We thank Drach et al. for their interest in our study and for sharing evidence from their intervention study focused on secondary syringe exchange. Consistent with the findings of their study is a large and growing body of evidence pointing to the important role injection drug users can play in enhancing HIV prevention efforts among their peers.
Fairly early on in the HIV epidemic, studies from Europe and the United States demonstrated that involving drug users in the delivery of HIV prevention efforts, including syringe exchange programs (SEPs), could help extend the reach, coverage, and effectiveness of these programs.1–3 These findings were likely, in part, a reflection of the fact that too many injection drug users remained marginalized and did not have access to conventional public health programs. The peer-to-peer model of using drug users as peer educators appears to address this barrier by providing a service that is more acceptable to drug users than professional-led programs.4 In our recent study,5 an important aspect of the change in syringe distribution policy that led to large declines in syringe borrowing and lending was the creation of peer-driven SEPs.
Recently, we have evaluated both the mobile and fixed syringe distribution activities of a local drug user organization—the Vancouver Area Network of Drug Users (VANDU). An examination of the fixed exchange showed that the drug user–led program was attracting a population of injectors who possessed several markers of heightened vulnerability to HIV infection.6 Surprisingly, despite being frequent injectors, the population using the VANDU fixed exchange was also less likely to report unsafe syringe disposal. More recently, we evaluated the VANDU outreach-based syringe distribution program and found similar results.7 This program was reaching high-risk injectors while helping to reduce syringe reuse.
Drach et al. are correct in pointing out that transforming US syringe exchange programs will require changes in political acceptance. Given the evidence concerning the important role that drug users can play in enhancing SEP delivery, a part of this political change must be growing acceptance that this population can and will work effectively to support prevention efforts if given the opportunity.
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