HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) All Versions of this Article: AJPH.2005.069591v1 AJPH.2005.069591v2 97/1/117    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (7) Citing Articles via Google Scholar Google Scholar Articles by Fuller, C. M. Articles by Vlahov, D. Search for Related Content PubMed PubMed Citation Articles by Fuller, C. M. Articles by Vlahov, D. Related Collections Epidemiology Health Policy HIV/AIDS

Crystal M. Fuller, MPH, PhD, Sandro Galea, MD, DrPH, Wendy Caceres, BS, Shannon Blaney, MPH, Sarah Sisco, MPH and David Vlahov, PhD

The authors are with the Harlem Community & Academic Partnership at the Center for Urban Epidemiological Studies, New York Academy of Medicine, New York, NY.

Correspondence: Requests for reprints should be sent to Crystal M. Fuller, 722 West 168th Street, Room 718, New York, NY 10032 (e-mail: cf317{at}columbia.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 

Objectives. Research has indicated that there is minimal use of pharmacies among injection drug users (IDUs) in specific neighborhoods and among Black and Hispanic IDUs. We developed a community-based participatory research partnership to determine whether a multilevel intervention would increase sterile syringe access through a new policy allowing nonprescription syringe sales in pharmacies.

Methods. We targeted Harlem, NY (using the South Bronx for comparison), and disseminated informational material at community forums, pharmacist training programs, and counseling or outreach programs for IDUs. We compared cross-sectional samples in 3 target populations (pre- and postintervention): community members (attitudes and opinions), pharmacists (opinions and practices), and IDUs (risk behaviors).

Results. Among community members (N = 1496) and pharmacists (N = 131), negative opinions of IDU syringe sales decreased in Harlem whereas there was either no change or an increase in negative opinions in the comparison community. Although pharmacy use by IDUs (N=728) increased in both communities, pharmacy use increased significantly among Black IDUs in Harlem, but not in the comparison community; syringe reuse significantly decreased in Harlem, but not in the comparison community.

Conclusions. Targeting the individual and the social environment through a multilevel community-based intervention reduced high-risk behavior, particularly among Black IDUs.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
The many strategies for preventing HIV/AIDS among injection drug users (IDUs) who cannot cease drug use have included syringe exchange programs and the removal of barriers to purchase (primarily through pharmacies) and possess syringes.¹ Syringe exchange programs, which couple syringe exchange with counseling, education, and referrals to care, have been shown to reduce HIV infection. However, obstacles such as fear of being identified as an IDU and police harassment have prevented some IDUs from using these programs.^2–7 Furthermore, inadequate syringe supplies, limited operation hours, and long travel distances have also been identified as barriers to syringe exchange program use.^8,9 As a result, numerous researchers urge the use of pharmacies as safe syringe sources to supplement syringe exchange programs.^1,10

Recognizing this need, New York State enacted the Expanded Syringe Access Demonstration Program (ESAP), which permits pharmacy syringe sales without a prescription. Since January 1, 2001, individuals aged 18 years or older have been permitted to purchase and legally possess up to 10 syringes without a prescription from pharmacies registered with the New York State Department of Health. Early data revealed that IDUs in East and Central Harlem (referred to as "Harlem" hereafter) and South Bronx minimally participated in ESAP.^11–14 In addition, studies indicated that Black and Hispanic drug users were less likely to use pharmacies as safe and legal syringe sources compared with their White counterparts, irrespective of geographic location.^11,12,14,15

In the summer of 2001, the Harlem Community and Academic Partnership recognized the disparities in both the use of ESAP and the burden of HIV disease in their community, and organized an intervention work group to address this issue. The partnership had been formed 2 years earlier, as described elsewhere,¹⁶ and currently includes 30 community-based organizations in Harlem, 4 academic institutions, and the local health department. Because of the complex social factors (e.g., police harassment, various types of discrimination) that contribute to injection risk, and previous work that shows how contextual factors (e.g., public policy, cultural norms, illegality of drug use) may influence individual behaviors, a multilevel design was chosen.^17–19 Using a community-based participatory research approach,²⁰ we targeted 3 populations: community residents, pharmacists, and IDUs. The specific goals for the intervention were (1) to sensitize community residents to drug users and dispel negative myths by providing education on the positive affect that ESAP could have in their community (e.g., reducing the risk and burden of HIV disease), (2) to provide education to pharmacists about what was and was not required by the law and provide information to help dispel negative perceptions of drug users, and (3) to increase awareness of ESAP among IDUs and provide the location and hours of ESAP-participating pharmacies and information about safe injection and syringe disposal practices. All activities were to be performed in a culturally appropriate manner to specifically reach Black and Hispanic IDUs.

