Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users Ricky N. Bluthenthal 1,2,3 , Greg Ridgeway 1 , Terry Schell 1 , Rachel Anderson 4 , Neil M. Flynn 4 & Alex H. Kral 5,6 Health Program and Drug Policy Research Center, RAND Corporation, Santa Monica, CA, USA, 1 Urban Community Research Center, Sociology Department, California State University Dominguez Hills, CA, USA, 2 The Public Health Consortium for HIV Disparities Research, Charles R. Drew University of Medicine and Science, CA, USA, 3 Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis, CA, USA, 4 RTI International, San Francisco Regional Office CA, USA 5 and Department of Family and Community Medicine, University of California, San Francisco, CA, USA 6 ABSTRACT Aim To determine whether syringe exchange programs’ (SEPs) dispensation policy is associated with syringe cover- age among SEP clients. Design Cross-sectional samples of SEPs and their clients. Setting SEPs in California, USA. Participants Twenty-four SEPs and their injection drug using (IDU) clients (n = 1576). Measurements Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self- reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange. Findings Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for- one exchange. Using propensity scoring methods, we compared syringe coverage by dispensation policies while con- trolling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits. Conclusion Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. SEPs should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage. Keywords HIV prevention, injection drug use, needle exchange programs, program effectiveness, sterile syringe access. Correspondence to: Ricky N. Bluthenthal, RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, California, 90407–2138, USA. E-mail: rickyb@rand.org Submitted 3 March 2006; initial review completed 13 June 2006; final version accepted 3 November 2006 INTRODUCTION Syringe exchange programs (SEPs) are regarded by public health officials and scientists as an effective strategy for preventing HIV infection among injection drug users (IDUs), yet little is known about what models of SEPs are most effective [1,2]. Surveys of SEP operators in the United States have found differences in operational characteristics among SEPs such as syringe dispensation policies, distributed HIV prevention materi- als (i.e. bleach, condoms), distributed other injection materials (i.e. cookers, cotton, ties), availability of other social and medical services and numbers of syringes exchanged [3,4]. Differences in SEP operational characteristics have also been noted in other countries [5,6]. RESEARCH REPORT doi:10.1111/j.1360-0443.2006.01741.x © 2007 RAND corporation Addiction, 102, 638–646