MORE SYRINGE ACCESS: Pharmacy Sales Part of HIV Prevention
HIV/AIDS prevention strategies targeted at injection drug users - - one of the most difficult groups to reach when it comes to comprehensive HIV prevention -- require state health departments and policy makers to take a multi-faceted approach, consisting of such strategies as pharmacy-based syringe sales, needle exchanges, and prescription-based syringe sales. Of the three, pharmacy-based syringe sales may require the least amount of state funding and oversight to operate. "It's a commercial transaction basically," said the CDC's Steve Jones, a medical epidemiologist. The pharmacy-based strategy is so promising as a means to prevent HIV transmission, that last month five of the nation's key health care groups -- the National Association of Boards of Pharmacy, the American Medical Association, the American Pharmaceutical Association, the Association of State and Territorial Health Officials and the National Alliance of State and Territorial AIDS Directors -- issued a call to action to their colleagues and state leaders to push for a change in state drug paraphernalia laws and regulations to permit pharmacy-based syringe sales. The call was based in part on the success of three states, Connecticut, Maine and Minnesota, which already amended state codes to remove penalties for syringe possession, and allow pharmacists to sell 10 syringes at a time without a prescription -- with no questions asked. Beth Weinstein, director of the AIDS Division at the Connecticut Department of Public Health, explained that her state's law, which passed in 1992, led to a 39% decrease in needle sharing within one year. The reduction, Weinstein pointed out, "was accomplished without any public money or any public program. It was simply allowing pharmacists to sell without a prescription." She said that the needle sharing rate prior to the law's passage was 52% and dropped to 32% within a year afterward, a 39% proportionate decrease. Because the law decriminalizes non-prescription syringe sales, the individual pharmacist "chooses whether to sell or not to sell. This is normal part of pharmacy practice now in Connecticut," Weinstein said. And so far it appears IDUs prefer pharmacy access to needle exchanges, as Weinstein pointed out, perhaps because pharmacies "are more accessible, in more places and timewise it's easier to get [syringes] when you want one."
Based on Connecticut's success, Maine enacted Public Law 394 in 1993 to allow pharmacists to sell syringes without a prescription. And in 1997, the state amended its drug paraphernalia law to decriminalize possession of 10 or fewer syringes. The Maine Bureau of Health held a conference for pharmacists, HIV providers and law enforcement officials to ensure that they understood the law and to answer their questions. As a result of this effort, the health bureau reports that syringes are more available everywhere, and although no studies have yet been completed, anecdotal evidence indicates that IDUs prefer purchasing syringes as opposed to needle exchange.
Minnesota has taken the concept one step further by including a needle disposal element in its Syringe Access Initiative, which took effect in the summer of 1998. Niki Oldenburg, a public health analyst who was appointed by the state Legislature to examine the law's effect, explained that the SAI was included in a comprehensive HIV prevention bill. "The disposal issue actually got highlighted," she said, "because the Minnesota Legislature felt it was an issue that needed to be addressed." To implement the law, the state AIDS director, the Minnesota Board of Pharmacy and the Minnesota Pharmaceutical Association sent a joint letter to pharmacies across the state to solicit their support and participation. One of the criteria for pharmacists' participation was that they agree to address disposal issues, and currently almost half of Minnesota pharmacies participate. "That's not to say the other 50% are against it," Oldenburg pointed out, noting that "there are plenty of pharmacies in rural Minnesota who feel it's just not an issue for them."
Pharmacists opting to participate in the initiative must agree to one of five options pertaining to disposal: collect used syringes on site; distribute educational materials provided by the state health department on proper disposal; participate in a sharps container distribution and collection program; refer customers to a medical facility that takes used syringes; or refer customers to the Minnesota AIDS line to identify syringe exchange programs. "Disposal is an integral part of the program," Oldenburg said. While participating pharmacists are not regulated, they do have to certify that they are participating in at least one disposal activity. Oldenburg explained that the state health department has already funded a pilot program that provided FITPACs -- an Australian-made sharps pack that can fit 10 new syringes and has a place to put used syringes -- to IDUs, and may eventually urge pharmacists to stock them. "Minnesota is extraordinary because in one sweep they removed the paraphernalia law penalties, got the pharmacists involved in syringe sales and made big steps on safe disposal of used syringes," Steve Jones said.
The Broader the Better
"For those of us working on prevention, we really want to take a broad-based approach," the Kaiser Family Foundation's Jen Kates said. She added that policy makers must continue to explore "what role can pharmacists and pharmacies play in HIV/AIDS prevention." Weinstein added, "Allowing pharmacists to sell syringes to drug users without a prescription is only one part of our HIV prevention efforts for IDUs. Other services include access to substance abuse treatment, HIV counseling and testing, and needle exchange programs." Jan Skelton, senior director of professional practice development at the American Pharmaceutical Association, said that she believes the nation's pharmacists are ready to become more engaged in the issue. "The reality is we're the most accessible," she said. Syringe access is "really an issue where pharmacists can play a very proactive role in helping achieve overall public health goals," she said, adding, "The issues that remain are disposal of needles and syringes, and that's across the board not just for IDUs, but for diabetics as well. So what we're trying to figure out is how to set up programs for pharmacists, and also make sure they are aware of treatment options in their area so they can refer those patients when the time is appropriate to get additional help and services." While pharmacists will require education and additional support, Skelton said the remaining challenge is that "pharmacists are trained at the very beginning that they're sort of the gatekeepers to the candy store, and drug abuse and drug diversion are very negative things within the profession, obviously." As a result, the issue must be reframed, she said, as "one of saving people's lives and trying to assist in the overall scope of the issue" (Amy Paulson, American Health Line, 12/10).