syringes by exchange modality: the mobile unit
reported 10770 exchange contacts with 93066 syringes exchanged; the on-site
modality reported 8425 exchange contacts and 53257 syringes exchanged. Fig. 2
shows the number of drug injectors recruited by month, indicating the high rate of
recruitment in the first month and a continuing downward trend until the fifth
month, when the number of subjects recruited stabilized.
More women participated in the on-site modality (22.8%) than the mobile
modality (16.3%) (P B0.01). There were no significant differences between the two
modalities in years of injection (11.5 years in the mobile vs 12.1 years in the on-site
modality; P B 0.27). However, participants in the on-site modality were more likely
to inject more frequently than in the mobile modality (7.2 vs 5.9, PB 0.01) (Table
2).
Fig. 2. Drug injectors recruited by the NEP by month.
R.R. Robles et al. / Health Policy 45 (1998) 209–220
215
Table 2
Characteristics of participants recruited by the NEP by modality
Modality
Percentage of women
Mean years of injection
Mean number of daily injections
Percentage informing shared use of syringes
On-site
Mobile
P
22.8
12.1
7.2
35.4
16.3
11.5
5.9
39.8
B0.01
0.27
B0.01
0.29
Fig. 3. Percentage of enumerated syringes returned in a week or less by month of project.
During the first 29 weeks of the program, some 1075 enumerated syringes were
circulated. Of these, some 433 (40.3%) were returned to the program. A high
percentage (91.1%) of those syringes were returned in the same community where
the needles were originally exchanged. A significant increase in returned syringes
was observed during the evaluation period. Some 12.4% of the syringes were
returned during the first week, and 32.5% at 8 months (Fig. 3).
Of the 433 enumerated returned syringes, 391 were tested for HIV seropositivity.
Some 104 (26.6%) of the returned syringes with blood presence were seropositive
and 241 (16.2%) without blood presence were HIV seropositive (Table 3).
Table 3
Result of ELISA tests performed on enumerated syringes returned
Visible traces of blood in syringe
N
Reactive ELISA (%)
No
Yes
Total
241
150
391
16.2
43.3
26.6
216
R.R. Robles et al. / Health Policy 45 (1998) 209–220
Table 4
Multivariate logistic regression results
Behavior
Odds ratio
95% C.I.
P
Shared use of syringes
Before NEP
During NEP
1.00
0.50
0.25–0.97
0.04
Shared use of ‘cookers’
Before NEP
During NEP
1.00
0.61
0.31–1.17
0.14
Drug injection on a daily basis
Before NEP
During NEP
1.00
0.83
0.49–1.43
0.51
All models include the behavior measurement collected during the previous measurement wave.
The results of the multivariate analyses are shown in Table 4. Syringe sharing
was significantly reduced during the period of program operation as compared to
the period before the program started (OR = 0.50, P= 0.04). That is, subjects
assessed while the program was in operation were half as likely to report syringe
sharing than subjects assessed prior to the establishment of the program. No
statistically significant differences were observed in the shared use of cookers
(OR= 0.61, P = 0.14) or in the frequency of injection (OR= 0.83, P= 0.51).
Fig. 4 shows the number of participants who entered drug treatment for each of
the eight months of the evaluation period. A total of 9.4% entered treatment over
the length of the evaluation period. As noted in Fig. 4, there was a tendency for an
increasing number of participants to enter treatment. During the first month only
1% entered treatment. By the third month, this rate substantially increased (12%)
and continued for the next two months. During the seventh month 28.9% of the
participants entered treatment. However, this increase was a response to a number
Fig. 4. Participants entering drug treatment programs as a fraction of new participants by month of
recruitment.
R.R. Robles et al. / Health Policy 45 (1998) 209–220
217
of strategies developed by outreach workers to encourage participants to enter
treatment. During the last month of the evaluation period, the number of participants entering treatment was reduced to a level similar to the level established
during the three months that preceded the special campaign to enroll participants
in treatment.
7. Comments
Our findings confirm that IDUs will participate in NEPs that can be easily
accessed and negotiated. It seems that the Puerto Rico NEP was readily adopted by
a group of drug injectors but was unable to recapture a large proportion of used
and potentially infected enumerated syringes. It is likely that enumerated NEP
syringes were sold, discarded after use, or given away by participants who also
routinely obtained new syringes from other sources (i.e. pharmacies, private sellers)
that do not collect used syringes. In addition, several NEP participants expressed
the concern that their use of encoded syringes might result in the loss of anonymity,
and this may have negatively affected retrieval of the encoded syringes. Police
harassment of drug users also appears to have discouraged participants of the
program from retaining the syringes and bringing them to the next exchange
encounter, a process that could entail waiting for two days or over the week-end.
