Pharmacy Syringe Sales: Implications for Syringe Access, Community Safety and HIV Prevention

Background Since 2005, California law has allowed over-the-counter (OTC) syringe sales subject to local authorization. Pharmacy sales of OTC syringes have been associated with reduced injection-mediated risks and decreases in HIV infection rates among injection drug users (IDUs). However, programs for OTC pharmacy syringe sales have not been adopted universally by pharmacists or IDUs. To address gaps in our knowledge and the scientific literature on access to pharmacies and OTC syringe purchase among IDUs, we conducted three unique studies.;Methods We used a novel combination of geographic information systems (GIS) and statistical modeling to: 1) determine the demographic and spatial factors associated with the availability of pharmacies and OTC syringe-selling pharmacies, 2) assess whether crime was associated with pharmacy syringe sales, and 3) identify the factors associated with OTC syringe purchase among IDUs. In the first study, we analyzed population level data from the American Community Survey (U.S. Census Bureau) and pharmacy data from Los Angeles (LA) County. We conducted multivariable logistic and Poisson regression analyses to determine whether sociodemographic characteristics of the population were associated with the presence of pharmacies in LA County census tracts during 2008. Using hot-spot analysis in a GIS, we identified clusters of pharmacies, OTC syringe-selling pharmacies, and sociodemographic characteristics, as well as their relationships. In the second study, we performed longitudinal analyses to determine whether introduction of pharmacy-based OTC syringe sales were associated with crime between January 2006 and December 2008, in Los Angeles Police Department (LAPD) Reporting Districts. We assessed crime pre- and post-initiation of OTC syringe sales and longitudinal associations between crime and OTC syringe sales, while controlling for confounders. In the third study, we used a cross-sectional design and targeted sampling to collect quantitative survey data from IDUs recruited in San Francisco during 2008. We also compiled a comprehensive list of retail pharmacies, their locations, and whether they sold OTC syringes. With logistic regression and spatial analyses we determined the demographic, behavioral, and spatial factors associated with the purchase of OTC syringes by IDUs.;Results Pharmacy Presence Within LA County census tracts (N=2054), increased population size (adjusted odds ratio (AOR): 1.21; 95% confidence interval [CI]: 1.15, 1.27), higher median age (AOR: 1.02; 95% CI: 1.01, 1.04) and higher percentage of households receiving public assistance (AOR: 0.97; 95% CI: 0.95, 0.99) were independently associated with the presence of pharmacies. Only 12% of census tracts had at least one pharmacy that sold OTC syringes and sociodemographic variables were not independently associated with their presence. Clusters of pharmacies (p<0.01) were found in locations that were distant from clusters of younger and economically disadvantaged populations, which are often at greater risk for HIV infection.;OTC Pharmacy Syringe Sales and Crime By December 2008, 9.3% (94/1010) of LAPD Reporting Districts had at least one OTC syringe-selling pharmacy. Both counts and rates of crime decreased between 2006 and 2008 in Reporting Districts with and without OTC syringe-selling pharmacies. Decreases in counts were statistically significant but decreases in rates were not. Using generalized estimating equations, we found that crime rates were negatively associated with OTC syringe sales (adjusted rate ratio: 0.89; 95% CI: 0.81, 0.99), while adjusting for sociodemographic characteristics.;Purchase of OTC Syringes among IDUs In multivariate analyses, older age, African-American race/ethnicity, increased injection frequency, the type of drug injected, and the source of syringe supply were independently associated with OTC syringe purchases. Notably, the prevalence of OTC syringe purchase was 53% lower among African American IDUs (adjusted prevalence ratio (APR): 0.47; 95% CI: 0.33, 0.67) and higher among injectors of methamphetamine (APR: 1.35; 95% CI: 1.07, 1.70). Importantly, two neighborhoods with high densities of IDUs had limited access to OTC syringes.;Conclusion Our combined statistical, epidemiological, and spatial analyses provided an innovative approach to assess the sociodemographic and geographic factors associated with the presence of community pharmacies and pharmacies that participated in OTC syringe sales. Such an approach can help identify locations where pharmacy availability may be particularly low and can inform public health policy decisions. Our longitudinal analyses of crime, OTC syringe sales, and sociodemographic variables indicated that OTC syringe sales in pharmacies were not associated with increased crime in surrounding communities. The research findings can help dispel the belief among some policymakers, pharmacists and communities that OTC syringe sales are associated with increases in crime, and remove an additional barrier to successful and broad implementation of OTC syringe sales programs. Finally, understanding the demographic characteristics and spatial and behavioral risk factors of people who purchased OTC syringes in local pharmacies can inform HIV prevention strategies on the local, state, and national level.