The deinstitutionalization of children and adolescents in El Salvador's child protection system.

BACKGROUND: In 2010, El Salvador introduced legislation aimed at reforming the country's Child Protective System (CPS), with a focus on promoting deinstitutionalization. OBJECTIVE: The study aim was to explore the impact of deinstitutionalization on the Salvadoran CPS. PARTICIPANTS AND SETTING: The study was conducted in El Salvador, granting authors unique access to key informants with extensive experience in the country's CPS. Unlike the United States, which is divided into states, El Salvador is divided into departments, and CPS providers were recruited from all 14 departments. Focus groups were facilitated in the East, West, and Central zones to ensure representation from all regions. METHODS: Qualitative semi-structured interviews (n = 26) were conducted in June/July of 2019, which were then followed by focus groups (n = 4) in August 2019. The analysis of the data employed a combination of deductive and inductive thematic coding methods. RESULTS: CPS providers offered valuable insights, categorized into five main themes: (1) Strengths of El Salvador's CPS, (2) Deinstitutionalization policy encompassing socioenvironmental contextual factors, (3) Challenges in the deinstitutionalization process, including insufficient follow-up on deinstitutionalized children, (4) Recommendations from participants, highlighting the importance of enhancing stakeholder coordination/collaboration, and (5) The necessity for a paradigm shift, emphasizing the need to redefine the social contract on protecting children from child maltreatment. CONCLUSIONS: The Salvadoran CPS requires substantial systemic changes. Encouragingly, key informants have demonstrated a commitment to reform not only the deinstitutionalization process but also the broader CPS system in El Salvador including case management and quality of care in institutional settings.

Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system

Objective: Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers. Methods: The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services' needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions. Results: HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions. Conclusion: Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step. Clinical trial registration: NCT00881699

Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system.

OBJECTIVE: Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers. METHODS: The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services' needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions. RESULTS: HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions. CONCLUSION: Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step. CLINICAL TRIAL REGISTRATION: NCT00881699.

Implementing Evidence-Based HIV Prevention for Female Sex Workers in Mexico: Provider Assessments of Feasibility and Acceptability.

This study examined service provider perceptions of feasibility and acceptability of implementing evidence-based practices for preventing HIV/AIDS and STIs in female sex workers (FSWs) in Mexico. Semi-structured interviews were conducted with 124 directors, supervisors and counselors from 12 reproductive health clinics located throughout Mexico participating in a large randomized controlled trial to scale-up the use of a psychoeducational intervention designed to promote FSW condom use and enhance safer sex negotiation skills. Feasibility was based on assessment of personal, organizational and social costs, benefits, and capacity. Costs included anxiety over intervention competency, purchase of condoms and other supplies, expenses of laboratory tests for HIV/STIs, and stigma associated with FSWs. Benefits included increase in personal knowledge and experience, enhanced clinic reputation and service delivery capacity, and increased public health. Capacity was expressed in terms of provider skills to deliver the intervention and additional workload. Acceptability was expressed in terms of provider enthusiasm in delivering these services and FSWs willingness to receive the services. Service provider evaluations of feasibility and acceptability of implementing evidence-based prevention interventions are grounded in local contexts that define costs and benefits of and capacity for implementation and determine features of the intervention and its implementation that are acceptable.

Factors associated with program effectiveness in the implementation of a sexual risk reduction intervention for female sex workers across Mexico: Results from a randomized trial.