Moreover, many of participants were homeless or lived with their nondrug-using
parents, where they had little privacy. Families in Puerto Rico will generally offer
shelter and food to members who use drugs or engage in other socially unacceptable behavior. However, keeping drug use paraphernalia at the parents’ home
would be against a still very prevalent norm of the Hispanic culture, ‘respect for
parents’. Thus, for the NEP to be able to recapture a larger number of used
enumerated syringes it would need to have more frequent exchange encounters so
that drug users did not need to keep and carry the syringes and expose themselves
to police harassment and family disapproval.
The on-site modality had a larger proportion of female participants than the
mobile modality. The intervention teams of both modalities were similar in gender
and occupational mix. The fact that women were more likely to exchange their
syringes at the on-site modality might also be related to the traditional Hispanic
cultural ideology still prevailing on the island. Participants in the on-site modality
could exchange syringes any time during the day, whenever they felt most comfortable because they were not as likely to be observed by peers or neighbors. In the
mobile modality all participants had to exchange syringes in a public setting which
may have inhibited some female participants from exchanging syringes.
The need for a more extensive and intensive exchange program also seems
evident by the fact that our ethnographic data shows that the black market
continued to be an important source of new syringes for IDUs [6]. It seems that the
NEP in Puerto Rico was not able to replace the black market as in other sites in
the US mainland [7]. Here again, a more intensive and extensive program is needed
for a NEP to replace the syringe black market.
218
R.R. Robles et al. / Health Policy 45 (1998) 209–220
While the NEP was not as effective as expected in recapturing enumerated
syringes and in replacing the syringe black market, the program was effective in
decreasing the sharing of syringes and cookers, and in increasing the use of new
syringes. These findings support studies in the US and other countries demonstrating that increased availability of sterile syringes can be an important factor in
reducing needle sharing, a behavior highly related to HIV transmission [4,10,16–
19].
The high prevalence of HIV seropositivity in returned needles, with and without
visible blood, suggests that after more than 16 years of the epidemic we need to
continue aggressive prevention programs to arrest this epidemic among drug
injectors. A more extensive and intensive NEP could be an effective strategy to
enhance our preventive programs in arresting this catastrophic virus.
Data related to availability of treatment suggest that NEPs need to consider
community-based treatment and/or preventive programs as program sites. These
organizations are already legitimized as health resources by the community and can
offer other services needed by participants. NEPs could be another strategy to
enhance the service program of these organizations.
NEPs by themselves cannot address the many health, drug use and social
problems of IDUs. Programs established outside service organizations need a
concerted effort of organizational resources to address this complex disease.
Undoubtedly, drug treatment programs need to play a central role in any serious
endeavor to address the health consequences of drug use.
There was no support in our study population for the view that NEPs promote
drug use. Our data show a gradual but statistically significant decline in self-reported frequency of injection and a decreasing level of initiation of drug use over
time.
This study is limited in that it did not identify the circumstances under which
syringe sharing was reduced. Moreover, we used self reports of respondents to
collect most of the data. This information may be subject to socially desirable
response problems of recall, intoxication and other sources of bias. However, high
validity of self-reported drug use in a multi-site study using similar methods has
been reported [7].
Despite these limitations, this study extends the useful information already
collected in previous studies regarding NEPs. This study suggests that the NEP did
help in reducing needle sharing in Puerto Rico, a different environment and cultural
site from that of previous studies. Therefore, such programs should be initiated,
continued and expanded to meet existing needs in areas where NEPs have not been
implemented or are still very limited, as in Puerto Rico. However, factors related to
the social environment, as well as cultural norms and traditions, need to be
seriously considered when planning NEPs.
Acknowledgements
This study was supported in part by the Puerto Rico Department of Health and
R.R. Robles et al. / Health Policy 45 (1998) 209–220
219
by a grant from the National Institute on Drug Abuse at the National Institutes of
Health. The authors would like to thank Carmen Feliciano, MD, Secretary, Puerto
Rico Department of Health, Commonwealth of Puerto Rico, for her continuous
support and Eddie Rı́os, PhD, MPH, Department of Microbiology and Immunology, School of Medicine, Universidad Central del Caribe, for his helpful comments
on earlier drafts of this manuscript.
