Recently, I was in Toronto for my annual “checkup” with Paul, my friendly research coordinator with the Ontario Cohort Study (OCS).  I’ve previously talked about my involvement in this Ontario HIV Treatment Network (OHTN)'s research cohort here. Today I wanted to provide a photo-post with more detail on what the testing process looks like from the ground.

But first some background on OCS for those who are unfamiliar with it. Almost 6,000 Ontario people living with HIV have been voluntarily recruited since the program began in 1996 when it was called HOOD, then HIIP before settling on the name OCS.  I’ve been in it since the beginning, participant number seven I believe, so there may be almost  seventeen years of history in their about me and my clinical progress.

Why the need for a longitudinal data base like OCS?  Well here’s what their website says

“The purpose of the OCS is to collect information on the clinical and health profiles of people living with HIV in care in Ontario to provide a robust information resource for clinical, socio-behavioural, population health, and health services research. Our aims are:

• To understand the pychosocial and health context of people living with HIV
• To understand patterns of health services use
• To understand issues related to mental health and addictions
• To examine HIV infection and its complications
• To examine HIV treatment and its complications, including adverse events and HIV drug resistance
• To examine co-morbid diseases and conditions among people living with HIV
• To examine social, psychological, and other factors related to behaviour that poses risk for secondary HIV transmission.” 

The information to accomplish all this is largely drawn from patient records and charts – particpants' CD4, viral load results and treatment information all go in to here, for instance via various automated or manually driven processes, with your informed consent at the outset, of course. All information collected is both anonymous  - there are complex controls for this – and confidential. 

Back to my visit to St Mike’s.  Besides being the location of the HIV Positive Care Clinic I’ve attended, mostly quarterly, since day one, it is also a collection point for OCS data.  And it is one of the two sites – the other is Sunnybrook Hospital – that engages a subset of OCS participants, a few hundred strong, in tests which additionally measure cognitive ability (often called “neuro-AIDS” work now) and also track a bundle of issues like housing, income, depression, mastery, substance use, impact of stigma and, on occasion, one–off suites of questions soliciting participants’ views on things like the criminalization of people living with HIV. The entire process takes about ninety minutes each year. Participants are compensated $50 for their trouble at each visit. 

So today, I’m going to walk you through that process, starting at the back doors of St Michael’s Hospital in downtown Toronto, a building that has clearly seen better days, and where the elevators don’t always work, including the day of this particular visit.  Now I’m a big fan of St Mikes, don’t get me wrong – they’ve kept me alive for almost twenty years, and I have a profound affection for those who work there - but it’s a classic inner city hospital that is an obvious candidate for a refit. Anyway, to the glamourless second floor I go to see Paul, the Research Coordinator who administers the tests that I’m to take. 

Paul always begins with explaining the parameters for the tests, what they are used for, how I am free not to participate in any of them, how some might be difficult or stressful, how Kleenex is available if there are tears. So far I’ve yet to need that, thankfully, although he’s right about the stressfulness, at least for those of us who dislike our weaknesses being exposed. Which is where the memory tests come in which he launches right in to as the first in the series he will be giving me today. 

Paul recites a series of 15 nouns, so slowly that it seems relatively easy for me to repeat them for him. But I cant, I seldom score more than seven, and last week was no better. I’ve tried various techniques and this time I thought I’d concentrate on just the first five and (literally) forget the rest.  Which I did although I managed to tack on two from the end I somehow remembered also. In any event, Paul then repeats the list, presumably to see if your short-term memory improves through repetition.  Mine does, but only marginally; I think I scored eight the second time around – but not surprisingly, I can’t remember now. 

Given that this is a longitudinal study, i.e. one that tracks people over time, I’m thinking tests like this must provide valuable information about how our memory works, or not, as we get older. With HIV and aging in the spotlight nowadays, this data has the potential, I suspect, to add considerably to our knowledge of what aging, or  HIV treatment, or HIV infection generally – does to our brain power. 

So having failed semi-miserably (I think) on the memory test, but knowing that I’ll likely do better from here on in, Paul moves on to a couple of tests which seem to measure my brain/hand coordination.  I'll be needing to put a series of shaped pegs in to shaped holes with the stopwatch running. Here is the board, with the pegs you need to fit into the holes using just one hand. You’ll note that the pegs have ridges on them which means they fit in to the similarly shaped holes only in one direction. 

