International Journal of Drug Policy 15 (2003) 36–45 How otherwise dedicated AIDS prevention workers come to support state-sponsored shortage of clean syringes in Vancouver, Canada P. M. Spittal a,b,* , W. Small c , E. Wood a,b , C. Johnston c , J. Charette c , N. Laliberté c , M. V. O’Shaughnessy a,b , M. T. Schechter a,b a British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6 b Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC, Canada c Vancouver Injection Drug Use Study (VIDUS), Vancouver, BC, Canada Received 28 February 2003; received in revised form 20 June 2003; accepted 7 July 2003 Abstract Vancouver continues to experience an ongoing HIV outbreak among injection drug users despite the presence of North America’s largest needle exchange programme. The present study utilizes ethnographic interviews and observations conducted with fixed site and mobile van ‘exchange agents’ to examine access to sterile syringes by IDUs in Vancouver between May 2000 and March 2001. Point-for-point exchange continues to be the dominant policy. Ethnographic evidence suggests that there is a large demand for sterile syringes (‘rigs’) when users do not have any to return, indicating policy/practice discrepancies. Despite policy, an intricate rig loaning system has evolved out of agreements made between needle exchange agents and their clients. Restrictive syringe exchange policies lead to considerable unmet needs among injection drug users. Policy makers must change their policies to better address issues of syringe access and in consultation with user groups, develop alternative models of needle distribution and recovery that do not necessarily include exchange. © 2003 Elsevier B.V. All rights reserved. Keywords: HIV; Syringes; Single room occupancy Introduction The Downtown Eastside of Vancouver is an entrenched inner city neighbourhood, among the most impoverished in Canada, and well known for its public drug use scene and bustling sex trade industry. Combined, the drug hustles and police sweeps create an atmosphere laden with danger, volatility and vulnerability. Overdoses in the alleys, parks and single room occupancy hotels (SRO) are commonplace, and physical violence and sexual assaults against women are prominent and persistent problems. Since the mid-1990s, the Downtown East Side has experienced an explosive and ongoing HIV epidemic among injection drug users (Spittal et al., 2002; Strathdee et al., 1997). The annual HIV inci- dence rate of 18% among injection drug users observed in 1997 is among the highest ever documented in high income countries (Strathdee et al., 1997), and the prevalence of * Corresponding author. Tel.: +1-604-806-8779; fax: +1-604-806-9044. E-mail address: pspittal@hivnet.ubc.ca (P.M. Spittal). hepatitis C exceeds 90% (Miller et al., 2002a). HIV inci- dence rates in recent years remain above 3%, higher than most North American cities (Spittal et al., 2001). At the same time, the neighbourhood is home to one of the largest needle exchange programmes (NEP) in North America. This programme was implemented in 1988 and exchanged more than 2.5 million needles in 2002 (Bardsley, Turvey, & Blatherwick, 1990; Tyndall et al., 2003). The role of NEPs in disease prevention among IDUs con- tinues to be highly controversial, particularly in the United States (Moss, 2000b). A ban on federal funding of NEPs remains in place in the US (Lurie & Drucker, 1997). When we previously reported that HIV prevalence among those who frequently attended the NEP in Vancouver was higher than among those who attended less frequently (Strathdee et al., 1997), some observers, both Canadian and Ameri- can, interpreted these observations to suggest that needle ex- change programs may promote the spread of HIV (Bellm, 1999; Bennett, 1998). For example, on September 11, 1997, Representative Dennis Hastert proposed an amendment to a yearly appropriations act that would prohibit the use of 0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0955-3959(03)00132-4