Clare Sears

Investigation of a secondary syringe exchange program for homeless young adult injection drug users in San Francisco, California, U.S.A.

This study investigated an HIV prevention program for homeless young adult injection drug users (IDUs) that combined a secondary syringe exchange program (SEP) with community‐level activities. Homeless young IDUs were recruited from street‐based settings in San Francisco, and a structured questionnaire was administered. The secondary SEP operated in a circumscribed geographic area, and for analytic purposes respondents were assigned to the intervention site group if they primarily spent time in this area (n = 67), or the comparison site group if they primarily spent time elsewhere (n = 55). Almost all (96%) intervention site youth had used the secondary SEP in the past 30 days and were significantly more likely to regularly use SEP. In bivariate analysis, comparison site IDUs were more likely to share syringes, reuse syringes, share the cotton used to filter drugs, and use condoms with casual sex partners only inconsistently. In multivariate analysis, comparison site remained positively associated with sharing syringes (adjusted odds ratio [AOR], 3.748; 95% confidence interval [CI], 1.406‐9.988), reusing syringes (AOR, 2.769; 95% CI, 1.120‐6.847), and inconsistent condom use with casual sex partners (AOR, 4.825; 95% CI, 1.392‐ 16.721). This suggests that the intervention was effective in delivering SEP services to homeless young adult IDUs, and that IDUs who frequented the intervention site had a lower HIV risk than comparison group IDUs.

Injection Risk Behavior among Women Syringe Exchangers in San Francisco

Women who inject drugs in cities where syringe exchange programs (SEPs) are well established may have different risks for HIV infection. In 1997, we interviewed 149 female syringe exchangers in San Francisco, CA, a city with high rates of injection drug use that is home to one of the largest and oldest SEPs in the United States. In this report, we describe their sociodemographics, health, and risk behavior, and we examine factors associated with recent syringe sharing. Fifty percent of respondents were women of color and the median age was 38 years. Most (86%) injected heroin and nearly half were currently homeless or had recently been incarcerated. One-third of all women reported needle sharing in the prior month. This was higher than the rate of needle sharing reported by a mixed gender sample of San Francisco exchangers in 1993, although it resembled the rate reported by a mixed gender sample in 1992. In a multivariate analysis, syringe sharing was associated with age, housing status, and sexual partnerships. Syringe sharers were more likely to be young, homeless, or have a sexual partner who was also an injection drug user. While wide access to sterile syringes is an important strategy to reduce HIV transmission among injection drug users (IDU), syringe exchange alone cannot eradicate risky injection by female IDU. Additional efforts to reduce risky injection practices should focus on younger and homeless female IDU, as well as address selective risk taking between sexual partners.

Drug Abuse Treatment on Demand in San Francisco: Preliminary Findings

Abstract This article reports on a process and capacity evaluation of San Franciscos Treatment on Demand Initiative, which was launched in 1997 to increase availability of publicly-funded substance abuse treatment. For the process evaluation, data from public documents, interviews with community key informants, and newspaper articles were analyzed. For the capacity evaluation, budget documents and admissions data for publicly-funded substance abuse treatment in San Francisco for fiscal years 1995–1998 were analyzed. Results from the process evaluation document the development of the community-oriented Treatment on Demand Planning Council, and its efforts to not only expand treatment, but to create a continuum of services to address the needs of San Franciscos richly diverse communities, to provide service enhancements, and to prioritize service needs. Process evaluation results also highlight the complexities of implementing treatment on demand, including the difficulty of opening new programs. Results from the capacity evaluation indicate that the San Francisco budget supporting publicly-funded treatment increased from

A Cohort Study of Syringe Exchangers and Nonexchangers in San Francisco

32 million to

Arresting Dress: Cross-Dressing, Law, and Fascination in Nineteenth-Century San Francisco

45.2 million over four years. During the same period, the number of persons entering the system in a single year increased by 18%, and the number of admissions in a single year increased by 15%. Implications of these findings are discussed.

