摘要：Objectives. We studied the effect of local approval of syringe exchange programs in California (through Assembly AB136) on program availability and performance. Methods. We determined the number of active syringe exchange programs in California by conducting Internet searches and obtaining information from the state and from local programs. To track changes in program availability and performance between 2000 and 2002, we interviewed 24 program directors annually for 3 years about program characteristics, syringe exchange policies, law enforcement contact, and other issues. We conducted multivariate analyses to determine whether AB136 approval status was associated with changes in performance. Results. Fifteen local governments (13 counties and 2 cities) enacted the new law by 2002, and operating syringe exchange programs increased from 24 to 35. The proportion of these programs that were not locally approved declined from 54% to 40%. No new approved programs were started in high-need counties. Total syringes exchanged increased by more than 1 million per year, average annual budgets increased by more than 50%, and police harassment of the program volunteers, clients, and operators declined. Improvements at approved syringe exchange programs accounted for these changes. Conclusions. Statewide approval and funding appears necessary to further syringe exchange availability in California. Federal officials, medical societies and associations, and public health agencies in the United States have endorsed syringe exchange programs (SEPs) as a crucial component of any comprehensive strategy to prevent HIV among injection drug users. 1 – 3 Yet the congressional prohibition on federal funding for these programs 4 and state and municipal drug paraphernalia and syringe prescription laws have hindered the implementation of these programs in the United States. 5 – 7 However, because of advocacy by activists and public health professionals, changes in state and local laws, and changes in viewpoint among law enforcement agencies and courts, 6 , 8 – 13 there has been a steady, if slow, increase in the numbers and geographic availability of SEPs. As of 2002, there were at least 184 programs operating in 36 states, the District of Columbia, Puerto Rico, and Native American–owned lands, 14 representing a near tripling of programs and an almost doubling of states covered since 1995. 15 Still, many drug users in the United States do not have access to SEPs, suggesting that wider implementation is needed. Achieving wide dissemination of effective prevention strategies is a persistent problem in public health. 16 , 17 In the case of SEPs, 3 general approaches have been observed: Hawaii, New Mexico, and New York have funded programs at the state level, leading to rapid implementation 18 ; Illinois, Ohio, and Pennsylvania have taken no state-level action, but local jurisdictions have acted on interpretations of state laws to approve programs; and California and Massachusetts have adopted statewide policies that formally permit local governments to implement and fund programs at their own discretion. 19 , 20 These various state-level approaches to SEP implementation are likely to affect program availability and performance. In the case of local implementation, the available data are not promising. In Massachusetts, no local referendum on opening a program has been approved since 1997, and the few local governments that had approved new programs reversed themselves in response to negative public reactions. 13 During this period, other local-implementation states—Ohio and Pennsylvania—appear to have fewer programs in 2002 (1 each) than in 1997 (2 each), although whether this decrease was the result of local governmental action is not clear. 14 , 21 , 22 However, the local-implementation approach has not been examined in detail in California or in any other state. Beginning in 2000, Assembly AB136 amended Section 11364.7 of the California Health and Safety Code to read, “No public entity, its agents, or employees shall be subject to criminal prosecution for distribution of hypodermic needles or syringes to participants in clean needle and syringe exchange projects authorized by the public entity pursuant to a declaration of a local emergency due to the existence of a critical local public health crisis.” This change codified an interpretation of the California Emergency Services Act that had been used by local jurisdictions to approve SEPs in California. However, there were 2 complications in the application of this policy change. First, because the California Emergency Services Act required renewal of declarations of public health emergencies every 14 to 21 days, many locales that enacted AB136 believed that repeated renewal was required, 19 although the law establishes no such requirement. Following this unstated requirement, 2 programs ceased operating because of lapses in emergency declarations due to newly elected officials in one case and lack of quorum at a Board of Supervisor meeting in the other. 19 Second, although the language of the legislation does not provide procedures for authorizing specific programs, both public officials and SEP personnel believed that approval status was not conferred unless the local jurisdiction formally endorsed specific programs. In Los Angeles County, despite enactment of AB136 in August 2000, SEPs were still regarded as unapproved by the California State Office of AIDS, Department of Health Services, because the county in which the SEPs resided never authorized any of the programs. 23 Similar situations arose in San Francisco and San Mateo counties and the city of San Diego (Michael Cunningham, California State Office of AIDS, written communication, May 2003). 19 Given these complications, the effect of AB136 on SEPs in California is uncertain. Therefore, we assessed the impact of AB136 during its first 3 years (2000–2002) in 5 areas: total number of programs, availability in high-need areas, number of locally approved programs, program performance over time, and association between performance and AB136–approval status.
