The development of the Police Practices Scale: Understanding policing approaches towards street-based female sex workers in a U.S. City.

Policing is an important structural determinant of HIV and other health risks faced by vulnerable populations, including people who sell sex and use drugs, though the role of routine police encounters is not well understood. Given the influence of policing on the risk environment of these groups, methods of measuring the aggregate impact of routine policing practices are urgently required. We developed and validated a novel, brief scale to measure police patrol practices (Police Practices Scale, PPS) among 250 street-based female sex workers (FSW) in Baltimore, Maryland, an urban setting with high levels of illegal drug activity. PPS items were developed from existing theory and ethnography with police and their encounters with FSW, and measured frequency of recent (past 3 months) police encounters. The 6-item scale was developed using exploratory factor analysis after examining the properties of the original 11 items. Confirmatory factor analysis was used to model the factor structure. A 2-factor model emerged, with law enforcement PPS items and police assistance PPS items loading on separate factors. Linear regression models were used to explore the relative distribution of these police encounters among FSW by modeling association with key socio-demographic and behavioral characteristics of the sample. Higher exposure to policing was observed among FSW who were homeless (ß = 0.71, p = 0.037), in daily sex work (ß = 1.32, p = 0.026), arrested in the past 12 months (ß = 1.44, p<0.001) or injecting drugs in the past 3 months (ß = 1.04, p<0.001). The PPS provides an important and novel contribution in measuring aggregate exposure to routine policing, though further validation is required. This scale could be used to evaluate the impact of policing on vulnerable populations' health outcomes, including HIV risk.

Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia.

BACKGROUND: Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities. SETTING: Philadelphia, PA, and Baltimore, MD. METHODS: Using surveillance data from Philadelphia (1984-2015) and Baltimore (1985-2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses. RESULTS: The Philadelphia (1993-2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995-2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore). CONCLUSIONS: Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care.

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility.

BACKGROUND: In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. METHODS: We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. RESULTS: We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. CONCLUSIONS: We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Quantifying Syringe Exchange Program Operational Space in the District of Columbia.

Syringe exchange programs (SEPs) are effective structural interventions for HIV prevention among persons who inject drugs. In 2000, a buffer zone policy (the 1000 Foot Rule) was implemented in Washington, DC, that prohibited SEP operations within 1000 feet of schools. We examined changes in the amount of legal SEP operational space over time. We used data pertaining to school operations and their approximate physical property boundaries to quantify the impact of the 1000 Foot Rule on legal SEP operational space from its implementation in 2000-2013. Adherence to the 1000 Foot Rule reduced SEP operational space by more than 50 % annually since its implementation. These findings demonstrate the significant restrictions on the amount of legal SEP operational space in Washington, DC, that are imposed by the 1000 Foot Rule. Changing this policy could have a significant impact on SEP service delivery among injectors.

Impact Evaluation of a Policy Intervention for HIV Prevention in Washington, DC.

Syringe exchange programs (SEPs) lower HIV risk. From 1998 to 2007, Congress prohibited Washington, DC, from using municipal revenue for SEPs. We examined the impact of policy change on IDU-associated HIV cases. We used surveillance data for new IDU-associated HIV cases between September 1996 and December 2011 to build an ARIMA model and forecasted the expected number of IDU-associated cases in the 24 months following policy change. Interrupted time series analyses (ITSA) were used to assess epidemic impact of policy change. There were 176 IDU-associated HIV cases in the 2 years post-policy change; our model predicted 296 IDU-associated HIV cases had the policy remained in place, yielding a difference of 120 averted HIV cases. ITSA identified significant immediate (B = -6.0355, p = .0005) and slope changes (B = -.1241, p = .0427) attributed to policy change. Policy change is an effective structural intervention for HIV prevention when it facilitates the implementation of services needed by vulnerable populations.

Client-identified needs and agency-provided services at a harm reduction community based organization in the District of Columbia.

BACKGROUND: Harm reduction case management relies on client-identified goals to drive the provision of care in order to "meet clients where they are at". This research measured the level of agreement between client-identified needs and agency-provided services at a community based organization (CBO) in Washington DC by examining: (1) the services clients most often identified, (2) the services most often given to clients by the CBO, and (3) the level of alignment between client-identified needs and services provided. METHODS: Case file reviews were completed for 151 clients who received case management services at the CBO between January 2010 and February 2011. Client-identified needs and agency-provided services were extracted from case files and divided into 9 matching need and service categories: pharmaceutical assistance (e.g., prescription renewal), medical or dental care, housing, mental health services, substance use services, support services (e.g., support group meetings), legal assistance, and employment/job training. Client-identified needs and services provided were analyzed using McNemar's Chi-square to assess for significant differences in discordant pairs. RESULTS: Clients were mostly Black (90.7 %), heterosexual (63.6 %), HIV positive (93.4 %), and over 40 years old at the time of intake (76.2 %). On average, clients identified 2.44 needs and received 3.29 services. The most common client-identified needs were housing (63.7 %), support services (34.3 %), and medical/dental care (29.5 %). The most common agency-provided services were housing (58.2 %), support services (51.4 %), and medical/dental care (45.2 %). In 6 of the 9 service categories, there were statistically significant (p < .01) differences between those who received services not asked for and those who did not receive asked for services in the categories of pharmaceutical assistance, medical/dental care, substance abuse services, support services, legal assistance, and food access. In each of these matched service categories, the percentage of clients who received services not asked for was significantly higher than those who did not. CONCLUSION: This research shows that, while there is general alignment between the services that clients most often want and the services most often provided, there are still instances where services are requested but are not being provided.

The evidence does not speak for itself: The role of research evidence in shaping policy change for the implementation of publicly funded syringe exchange programs in three US cities.

BACKGROUND: A breadth of literature exists that explores the utilization of research evidence in policy change processes. From this work, a number of studies suggest research evidence is applied to change processes by policy change stakeholders primarily through instrumental, conceptual, and/or symbolic applications, or is not used at all. Despite the expansiveness of research on policy change processes, a deficit exists in understanding the role of research evidence during change processes related to the implementation of structural interventions for HIV prevention among injection drug users (IDU). This study examined the role of research evidence in policy change processes for the implementation of publicly funded syringe exchange services in three US cities: Baltimore, MD, Philadelphia, PA, and Washington, DC. METHODS: In-depth qualitative interviews were conducted with key stakeholders (n=29) from each of the study cities. Stakeholders were asked about the historical, social, political, and scientific contexts in their city during the policy change process. Interviews were transcribed and analyzed for common themes pertaining to applications of research evidence. RESULTS: In Baltimore and Philadelphia, the typological approaches (instrumental and symbolic/conceptual, respectively) to the applications of research evidence used by harm reduction proponents contributed to the momentum for securing policy change for the implementation of syringe exchange services. Applications of research evidence were less successful in DC because policymakers had differing ideas about the implications of syringe exchange program implementation and because opponents of policy change used evidence incorrectly or not at all in policy change discussions. CONCLUSION: Typological applications of research evidence are useful for understanding policy change processes, but their efficacy falls short when sociopolitical factors complicate legislative processes. Advocates for harm reduction may benefit from understanding how to effectively integrate research evidence into policy change processes in ways that confront the myriad of factors that influence policy change.