OBJECTIVE: The overall aim of this paper is to examine effectiveness of an evidence-based intervention in community settings, and the factors associated with effectiveness. Limited research in the area of HIV prevention has focused on evaluating intervention program effectiveness in real-world settings. METHODS: We implemented an efficacious theory-based sexual risk reduction intervention for female sex workers (FSW) called Mujer Segura across 13 different clinics in 13 sites across Mexico. The overall design was a cluster randomized Type I design simultaneously testing intervention program effectiveness with an observational study of implementation factors. We aimed to examine the effectiveness of Mujer Segura at reducing HIV/STI incidence among FSW participants at each site, and to examine the client-, provider-, organization-, and structure-related factors associated with program effectiveness. RESULTS: We found lower HIV/STI incidence density in the intervention relative to the control group in 5 sites we labeled as "program effective sites," but not in 8 sites we labeled as "program ineffective sites." Using generalized estimating equations controlling for site and computed mean difference effect sizes, we examined statistically and practically significant differences, respectively, between the two groups of sites along various client-, provider-, organization-, and structure-related characteristics. Results indicated that client-level HIV/AIDS related knowledge, and proficiency and engagement in the organizational social context were associated with program effectiveness. CONCLUSIONS: Enormous resources are required to systematically and adequately test the role of multilevel factors on program effectiveness. We successfully implemented Mujer Segura in 13 sites in Mexico. Results suggest that other measures may need to be included in future implementation studies than the ones included here. We were able to point to a few specific factors that should be targeted to increase effectiveness of similar evidence-based programs in low- and other middle-income countries like Mexico. TRIAL REGISTRATION: ClinicalTrials.gov NCT01465607.

A Conceptual Model to Assess Stress-Associated Health Effects of Multiple Ecosystem Services Degraded by Disaster Events in the Gulf of Mexico and Elsewhere.

Few conceptual frameworks attempt to connect disaster-associated environmental injuries to impacts on ecosystem services (the benefits humans derive from nature) and thence to both psychological and physiological human health effects. To our knowledge, this study is one of the first, if not the first, to develop a detailed conceptual model of how degraded ecosystem services affect cumulative stress impacts on the health of individual humans and communities. Our comprehensive Disaster-Pressure State-Ecosystem Services-Response-Health (DPSERH) model demonstrates that oil spills, hurricanes, and other disasters can change key ecosystem components resulting in reductions in individual and multiple ecosystem services that support people's livelihoods, health, and way of life. Further, the model elucidates how damage to ecosystem services produces acute, chronic, and cumulative stress in humans which increases risk of adverse psychological and physiological health outcomes. While developed and initially applied within the context of the Gulf of Mexico, it should work equally well in other geographies and for many disasters that cause impairment of ecosystem services. Use of this new tool will improve planning for responses to future disasters and help society more fully account for the costs and benefits of potential management responses. The model also can be used to help direct investments in improving response capabilities of the public health community, biomedical researchers, and environmental scientists. Finally, the model illustrates why the broad range of potential human health effects of disasters should receive equal attention to that accorded environmental damages in assessing restoration and recovery costs and time frames.

Measuring Current Drug Use in Female Sex Workers and Their Noncommercial Male Partners in Mexico: Concordance Between Data Collected From Surveys Versus Semi-Structured Interviews.

BACKGROUND: Self-reports are commonly used to assess prevalence and frequency of drug use, but it is unclear whether qualitative methods like semi-structured interviews are as useful at obtaining such information as quantitative surveys. OBJECTIVES: This study compared drug use occurrence and frequency using data collected from quantitative surveys and qualitative interviews. We also examined whether combining data from both sources could result in significant increases in percentages of current users and whether the concordance between the two sets of data was associated with the type of drug use, age, gender and socioeconomic status. METHODS: Self- reports of recent marijuana, heroin, crack, cocaine, crystal/methamphetamine, inhalant, and tranquilizer use were collected using both methods from a cohort of Mexican female sex workers and their non-commercial male partners (n = 82). RESULTS: Participants were significantly less likely to report marijuana, cocaine and tranquilizer use and frequency of use during the qualitative interviews than during the quantitative surveys. Agreement on frequency of drug use was excellent for crystal/methamphetamine, heroin and inhalant use, and weak for cocaine, tranquilizers and marijuana use. Older participants exhibited significantly higher concordance than younger participants in reports of marijuana and methamphetamine use. Higher monthly income was significantly associated with higher concordance in crack use but lower concordance with marijuana use. CONCLUSIONS: Although use of such data can result in an underreporting of drug use, qualitative data can be quantified in certain circumstances to triangulate and confirm the results from quantitative analyses and provide a more comprehensive view of drug use.

Sustainability of Evidence-Based Practices for HIV Prevention among Female Sex Workers in Mexico.