We report the final results of our non-randomized, multilevel intervention, including pre- and postintervention evaluations in both intervention (Harlem) and comparison (South Bronx) communities. Using a community-based participatory research approach, we obtained data on 3 target populations: community residents, pharmacists, and IDUs.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
Study Population
Community residents, pharmacists, and IDUs were sampled at 2 time points: preintervention and postintervention. Community residents were drawn from randomly selected households on the basis of geographic eligibility (identified by the nearest major intersection) in each of 2 locations in New York: Harlem (intervention) and South Bronx (comparison). Further randomization of adults within the household was performed by selecting the individual aged 18 years or older who reported a birth date closest to the call date. The final community sample size was 742 residents preintervention (intervention = 494; comparison = 248) and 754 residents postintervention (intervention = 505; comparison = 249).

Pharmacies were selected from a database of listings from the New York State Department of Health combined with listings obtained from Yellowpages.com (http://www.yellowpages.com), an online directory collected from phone books and new business listings. Because of the modest number of pharmacies registered in South Bronx, the Bedford-Stuyvesant community in Brooklyn (with similar demographics) was added to the comparison community, which yielded 106 pharmacies in the comparison community and 45 in the intervention community. Pharmacies were excluded from the study if their phone was disconnected, if they did not provide over-the-counter services, or if the supervising pharmacist was unwilling to participate. Pharmacists were only called when customer volume was expected to be low (on the basis of pilot testing). In the intervention community, 53% (n = 24) of the pharmacists participated in the preintervention phone survey and 62% (n = 28) participated in the postintervention survey. In the comparison community, 44% (n = 47) and 31% (n = 33) participated in the pre- and postintervention surveys, respectively. Although it is likely that some pharmacists surveyed preintervention were the same pharmacists surveyed post-intervention, confidentiality issues prevented linking these individuals at these 2 time points.

To enhance feasibility and efficiency of this study, 2 preexisting IDU studies that used similar recruitment techniques provided the samples for pre- and postintervention periods. IDUs for both studies were recruited at community research sites within each target community using targeted and respondent-driven sampling methods. The first study was an observational cohort study that targeted IDUs between 18 and 35 years of age and the second was an observational cross-sectional study (Urban Resource Center Cross-Sectional Survey) conducted among IDUs aged 18 years and older. The final sample (combined across each study) included 278 IDUs in the preintervention period (intervention = 134; comparison = 144) and 450 IDUs in the postintervention period (intervention = 239; comparison = 211). Because these studies ran concurrently and were conducted by the same research staff, participants were allowed to participate in only 1 of the 2 studies.

Data Collection
Surveys were conducted pre- and postintervention for each population in the intervention and the comparison communities. An anonymous random-digit-dial telephone survey was conducted among community residents preintervention (February 2002) and postintervention (July 2003). In addition to demographics, respondents were asked about approval or disapproval of drug use, and the effect of ESAP on street-discarded syringes, crime, drug use, and the spread of HIV. Surveys lasted approximately 25 minutes and were administered in English and Spanish. Spanish-language surveys had previously been back-translated for verification of consistency.

Pharmacists also participated in anonymous, cross-sectional surveys regarding their opinions and attitudes about ESAP both pre-intervention (April 2002) and postintervention (August 2003). In addition to individual pharmacist demographics, pharmacists were asked about their support for ESAP and their opinions of ESAP’s effect on street-discarded syringes, drug abuse, and HIV transmission.

