NIMBY localism and national inequitable exclusion alliances: The case of syringe exchange programs in the United States.

Syringe exchange programs (SEPs) aim to reduce the harm associated with injection drug use (IDU). Although they have been accepted as critical components of HIV prevention in many parts of the world, they are often unwelcome and difficult to set up and maintain, even in communities hardest hit by IDU-related HIV transmission. This research examines socio-cultural and political processes that shape community and institutional resistance toward establishing and maintaining SEPs. These processes are configured and reinforced through the socio-spatial stigmatizing of IDUs, and legal and public policy against SEPs. Overarching themes the paper considers are: (1) institutional and/or political opposition based on (a) political and law enforcement issues associated with state drug paraphernalia laws and local syringe laws; (b) harassment of drug users and resistance to services for drug users by local politicians and police; and (c) state and local government (in)action or opposition; and (2) the stigmatization of drug users and location of SEPs in local neighborhoods and business districts. Rather than be explained by "not in my back yard" localism, this pattern seems best conceptualized as an "inequitable exclusion alliance" (IEA) that institutionalizes national and local stigmatizing of drug users and other vulnerable populations.

HIV among injection drug users in large US metropolitan areas, 1998.

This article estimates HIV prevalence rates among injection drug users (IDUs) in 95 large US metropolitan areas to facilitate social and policy analyses of HIV epidemics. HIV prevalence rates among IDUs in these metropolitan areas were calculated by taking the mean of two estimates: (1) estimates based on regression adjustments to Centers for Disease Control and Prevention (CDC) Voluntary HIV Counseling and Testing data and (2) estimates based on the ratio of the number of injectors living with HIV to the number of injectors living in the metropolitan area. The validity of the resulting estimates was assessed. HIV prevalence rates varied from 2 to 28% (median 5.9%; interquartile range 4.0-10.2%). These HIV prevalence rates correlated with similar estimates calculated for 1992 and with two theoretically related phenomena: laws against over-the-counter purchase of syringes and income inequality. Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates, predictors and consequences of HIV prevalence rates among drug injectors in metropolitan areas and for assessing and targeting the service needs for drug injectors.

Racial/ethnic disparities in injection drug use in large US metropolitan areas.

PURPOSE: Because blacks and Latinos bear a disproportionate burden of injection-related health problems compared with whites, we sought to describe black/white and Latino/white disparities in injecting drugs in 94 US metropolitan statistical areas (MSAs) in 1998. METHODS: Using US Census data and three databases documenting injectors' use of different healthcare services (drug treatment, HIV counseling and testing, and AIDS diagnoses), we calculated database-specific black/white and Latino/white disparities in injecting in each MSA and created an index of black/white and Latino/white disparities by averaging data across the three databases. RESULTS: The median black/white injecting disparity in the MSAs ranged from 1.4 to 3.7 across the three databases; corresponding median Latino/white injecting disparities ranged from 1.0 to 1.1. Median black/white and Latino/white index disparity values were 2.6 and 1.0, respectively. CONCLUSIONS: Although whites were the majority of injectors in most MSAs, database-specific and index black/white disparity scores indicate that blacks were more likely to inject than whites. While database-specific and index disparity scores indicate that Latinos and whites had similar injecting rates, they also revealed considerable variation in disparities across MSAs. Future research should investigate these disparities' causes, including racial/ethnic inequality and discrimination, and study their contributions to the disproportionate burden of injection-related health problems borne by blacks and Latinos.

Estimating numbers of injecting drug users in metropolitan areas for structural analyses of community vulnerability and for assessing relative degrees of service provision for injecting drug users.

This article estimates the population prevalence of current injection drug users (IDUs) in 96 large US metropolitan areas to facilitate structural analyses of its predictors and sequelae and assesses the extent to which drug abuse treatment and human immunodeficiency virus (HIV) counseling and testing are made available to drug injectors in each metropolitan area. We estimated the total number of current IDUs in the United States and then allocated the large metropolitan area total among large metropolitan areas using four different multiplier methods. Mean values were used as best estimates, and their validity and limitations were assessed. Prevalence of drug injectors per 10,000 population varied from 19 to 173 (median 60; interquartile range 42-87). Proportions of drug injectors in treatment varied from 1.0% to 39.3% (median 8.6%); and the ratio of HIV counseling and testing events to the estimated number of IDUs varied from 0.013 to 0.285 (median 0.082). Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates and predictors of the population density of drug injectors in metropolitan areas and for assessing the extent of service delivery to drug injectors. Although service provision levels varied considerably, few if any metropolitan areas seemed to be providing adequate levels of services.