OBJECTIVE: This study examined service provider perceptions of requirements for successful sustainment of an efficacious intervention for preventing HIV/AIDS and STIs in female sex workers (FSWs) in Mexico. METHODS: Semi-structured interviews were conducted with 77 leaders and counselors from 12 community-based reproductive health clinics located throughout Mexico participating in a large hybrid effectiveness-implementation randomized controlled trial to scale-up the use of Mujer Segura, a psychoeducational intervention designed to promote condom use and enhance safer sex negotiation skills among FSWs. RESULTS: Five sets of requirements for sustainment were identified: 1) characteristics of the provider, including competence in delivering the intervention, need for continued technical support and assistance from outside experts, and satisfaction with addressing the needs of this population; 2) characteristics of the clients (i.e., FSWs), including client need and demand for services and incentives for participation; 3) characteristics of the organization, including its mission, benefits, and operations; 4) characteristics of the outer setting, including financial support and relationship with the community-based organization's central offices, and transportation and security in areas where FSWs live and work; and 5) outcomes associated with the intervention itself, including a reduction of risk through education and increased outreach through referrals from FSWs who received the intervention. CONCLUSIONS: Although the requirements for successful sustainment of interventions like Mujer Segura are consistent with the factors identified in many models of implementation, the results illustrate the importance of local context in assigning priority to these model elements and suggest that the five categories are not discrete entities but interconnected.

Client perspectives on design and implementation of a couples-based intervention to reduce sexual and drug risk behaviors among female sex workers and their noncommercial partners in Tijuana and Ciudad Juárez, México.

This mixed-methods study examined the acceptability of a hypothetical couples-based HIV prevention program for female sex workers and their intimate (non-commercial) male partners in Mexico. Among 320 participants, 67 % preferred couples-based over individual programs, particularly among men. Reasons cited for preferring couples-based programs included convenience and health benefits for both partners. Participants reported that they would benefit from general health information and services, HIV counseling and testing, job training (particularly for men) and other services. However, qualitative interviews revealed that barriers relating to the environment (i.e., poor access to services), providers (i.e., lack of a therapeutic alliance), and intimate relationships (i.e., mistrust or instability) would need to be addressed before such a program could be successfully implemented. Despite women's concerns about privacy and men's preferences for gender-specific services, couples-based HIV prevention programs were largely acceptable to female sex workers and their intimate male partners.

Sex workers' noncommercial male partners who inject drugs report higher-risk sexual behaviors.

Female sex workers are less likely to use condoms with noncommercial male partners than clients. We compare noncommercial male partners who do and do not inject drugs in Tijuana and Ciudad Juárez, Mexico. Sexual risk behaviors were more prevalent among injectors, who could promote HIV/sexually transmitted infection transmission in this region.

"Eyes that don't see, heart that doesn't feel": coping with sex work in intimate relationships and its implications for HIV/STI prevention.

Partner communication about HIV sexual risk behaviors represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors. Using qualitative data from a social epidemiology study of risk for HIV and other sexually transmitted infections (STIs) among female sex workers and their intimate, non-commercial male partners along the Mexico-U.S. border, we examined both partners' perspectives on sex work and the ways in which couples discussed associated HIV/STI risks in their relationship. Our thematic analysis of individual and joint interviews conducted in 2010 and 2011 with 44 couples suggested that broader contexts of social and economic inequalities profoundly shaped partner perspectives of sex work. Although couples accepted sex work as an economic contribution to the relationship in light of limited alternatives and drug addiction, it exacted an emotional toll on both partners. Couples employed multiple strategies to cope with sex work, including psychologically disconnecting from their situation, telling "little lies," avoiding the topic, and to a lesser extent, superficially discussing their risks. While such strategies served to protect both partners' emotional health by upholding illusions of fidelity and avoiding potential conflict, non-disclosure of risk behaviors may exacerbate the potential for HIV/STI acquisition. Our work has direct implications for designing multi-level, couple-based health interventions.

'Where sex ends and emotions begin': love and HIV risk among female sex workers and their intimate, non-commercial partners along the Mexico-US border.