Data collected among IDUs from both observational studies focused on social and behavioral risk factors for HIV, hepatitis C virus, and hepatitis B virus infections. In addition to existing sociodemographic data, new ESAP-related variables were added to both surveys and included knowledge about ESAP, source of pharmacy syringes, syringe sharing, and syringe reuse. IDUs surveyed from January 1, 2001, to June 31, 2002, comprised the preintervention sample and those surveyed from July 1, 2002, to September 1, 2004, comprised the postintervention sample.

Intervention Activities
The Harlem ESAP Intervention Project spanned between July 1, 2002, and June 30, 2003, and was fully designed and implemented by the Intervention Work Group. Activities targeting community members included visits to IDU-servicing community-based organizations and training programs conducted at these organizations, presentations to Harlem community boards, participation in health fairs and harm reduction meetings, and an ESAP community forum at a local church. Pamphlets were distributed and posters were hung in community centers, hair salons, barbershops, and bodegas.

All ESAP-registered and non-ESAP-registered pharmacists in the intervention community were visited and provided with ESAP information and registration assistance. They were also invited to a pharmacist and pharmacy clerk training workshop. Each registered pharmacy received pharmacy-tailored ESAP posters, pamphlets, ESAP guides, free safe syringe-disposal containers (Fitpacks), and regular program progress updates.

Intervention activities for IDUs included education about ESAP during HIV pre- and posttest counseling, small group training sessions regarding ESAP and safe syringe-disposal practices, and ESAP stickers and posters posted in communities where there was high drug use. The New York Academy of Medicine and other IDU-servicing community-based organizations conducted 1-on-1 and small group outreach to IDUs by disseminating ESAP pamphlets, which included a list and map of all registered pharmacies in Harlem. All ESAP educational materials included a toll-free telephone number (1-866-SAFE-SHOT) for a service that provided 24-hour information about ESAP, safe injection, syringe disposal, and legal matters to IDUs and pharmacists and staffed during regular business hours and voice-prompted after business hours.

Data Analysis
Intervention activity materials were tabulated by population and activity category. Chi-square tests were used to compare pre- and postintervention periods for community resident, pharmacist, and IDU cross-sectional samples. In addition, pharmacy use reported by IDUs during the pre- and postintervention periods was stratified by race/ethnicity to determine the effect of the intervention on Black and Hispanic IDUs. P values < .05 were used to help determine significant differences for all group comparisons.

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
Intervention Activities
Table 1 presents the intervention activities implemented at each targeted population level. At the community level, there were 90 contacts with community-based organizations, which included 4 community-based organization training sessions or forums, 9 health fairs or community meetings, and 50 1-on-1 visits (3 visits or contacts with each community-based organization on average). This resulted in the distribution of 11400 ESAP pamphlets, 1485 ESAP posters, 510 ESAP stickers, and 60 Fitpacks. With regard to pharmacies, there were 128 1-on-1 visits (3 visits to each pharmacy on average), and 2 pharmacist training sessions or forums that resulted in the distribution of 95 ESAP pharmacy guides, 94 ESAP posters, and 586 Fitpacks. Finally, 60 1-on-1 counseling sessions, 16 focus groups, and 87 IDU-targeted outreach events were conducted. A total of 5350 ESAP pamphlets, 750 ESAP stickers (posted on billboards, construction scaffolding, and vacant buildings) and 2000 Fitpacks were distributed.

Pharmacists
Attitudes and perceptions of ESAP-registered pharmacists about nonprescription syringe sales to IDUs, both pre- and post-intervention, are reported in Table 3. There were no differences in the pre- and post-intervention pharmacist samples with respect to gender and pharmacy type (chain vs independent). However, there were significantly more Black (26%), and fewer White pharmacists (17%) sampled postintervention than preintervention (14% and 32%, respectively; P< .01) in the intervention community. There were significantly more Whites (26%) and fewer Middle Eastern pharmacists (3%) sampled postintervention than preintervention (20% and 38%, respectively; P< .02) in the comparison community. A smaller proportion did not support ESAP (27%), and a larger proportion reported they were undecided (23%) postintervention than preintervention (41% and 0%, respectively; P< .06) in the intervention community. This difference was only marginally significant. In the comparison community, there was a significantly larger proportion that did not support ESAP (63%) and fewer who supported ESAP (34%) postintervention than preintervention (39% and 61%, respectively; P< .05). The majority of registered pharmacists surveyed reported selling syringes during both time periods for each community.