References
[1] Centers for Disease Control and Prevention, US HIV and AIDS cases reported through December
1995, HIV/AIDS Surveillance Report 1995;7:1 – 39.
[2] Puerto Rico Department of Health, AIDS in Puerto Rico, Puerto Rico AIDS Surveillance Program
1995;4:1–6.
[3] Diaz T, Buehler JW, Castro KG, Ward JW. AIDS trends among Hispanics in the United States.
American Journal of Public Health 1993;83:504 – 9.
[4] Robles RR, Colón HM, Matos TD, Reyes JC, Marrero CA, López CM. Risk factors and HIV
infection among three different cultural groups of intravenous drug users. In: Brown BS, Beschner
GM, editors. Handbook on risk of AIDS: Injection drug users and sexual partners. Westport, CT:
Greenwood Publishing, 1993:256–74.
[5] Colón HM, Robles RR, Sahai H, Reyes JC, Matos TD. HIV seroprevalence among injection drug
users in Puerto Rico: A comparative perspective. In: Brown BS, Beschner GM, editors. Handbook
on risk of AIDS: Injection drug users and sexual partners. Westport, CT: Greenwood Publishing,
1993:72–87.
[6] Finlinson HA, Colón HM, Robles RR, Deren S, Soto M, Muñoz A, Access to sterile syringes by
injection drug users in Puerto Rico, Paper presented at the Annual Meeting of the Society for
Applied Anthropology. San Juan, Puerto Rico, April 22 – 26, 1998.
[7] Watters JK, Estilo MJ, Clark GL, Lorvick J. Syringe and needle exchange as HIV/AIDS prevention
for injection drug users. Journal of the American Medical Association 1994;271:115 – 20.
[8] Hart GJ, Carvell ALM, Woodward N, Johnson AM, Williams P, Parry JV. Evaluation of needle
exchange in central London: Behavious change and anti – HIV status over one year. AIDS
1989;3:261–5.
[9] Carvell AM, Hart GJ. Help–seeking and referrals in a needle exchange: A comprehensive service
to injecting drug users. British Journal of Addiction 1990;85:235 – 40.
[10] Hartgers C, Buning EC, van Santen GW, Verster AD, Coutinho RA. The impact of the needle and
syringe–exchange programme in Amsterdam on injecting risk behaviour. AIDS 1989;3:571 – 6.
[11] Groseclose SL, Weinstein B, Jones TS, Valleroy LA, Fehrs LJ, Kassler WJ. Impact of increased
legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992–1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology
1995;10:82–9.
[12] Vlahov D. Deregulation of the sale and possession of syringes for HIV prevention among injection
drug users (Editorial). Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1995;10:71–2.
[13] Robles RR, Colón HM, Freeman DH. Copping areas as sampling and recruitment sites for
out-of-treatment crack and injection drug users. Drugs and Society 1993;7:91 – 105.
[14] Mental Health and Anti-Addiction Services Administration, Management Information Systems,
Mental Health and Anti-Addiction Services Administration, Puerto Rico Department of Health.
San Juan, PR, 1994.
[15] Puerto Rico Police Department, Annual Report, Puerto Rico Police Department, Commonwealth
of Puerto Rico. San Juan, Puerto Rico, 1995.
220
R.R. Robles et al. / Health Policy 45 (1998) 209–220
[16] Kaplan EH, Heimer R. HIV prevalence among intravenous drug users: Model-based estimates from
New Haven’s legal needle exchange. Journal of Acquired Immune Deficiency Syndromes
1992;5:163–9.
[17] Normand J, Vlahov D. Preventing HIV transmission: The role of sterile needles and bleach.
Washington DC: National Academy Press, 1995.
[18] Centers for Disease Control and Prevention, Syringe exchange programs — United States, 1994 –
1995, Mortality and Morbidity Weekly Report 1995;44:684 – 691, 759.
[19] Koester SK, Hoffer L. ‘‘Indirect sharing’’: Additional HIV risks associated with drug injection.
AIDS and Public Policy Journal 1994;9:100 – 5.
.
.
Purchase answer to see full
attachment