This study explores the affective dimensions of female sex workers' relationships with their intimate, non-commercial partners and assesses how emotions shape each partner's sexual and drug-related risk within their relationship. We draw on qualitative data from a study of HIV, sexually transmitted infections and high-risk behaviours among female sex workers and their non-commercial partners in Tijuana and Ciudad Juárez, Mexico, to illustrate that these couples share relationships based on love, trust, respect and emotional and material support. These relationships range in emotional intensity, which shapes partners' decisions not to use condoms with each other. Drugs were important in most couples' relationships. Among injectors, syringe sharing was common and represented both a sign of care and a pragmatic reaction to conditions of material scarcity. Our findings suggest that couple-based HIV interventions to address dual sexual and drug-related risks should be tailored to the emotional dynamics of sex workers' intimate relationships.

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico-US border cities: a mixed methods analysis.

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs' intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners' anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.

Ethnic differences in the prevalence and predictors of restless legs syndrome between Hispanics of Mexican descent and non-Hispanic Whites in San Diego county: a population-based study.

STUDY OBJECTIVES: To investigate the prevalence and predictors of RLS in Hispanics of Mexican descent (HMD) and non-Hispanic whites (NHW). DESIGN: A population-based random digit dialing telephone questionnaire. SETTING: San Diego County California PARTICIPANTS: 1,754 HMD and 1,913 NHW adults ≥ 18 years of age able to participate in a telephone interview in English or Spanish. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: RLS was defined by the presence of all 4 criteria of the International Restless Legs Study Group. Sleepiness was measured by the Epworth Sleepiness Scale. Acculturation was evaluated using the Short Acculturation Scale for Hispanics. Risk factors for RLS were by self-report. The survey was conducted in the subject's language of choice. RLS prevalence was significantly lower in HMD than in NHW (14.4% vs.18.3%, p = 0.002). High acculturation HMD had a significantly greater RLS prevalence than the low acculturation group (17.4% vs. 12.8%, p = 0.008). Predictors of RLS varied between HMD and NHW. Female gender (OR 1.40, 95% CI 1.04, 1.90, p = 0.027), smoking (OR 1.82, 95% CI 1.27, 2.61, p = 0.001), and acculturation (OR 1.47, 95% CI 1.10, 1.97, p = 0.009) were independent predictors of RLS in HMD, while only older age (OR 1.01, 95% CI 1.0, 1.02) was an independent predictor of RLS for NHW. CONCLUSION: The prevalence of RLS was significantly lower in HMD than in NHW, and significantly greater in high acculturation HMD. Our data suggest that risk factors for RLS vary by race/ethnicity and acculturation is an independent risk for RLS in HMD.

Implementation of an efficacious intervention for high risk women in Mexico: protocol for a multi-site randomized trial with a parallel study of organizational factors.

BACKGROUND: Studies of implementation of efficacious human immunodeficiency virus (HIV) prevention interventions are rare, especially in resource-poor settings, but important, because they have the potential to increase the impact of interventions by improving uptake and sustainability. Few studies have focused on provider and organizational factors that may influence uptake and fidelity to core intervention components. Using a hybrid design, we will study the implementation of an efficacious intervention to reduce sexually transmitted infections (STIs) among female sex workers (FSWs) in 12 cities across Mexico. Our protocol will test a 'train-the-trainer' implementation model for transporting the Mujer Segura (Healthy Woman) intervention into community-based organizations (CBOs). METHODS: We have partnered with Mexican Foundation for Family Planning (Mexfam), a non-governmental organization that has CBOs throughout Mexico. At each CBO, trained ethnographers will survey CBO staff on characteristics of their organization and on their attitudes toward their CBO and toward the implementation of evidence-based interventions (EBIs). Then, after CBO staff recruit a sample of 80 eligible FSWs and deliver a standard-care, didactic intervention to 40 women randomly selected from that pool, a Mexfam staff person will be trained in the Mujer Segura intervention and will then train other counselors to deliver Mujer Segura to the 40 remaining participating FSWs. FSW participants will receive a baseline behavioral assessment and be tested for HIV and STIs (syphilis, gonorrhea, and chlamydia); they will be reassessed at six months post-intervention to measure for possible intervention effects. At the same time, both qualitative and quantitative data will be collected on the implementation process, including measures of counselors' fidelity to the intervention model. After data collection at each CBO is complete, the relative efficacy of the Mujer Segura intervention will be analyzed, and across CBOs, correlations will be examined between individual and organizational provider characteristics and intervention efficacy. DISCUSSION: This cooperative, bi-national research study will provide critical insights into barriers and facilitating factors associated with implementing interventions in CBOs using the 'train the trainer' model. Our work builds on similar scale-up strategies that have been effective in the United States. This study has the potential to increase our knowledge of the generalizability of such strategies across health issues, national contexts, and organizational contexts. TRIAL REGISTRATION: NCT01465607.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: exemplars from research with drug using populations.

Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors' research on HIV risk amongst injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts.

Deportation experiences of women who inject drugs in Tijuana, Mexico.

Deportation from the United States for drug offenses is common, yet the consequences of deportation for women drug users are poorly documented. In 2008, in Tijuana, Mexico, we conducted an exploratory qualitative study of migration, deportation, and drug abuse by interviewing 12 Mexican injection-drug-using women reporting U.S. deportation. Women reported heavy drug use before and after deportation, but greater financial instability and physical danger following deportation than when in the United States. We identified an unmet need for health and social services among deported drug-using women, including HIV prevention, drug treatment, physical and mental health services, and vocational training. Binational coordination is needed to help deported women resettle in Mexico.

A qualitative view of drug use behaviors of Mexican male injection drug users deported from the United States.

Deportees are a hidden yet highly vulnerable and numerous population. Significantly, little data exists about the substance use and deportation experiences of Mexicans deported from the United States. This pilot qualitative study describes illicit drug use behaviors among 24 Mexico-born male injection drug users (IDUs), ≥ 18 years old, residing in Tijuana, Mexico who self-identified as deportees from the United States. In-person interviews were conducted in Tijuana, Mexico in 2008. Content analysis of interview transcripts identified major themes in participants' experiences. Few participants had personal or family exposures to illicit drugs prior to their first U.S. migration. Participants reported numerous deportations. Social (i.e., friends/family, post-migration stressors) and environmental factors (e.g., drug availability) were perceived to contribute to substance use initiation in the U.S. Drugs consumed in the United States included marijuana, heroin, cocaine, methamphetamine, and crack. More than half of men were IDUs prior to deportation. Addiction and justice system experiences reportedly contributed to deportation. After deportation, several men injected new drugs, primarily heroin or methamphetamine, or a combination of both drugs. Many men perceived an increase in their substance use after deportation and reported shame and loss of familial social and economic support. Early intervention is needed to stem illicit drug use in Mexican migrant youths. Binational cooperation around migrant health issues is warranted. Migrant-oriented programs may expand components that address mental health and drug use behaviors in an effort to reduce transmission of blood-borne infections. Special considerations are merited for substance users in correctional systems in the United States and Mexico, as well as substance users in United States immigration detention centers. The health status and health behaviors of deportees are likely to impact receiving Mexican communities. Programs that address health, social, and economic issues may aid deportees in resettling in Mexico.

Barriers to pharmacy-based syringe purchase among injection drug users in Tijuana, Mexico: a mixed methods study.

Injection drug users (IDUs) may be denied purchase of sterile syringes even where purchase without a prescription is legal. This study examined barriers to over-the-counter (OTC) syringe purchase among IDUs in Tijuana, Mexico. A quantitative survey and subsequent focus groups were used to quantify barriers to purchase, identify their correlates and provide in-depth exploration of syringe purchase experiences. Of 627 IDUs, 81% purchased a syringe in the past 6 months and 16% were refused or overcharged. Factors independently associated with refusal/overcharging were homelessness, receptive syringe sharing, >5 uses per syringe, and number of lifetime abscesses. Few pharmacies sold syringes to IDUs, who adapted by limiting purchase attempts to pharmacies known to sell syringes consistently. Failed purchases occurred when drug withdrawal required purchase at unusual times or locations, often following release from jail. IDUs reported syringe sharing, syringe reuse, and searching through unsecured medical waste for syringes in response to failed purchase attempts. Interventions to expand OTC syringe sales to IDUs, particularly near detention facilities, will facilitate safer injection practices.