Injection Drug Users
Table 4 illustrates injection practices pre- and postintervention among IDUs in the intervention and comparison communities. In the intervention community, the mean age of IDUs was significantly younger during the postintervention period (36 years) compared with preintervention (39 years; P<.01). However, in the comparison community, mean age did not differ by period. In both communities, there was a significant increase in the proportion of men surveyed when comparing pre- and postintervention periods. There tended to be more Hispanic (66%) and White (18%) and fewer Black IDUs (16%) in the intervention community postintervention than preintervention (49%, 8%, and 43%, respectively; P<.01). A similar trend was observed in the comparison community except that there were fewer White IDUs in the postintervention than the preintervention period, and fewer Black IDUs overall.

To further examine the effect of the intervention on IDUs by race/ethnicity, stratified analysis revealed that Black IDUs in the intervention community were significantly more likely to use pharmacies postintervention (22%) than preintervention (5%; P< .02), although there was no significant difference in pharmacy use among Black IDUs in the comparison community postintervention (11%) than preintervention (8%; P > .99). There was also a significant increase among Hispanic IDUs in both intervention and comparison communities when comparing postintervention and preintervention periods (34% vs 15%, P< .005; and 29% vs 13%, P< .001, respectively).

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
A multilevel intervention that was implemented by a community and academic partnership to create a more socially receptive environment appears to have contributed to positive behavior change in the intervention community, and either no change of opinions or increased negative opinions in the comparison community. Specifically, there was an increase in positive opinions and a decrease in negative opinions and attitudes toward pharmacy syringe sales to IDUs among community residents and pharmacists in the intervention community. Also, negative attitudes shifted to an "undecided" viewpoint in the intervention community only. Thus, in some cases negative perceptions might not have been completely dispelled, but pharmacists’ previous negative opinions might have been shifted toward a more positive opinion of ESAP. Finally, although there was an increase in pharmacy use among IDUs in both communities, there was a significant decrease in syringe reuse, as well as a significant increase in pharmacy use among Black IDUs in the intervention community when pre-and postintervention periods were compared.

Elements of multilevel community interventions (or structural interventions) with multilevel pre- and postintervention evaluation and comparison communities have been described in the literature.²¹ Community and academic partnerships have also been described^22,23 and used in community-based participatory research to address a variety of health-related problems,^20,24 but to date most partnerships have been evaluated on process rather than outcome. Although multilevel interventions (individual, provider, community) have been considered important to the research community,^25–28 they have been designed and led by research professionals.^25,26 Examples include nonrandomized pre- and postintervention designs for disease prevention projects, which in general have the closest similarity to the results reported here. For instance, HIV intervention programs for drug users have used community outreach to achieve reductions in individual-level risk behaviors,²⁹ but generally the evaluations have been conducted using individual pre- and postintervention questionnaires. Drug abuse treatment has been evaluated at the individual level by comparing in-treatment with out-of-treatment populations,³⁰ but follow-up typically has been limited to in-treatment modalities. Using community ecological designs, injection risk behaviors of syringe exchange program participants and nonparticipants have been evaluated before the start of the syringe program rather than after.^1,31 More recently, Connecticut policy makers changed a law to allow nonprescription syringe sales in pharmacies, and separate evaluations of drug users and pharmacists show that program use and changes in risk behavior occurred after the law was changed.^32,33 Data from Connecticut have also been compared with data from other states that had more restricted syringe access.³⁴ These latter studies are what stimulated the law change in New York State as well as the multilevel intervention program we described.

Limitations
Although our findings provide solid evidence of an intervention effect, there were a few limitations in the analytic approach. The use of cross-sectional data to evaluate the effect of a community-based multilevel intervention on individual behavior may be subject to some sources of bias and may be less sensitive to the effect of recent behavior change than prospective studies. However, the pre- and postintervention cross-sectional analytic method chosen here is a prudent and more cost-efficient first approach to determine the effect of a multilevel design. Separate cross-sectional evaluations of each level may also be limited in that they do not provide estimates of the independent effects of each factor examined (i.e., community-level and pharmacy-level factors) on IDU behavior. If the sample size permitted, such information would be significant from a public health and research perspective by identifying the role of the social environment, which in turn lends further support for a multilevel intervention design. However, separate analyses have merit and provide firm evidence of the intervention effect.