Over time I've learned how to perform this test with some semblance of dexterity. I am less nimble-fingered when the requirement is next to repeat the task using only my left hand but again experience has somehow increased my dexterity in this, advancing years or not. 

Next to a timed pencil on paper test – I was not allowed to photograph this – in which you are required to match a series of numbers with symbols, the code for which is provided at the top of the page.  I always fly though this one with flying colours (I think). 

Back to memory tests, this one revolving around a series of blue plastic blocks mounted on a small board.  Paul touches/taps these blocks in seeming random order (I’m sure it’s not) first in a sequence of three, then four, then six taps. I'm asked to repeat his series of taps each time, in the right order.  It’s easy-peasy at three, easy at four but by the time he has gone though a sequence of six taps it’s a challenge. It’s even more challenging when we do things backwards. I have to repeat the taps in the reverse order that he showed me. It’s tricky, to say the least, and I’m stumbling by the end. 

More challenges to my memory come next in a reprise of the fifteen nouns ordeal. Sixty minutes (?) have elapsed since we last visited this list of nouns and now I have to repeat those that I remember.  My strategy of concentrating on remembering the first five has collapsed by this time, although I manage to salvage about five nouns nevertheless. Then one final variation – Paul reads me a list of words and I am asked to say which of those words was included in the original list. I’m hit and miss here – after all I really only listened to the first five first time around.

Then on to a battery of questions - on my mental health and any feelings of anxiety or depression, my ability to perform tasks, my housing situation, my mastery of my circumstances, the supports I’m receiving, the kind of health services I’ve used, my alcohol and substance use, even my smoking history (which data collectively,  I’m thinking, will be highly useful for The Smoking Project which I co-chair.)  

Towards the end – it’s late afternoon by now -  there is series of questions on my meds.  Have I missed any doses in the last week, I’m asked? I’m pretty good at adherence but fess up to  missing my mid-day dose just that day, having forgotten to pack it that morning before I left for Toronto.  (There are those memory issues  again.) Veteran of many regimes, I do poorly in remembering what meds I’m on now too.  Paul reverts to charts that he shows me to help me remember the names. 

A few questions about my recent sexual history  - how many partners I’ve had, their status and what I’ve done with them - which is deemed personal enough for Paul to hand his laptop over for participants to input their responses privately. And then the process is done. I’ve always found it a surprisingly draining ninety minutes, a little bit invasive, a little bit tiresome, which is why I never have any trouble accepting the $50 that Paul proffers at the end. There is, in fact, a deep feeling that I’ve truly earned it. 

But, as I  step out into the cool night air, it’s already dark and I’m feeling content, if not smug. Glad that I have $50 in my pocket which I feel the need to turn into something fast, so I cross the street to Fran’s Restauarant and spend half of it on my dinner – but also content that I feel like I’ve truly contributed to something worthwhile.  I’m tuned in enough to realize that the questions I’ve been asked and tests that have been administered will help in some small way to expand our collective knowledge of how HIV affects us in a myriad of ways. And that feels good. 

So does having the meatloaf dinner and strawberry milkshake at Fran’s the test paid for.  But that’s another story.

This rapid response prepared by the Ontario HIV Treatment Network (OHTN) summarizes the available research evidence to inform the following two questions: 

1. What are public perceptions and opinions of needle exchange programs, methadone clinics, supervised injection facilities/safe injection sites and other harm reduction interventions?

2. How can negative public perceptions of these interventions be addressed?

Key Take-Home Messages

Public opinion polls and surveys taken between 2003 and 2007 in Ontario, Quebec, British Columbia and nationwide in Canada, have found majority support for harm reduction programs, including heroin-assisted treatment (HAT) and supervised injection facilities (SIFs).

Positive public perception of harm reduction programs often involved an acknowledgement that drug addiction and drug-related issues, such as poverty, disease and crime, requires a pragmatic solution beyond drug enforcement and control.

Negative public perception was usually based on a concern that these programs condone and even promote illegal drug use, attract people who use drugs and bring violence into local communities of program sites, and would do nothing to re-integrate people who use drugs back into society.

There have been several studies and in-depth analyses on successful, and unsuccessful, experiences with addressing and changing negative public perceptions of harm reduction interventions.