Access to Drug Abuse Treatment Under Treatment on Demand Policy in San Francisco

This paper presents a cohort study of injection drug users (n=229) who did and did not use syringe exchange in San Francisco in 1993. Participants were interviewed at baseline, six months (49%), and 12 months (57%). At baseline, exchangers were less likely than nonexchangers to share syringes (21% vs. 37%), have multiple sharing partners (7% vs. 19%), and reuse their syringes (73% vs. 90%). These differences persisted in multivariate analysis adjusting for gender, age, race, education, and injection frequency. For the subset of participants who provided data at all three time points (n=101), rates of syringe sharing, syringe reuse, and indirect sharing decreased over time for both exchangers and nonexchangers. Nonetheless, levels of indirect sharing remained high among exchangers in this study (>45%) and decreased significantly less than nonexchanger levels over time. The implications of these Findings for syringe exchange programs and research are discussed.

Investigating the Effects of San Francisco's Treatment on Demand Initiative on a Publicly-Funded Substance Abuse Treatment System: A Time Series Analysis

Acknowledgments vii Introduction. Not Belonging 1 1. Instant and Peculiar 23 2. Against Good Morals 41 3. Problem Bodies, Public Space 61 4. A Sight Well Worth Gazing Upon 78 5. Indecent Exhibitions 97 6. Problem Bodies, Nation-State 121 Conclusion. Against the Law 139 Notes 149 Bibliography 175 Index 191

Effects of Treatment History and Centralized Intake on Drug Treatment Outcomes

Objectives: We evaluated whether implementation of Treatment on Demand (TOD) policy in San Francisco was associated with improved access to drug abuse treatment. Methods: Data came from San Franciscos treatment program waiting list over 4 years spanning the implementation of TOD policy. Access measures were monthly applicants waiting and days waited by treatment admissions. Quantitative analyses with 69 treatment facilities contrasted those receiving vs. not receiving TOD funds. Qualitative data came from interviews with facility administrators. Results: There was a small statistically significant decline in monthly waiting lists in the number of people waiting for treatment during the study period. The days waited by those admitted to treatment, however, significantly increased in TOD-funded facilities. Facilities used varied criteria for completing the access measures, which limit the utility of the measures. Conclusions: Access to treatment improved slightly with implementation of TOD policy.

Attitudes toward the integration of smoking cessation treatment into drug abuse clinics

Abstract This study investigated effects of San Franciscos Treatment on Demand Initiative, which was designed to increase substance abuse treatment capacity, on the host treatment system. Secondary data on substance abuse treatment admissions, from 1995 through 2000, were obtained from the Department of Public Health, Community Substance Abuse Services, San Francisco, California. Data on 73,988 admissions were retained and grouped by week of admission. Time series analysis was used to assess the effects of time and treatment on demand (independent variables) on weekly number of admissions, sociodemographic characteristics and types of treatment received (dependent variables). As a function of treatment on demand, the number of weekly new admissions significantly increased. Standard outpatient treatment and comprehensive care admissions constituted greater proportions of admissions after treatment on demand. Persons with a primary heroin, cocaine or alcohol problem constituted greater proportions of admissions, and first-time treatment clients constituted a smaller proportion of admissions. Findings suggest that a capacity expansion initiative can increase system wide admissions and redistribute admissions among modalities towards more comprehensive care treatments.

Electric Brilliancy: Cross-Dressing Law and Freak Show Displays in Nineteenth-Century San Francisco

Abstract This study assesses differences between first-time treatment clients (n=90) and repeat treatment clients (n=361), including whether entering treatment through a central intake unit affects outcomes differently for the two groups. Interview data were collected at baseline, one-month and 12-month follow-up. Study groups were similar in gender, race and age, but repeat treatment participants were more educated, more likely to primarily use heroin and more likely to have ever injected drugs. First-time treatment clients were more likely to have been required to enter treatment, but less likely to have applied to another program or to be in the program they desired. First-time treatment clients were also more likely to be in outpatient or day treatment, and less likely to be in residential treatment. Problem severity decreased for both groups over time, with no significant differences between groups. There was one significant interaction effect of study group and length of stay on social problem severity, such that longer stays in treatment led to a greater reduction in social problems for repeat treatment clients. Route of treatment entry (CIU/non-CIU) was not associated with problem severity nor change in problem severity over time for either study group.