As with any community intervention, there was the potential for a contamination effect; our finding of increased pharmacy use in both communities may be an example of this effect. However, in the comparison community there was a decrease in IDU knowledge of the legality of syringe possession despite an increase in pharmacy use. A possible explanation for these contradictory findings in the comparison community is that some ESAP information may have spread more efficiently among drug-use networks, such as which pharmacists are selling syringes, as opposed to more detailed information, such as when syringes are legal and illegal to possess.

We must also note the possibility of selection bias which may partially explain the changes that we have observed. Specifically, pre- and postintervention IDU samples differed with respect to age, race, and gender, which could have been independently associated with pharmacy use. There have been no differences observed in pharmacy use by gender, although older IDUs and minorities have been significantly less likely to use pharmacies in previous reports.^12–14,35 The fact that the postintervention sample tended to be younger and that there was a larger proportion of White IDUs in the intervention community may partially explain the increase in pharmacy use. Yet some of the demographic differences provide notable evidence of an intervention effect. For example, the increased proportion of Hispanic and Latino IDUs coupled with the increased pharmacy use among this group in both communities may suggest more of a contamination effect, which in fact is a positive effect from a public health perspective given their minimal use before the start of this project.^11,14,15,35

The pharmacy participation rates may also indicate the possibility of selection bias; for example, those that participated may have been more likely to support ESAP. To assess this potential bias, we compared the participants to the nonparticipants with regard to pharmacy type (chain vs nonchain) because previous data indicated nonchain pharmacies to be more supportive of ESAP. For pre- and postintervention samples in each community, there were no differences with respect to the proportion of nonchain pharmacies, which provides some evidence of balance with respect to ESAP supporters. We also noted race/ethnicity differences in pre- and postintervention pharmacy samples in both communities. However, previous research has not found an association between pharmacists’ race/ethnicity and ESAP support.³⁶

Finally, the use of community-based participatory research could also be a drawback for others who want to conduct similar interventions, because it can take a year or more to develop trusting and productive relationships between academic centers and community-based organizations²⁰; thus, in order for this approach to work with urgent public heath problems, a viable partnership needs to be in place. The evaluation presented here suggests that establishing this type of partnership can be a worthwhile investment for future programs implemented in this community.

Conclusions
Although structural or multilevel intervention approaches have been suggested for a variety of public health problems—including HIV prevention as early as the year 2000²¹—this is the first community-based multilevel intervention, to our knowledge, that has been evaluated in the HIV-prevention arena with pre- and postintervention measures for community, provider, and individual populations. The findings presented here have important implications for both research and practice. Multilevel interventions, which take into account critical elements of the social environment that may hinder positive behavior change, should be considered a viable disease prevention strategy. Without addressing multiple competing social forces, a public health program such as ESAP will be minimally used, particularly by Black and Hispanic drug users who historically have been mistreated. We have shown here that this intervention strategy may be an efficient and effective strategy to increase the likelihood of individual behavior change and, consequently, a strategy to help reduce racial disparities in a variety of health outcomes.

	Acknowledgments

 
This research was supported by the Centers for Disease Control and Prevention (grant U62/CCU202061-16), the Robert Wood Johnson Foundation, and the National Institute on Drug Abuse (grants R01 DA14219, DA 13146, and DA 12801).

We acknowledge the outreach and interview staff as well as the project directors for their efforts in maintaining quality data collection.

Human Participant Protection
This study was approved by the institutional review board at New York Academy of Medicine where all research activities were conducted. All study participants underwent informed consent.

	Footnotes

 
Peer Reviewed

Contributors
C.M. Fuller designed the research study, directed all data collection and analysis, and led development of the article. S. Galea designed the research study, codirected all data collection, and assisted with article development. W. Caceres was the primary contributor to the article development. S. Blaney conducted all data analysis. S. Sisco coordinated data collection efforts and provided assistance with article development. D. Vlahov assisted with the research design and provided key input in all data collection efforts.

