~ Pergamon 0277-9536(95)00193-X Soc. Sci. Med. Vol. 42, No. 5, pp~ 691-703. 1996 Copyright ,~" 1996ElsevierScienceLtd Printed in Great Britain.All rights reserved 0277-9536/96$15.00 + 0.00 SYRINGE-MEDIATED DRUG SHARING AMONG INJECTING DRUG USERS: PATTERNS, SOCIAL CONTEXT AND IMPLICATIONS FOR TRANSMISSION OF BLOOD-BORNE PATHOGENS JEAN-PAUL C. GRUND, t SAMUEL R. FRIEDMAN,-' L. SYNN STERN, 3 BENNY JOSE,-' ALAN NEAIGUS] RICHARD CURTIS 2 and DON C. DES JARLAIS 4 LThe Lindesmith Center, 888 Seventh Avenue, New York, NY 10106 and Department of Sociology, University of Connecticut, 344 Mansfield Road, U-68, Storrs, Connecticut, CT 06268, U.S.A., -'National Development and Research Institutes Inc., New York, N.Y., U.S.A., 3Eastern Connecticut Health Outreach Project, Windham Regional Community Council, Willimantic, Conn., U.S.A. and 4Beth Israel Medical Center, New York, N.Y., U.S.A. Abstract--Drug injectors are at risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens through the exchange of (infected) blood resulting from unhygienic injecting practices. Research attention and public discussion have focused primarily on the sharing of syringes and needles. While the focus on syringe sharing has sparked important interventions(bleach distribution, syringe exchange) it may have obscured the social relationship in which injecting equipment is used. Drug sharing plays a crucial role in the social organization of the drug using subculture. In this paper, various drug sharing practices and other distinguishable aspects of the injecting process--collectively termed Syringe-Mediated Drug Sharing (SMDS)--are described. All of these behaviors may put injecting drug users (IDUs) at risk for infection. The purpose of this paper is to stimulate scientific inquiry into SMDS behaviors and the social contexts which shape them. Descriptions are based primarily on field studies in Rotterdam and New York City. Recommendations for safer injecting training and education are proposed, as are directions for future research. Key words--injecting drug use, blood-borne pathogens, HIV risk factors, drug sharing, social factors, epidemiology, ethnography INTRODUCTION Injecting drug users (IDUs) are at risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens through the exchange of (infected) blood resulting from unhygienic injecting practices. Research attention and public discussion have focused primarily on the sharing of syringes and needles [1, 2]. (Throughout the rest of this text, unless otherwise specified, we will use the terms syringe and syringe sharing, referring to both the needle and syringe.) Syringe sharing occurs in many ways and contexts, including picking up syringes which others had used and abandoned [3], social sharing by couples [4, 5], 'running mates" or 'dyads' [6, 7], borrowing from an acquaintance or stranger, or renting or buying used syringes in a 'shooting gallery' (places where IDUs go to inject drugs, which often charge an entrance fee) [8]. The term 'syringe sharing' blurs the risks involved in the collective use of other equipment and materials, such as cookers (drug mixing containers*), filters (e.g. cotton) and water, that are used during injection preparation and for rinsing a used syringe [9, 10]. Koester et al., in Denver, *While in the Netherlands and in the United Kingdom spoons are mostly used as cookers, in the United States metal bottle caps are more prevalent. Colorado for example, observed water in shared containers which had been pinked by blood from the syringes placed in it [11]. The early recognition of the association between syringe sharing and HIV transmission may have induced a certain narrowing of focus in which the physical instruments of transmission--the syringe and needle have been somewhat "fetishized' [12], thereby dissociating it from its context. While the focus on syringe sharing has sparked important interventions such as bleach bottle distribution and syringe exchange programs, it may have obscured the social relationships in which these objects are used [12, 13]. These relationships include possibilities for trans- mission of HIV and other blood-borne pathogens, as well as vehicles for intervention. Although most popular, and many scientific, publications usually emphasize the negative sides of the drug world, this subculture "would not be able to persist over time without some positive social relationships" [7], including the recurrent sharing of valued items such as housing, food, money, clothing and drugs. Drug sharing is a normal and frequent activity in the drug scene. In half of the observations of drug taking in our Rotterdam study of regular heroin/cocaine users, drugs were shared among two or more individuals, IDUs and non-IDUs alike [14]. 691