Accepted for publication February 1, 2006.

	References

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
1. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington, DC: National Academy of Medicine; 1995.

2. Rich JD, Strong L, Towe CW, McKenzie M. Obstacles to needle exchange participation in Rhode Island. J Acquir Immune Defic Syndr. 1999;21(5):396–400.[Web of Science][Medline]

3. Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law enforcement on syringe exchange programs: a look at Oakland and San Francisco. Med Anthropol. 1997;18(1):61–83.[Medline]

4. Hagan H, Jarlais DC, Friedman SR, Purchase D, Alter MJ. Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma syringe exchange program. Am J Public Health. 1995;85(11): 1531–1537.[Abstract/Free Full Text]

5. Hagan H, Thiede H. Changes in injection risk behavior associated with participation in the Seattle needle-exchange program. J Urban Health. 2000;77(3): 369–382.[CrossRef][Web of Science][Medline]

6. Vlahov D, Des Jarlais DC, Goosby E, et al. Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy. Am J Epidemiol. 2001;154(12):S70–S77.[Free Full Text]

7. Des Jarlais DC, Marmor M, Paone D, et al. HIV incidence among injecting drug users in New York City syringe-exchange programmes. Lancet. 1996; 48(9033):987–991

8. Lurie P, Jones TS, Foley J. A sterile syringe for every drug user injection: how many injections take place annually, and how might pharmacists contribute to syringe distribution? J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S45–S51.[Web of Science][Medline]

9. Rockwell R, Des Jarlais DC, Friedman SR, Perlis TE, Paone D. Geographic proximity, policy and utilization of syringe exchange programmes. AIDS Care. 1999;11(4):437–442.[CrossRef][Web of Science][Medline]

10. Lazzarini Z, Schoenbaum EE, O’Neill CH. In New York City, syringe laws and regulations deter physicians and pharmacists from prescribing and selling syringes to persons who may be injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1): S141–S143.[Web of Science][Medline]

11. Vlahov D, Fuller C, Finkelstein R, et al. New York State Expanded Syringe Access Demonstration Program: Evaluation Report to the Governor and the New York State Legislation. New York, NY: New York Academy of Medicine; 2003.

12. Fuller CM, Ahern J, Vadnai L, et al. Impact of increased syringe access: preliminary findings on injection drug user syringe source, disposal, and pharmacy sales in Harlem, New York. J Am Pharm Assoc (Wash). 2002;42(6, Suppl 2):S77–S82.[CrossRef]

13. Des Jarlais DC, McKnight C, Friedmann P. Legal syringe purchases by injection drug users, Brooklyn and Queens, New York City, 2000–2001. J Am Pharm Assoc (Wash). 2002;42(6):S73–S76.[CrossRef]

14. Deren S, Fuller CM, Poujet ER, et al. Impact of expanding syringe access in New York on sources of syringes for IDUs in Harlem and the Bronx. Int J Drug Policy. 2003;14(5–6):373–379.[CrossRef]

15. Pouget ER, Deren S, Fuller CM, et al. Receptive syringe sharing among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program. J Acquir Immune Defic Syndr. 2005;39(4):471–477.[CrossRef][Web of Science][Medline]

16. Galea S, Factor SH, Bonner S, et al. Collaboration among community members, local health service providers, and researchers in an urban research center in Harlem, New York. Public Health Rep. 2001;116: 530–539.[Web of Science][Medline]

17. Fuller CM, Borrell LN, Latkin CA, et al. The effect of race, neighborhood, and social network on adolescent initiation of injection drug use. Am J Public Health. 2005;95(4):689–695.[Abstract/Free Full Text]

18. Sorensen G, Emmons K, Hunt MK, et al. Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations. Prev Med. 2003;37(3):188–197.[CrossRef][Web of Science][Medline]

19. Fortmann SP, Varady AN. Effects of a community-wide health education program on cardiovascular disease morbidity and mortality: the Stanford Five-City Project. Am J Epidemiol. 2000;152(4):316–323.[Abstract/Free Full Text]

20. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202.[CrossRef][Web of Science][Medline]

21. Blankenship KM, Bray SJ, Merson MH. Structural interventions in public health. AIDS. 2000;14(Suppl 1): S11–21.[CrossRef]

22. Goldmon MV, Roberson JT Jr. Churches, academic institutions, and public health: partnerships to eliminate health disparities. N C Med J. 2004;65(6): 368–372.[Medline]

23. Adams A, Miller-Korth N, Brown D. Learning to work together: developing academic and community research partnerships. WMJ. 2004;103:15–19.[Medline]

24. Lasker RD, Weiss ES. Broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. J Urban Health. 2003;80(1):14–47.[Web of Science][Medline]

25. Manhart LE, Holmes KK. Randomized controlled trials of individual-level, population-level, and multilevel interventions for preventing sexually transmitted infections: what has worked? J Infect Dis. 2005; 191(Suppl 1):S7–24.[CrossRef][Web of Science][Medline]

26. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999; 89(9):1322–1327.[Abstract/Free Full Text]

27. Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-level HIV prevention intervention for young gay men. Am J Public Health. 1996; 86(8 Pt 1):1129–1136.[Abstract/Free Full Text]

28. Waterman SH, Hill LL, Robyn B, et al. A model immunization demonstration for preschoolers in an inner-city barrio, San Diego, California, 1992–1994. Am J Prev Med. 1996;12(4 Suppl):8–13.[Web of Science][Medline]

29. Coyle SL, Needle RH, Normand J. Outreach-based HIV prevention for injecting drug users: a review of published outcome data. Public Health Rep. 1998;113 (Suppl 1):19–30.[Medline]

30. Metzger DS, Woody GE, McLellan AT, et al. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr. 1993;6(9):1049–1056.[Web of Science][Medline]

31. Vlahov D. The role of epidemiology in needle exchange programs. Am J Public Health. 2000;90(9): 1390–1392.[Free Full Text]

32. Valleroy LA, Weinstein B, Jones TS, Groseclose SL, Rolfs RT, Kassler WJ. Impact of increased legal access to needles and syringes on community pharmacies’ needle and syringe sales–Connecticut, 1992–1993. J Acquir Immune Defic Syndr Hum Retrovirol. 1995; 10(1):73–81.[Web of Science][Medline]

33. Groseclose SL, Weinstein B, Jones TS, Valleroy LA, Fehrs LJ, Kassler WJ. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers–Connecticut, 1992–1993. J Acquir Immune Defic Syndr Hum Retrovirol. 1995;10(1):82–89.[Web of Science][Medline]

34. Diaz T, Chu SY, Weinstein B, Mokotoff E, Jones TS. Injection and syringe sharing among HIV-infected injection drug users: implications for prevention of HIV transmission. Supplement to HIV/AIDS Surveillance Group. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S76–81.[Web of Science][Medline]

35. Fuller CM, Galea S, Blaney S, et al. Explaining the relationship between race/ethnicity and pharmacy purchased syringes among injection drug users in New York City. Ethnicity and Disease. 2004;14:589–596.[Web of Science][Medline]

36. Coffin PO, Ahern J, Dorris S, Stevenson L, Fuller C, Vlahov D. More pharmacists in high-risk neighborhoods of New York City support selling syringes to injection drug users. J Am Pharm Assoc (Wash). 2002; 42(6 Suppl 2):S62–S67.[CrossRef]

This article has been cited by other articles:

				D. C. D. Jarlais and S. Semaan HIV Prevention for Injecting Drug Users: The First 25 Years and Counting Psychosom Med, June 1, 2008; 70(5): 606 - 611. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) All Versions of this Article: AJPH.2005.069591v1 AJPH.2005.069591v2 97/1/117    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (7) Citing Articles via Google Scholar Google Scholar Articles by Fuller, C. M. Articles by Vlahov, D. Search for Related Content PubMed PubMed Citation Articles by Fuller, C. M. Articles by Vlahov, D. Related Collections Epidemiology Health Policy HIV/AIDS