Successful strategies often involved: public education about both the immediate goals (save lives and improve public amenity) and long-term goals (cessation of drug use and re-integration); eliciting endorsement from respected public figures and organizations; and remodeling the debate around illegal drug use to one based on morals and public health, rather than on drug policy and enforcement.

Unsuccessful strategies often appeared to be the result of insufficient knowledge transfer in and consultation with communities; negative portrayals and messaging in the media; and non-local and culturally insensitive approaches.

The Issue and Why It’s Important

There has been growing local and international support since the 1990s, particularly from the HIV/AIDS and medical community, for harm reduction programs as a pragmatic approach to minimize the harmful consequences of individual behaviours – even if these behaviours are deemed risky or illegal.(1;2)

Harm reduction interventions are important for preventing HIV and hepatitis B/C for people who use injection drugs because of the high incidence and prevalence rates in this population.(3-5)

According to a national addiction survey in 2006, it is estimated that there are over 4.1 million people in Canada who have injected drugs at some point in their lives, and nearly 270,000 people had reported using injection drugs that year.(6) In Ontario alone, there are approximately 41,000 people who use injection drugs who are at a higher risk of becoming infected with HIV or HCV, and of other drug-related morbidities and mortality, than the general population.

There is a growing body of evidence internationally, particularly in Western countries, confirming the successes of harm reduction interventions in reducing HIV and HCV transmissions, decreasing drug overdoses, increasing access to and enrolment in drug treatment programs, and minimizing public order issues, among others.(2;7-9) However, in order to scale up harm reduction interventions, there needs to be widespread support from the public that stems from a cultural change in attitudes towards drug addiction. Public opinions and perceptions of harm reduction interventions often have a significant impact on political will to establish and sustain these programs. For example, it has been suggested that the continued existence of InSite – prior to the 2011 Supreme Court decision – has largely been due to the measured support of British Columbians and Canadians.(10;11) In contrast, there have been incidences in the United States where public opposition has led to closure of existing needle exchange programs.(12;13)

Although there has been a growing number of needle exchange programs (NEPs) and methadone treatment clinics across Canada, the same has not occurred for SIFs, despite the positive outcomes of InSite in Vancouver, British Columbia, which is the only SIF in North America. The recent decision from the Supreme Court of Canada to allow InSite to continue operations under an exemption from the federal drug control legislation (14) has created an opportunity for the rest of Canada to follow suit. Thus, it is an opportune time to review public opinions in Canada and to develop strategies that could improve the negative perceptions of harm reduction strategies.

What We Found

We found 40 published studies, reviews and commentaries that explored public opinions and perceptions of harm reduction programs, and/or discussed experiences with strategies to change them.

Public opinion and perceptions

Most studies, polls, and surveys on public opinions and perceptions come from Canada, the U.S., the U.K., and Australia.(10;15-23) These surveys have predominantly found a clear majority supporting different harm reduction programs, ranging from NEPs and SIFs, to HAT and methadone clinics. Some repeated polls in the U.S. and Australia have shown a steady increase in support for these programs since the 1990s.(17;18;21)

A 2006 survey of 1,407 Canadians was completed for Canada’s Privy Council Office, commissioned by Prime Minster Stephen Harper’s senior staff, to gauge public support for InSite in Vancouver.

The results of the poll indicated that 56% of Canadians want more supervised injection sites to be created in Canada, and another 68% of Canadians support needle exchange. The support was strongest in British Columbia, where 70% of those polled support needle exchanges and 64% support additional safe injection programs.(10;11) Similar trends were found in separate polls conducted in Ontario and Quebec.(16;23) A recent report released from the Toronto and Ottawa Supervised Consumption Assessment Study (TOSCA) (24) found that 56% of more than 900 Ontarians surveyed in 2009 strongly agreed with the establishment of SIFs “if it can be shown that supervised injection facilities reduce neighbourhood problems related to injection drug use.” However, this slight majority support changed depending on the goal of establishing the SIFs: the proportion fell to 48% if the establishment was based on reducing overdose deaths or infectious disease among people who use drugs, or on increasing their contact with health and social workers; and fell even more to 31% if they were established to encourage safer drug use.

However, it has been shown that poll results can vary greatly depending on who commissioned the study, as well as on the wording and phrasing of the survey questions.(21) For example, a survey conducted in 1997 by the Human Rights Campaign, a gay and lesbian lobbying group, found 55% of those polled supported NEPs, yet, a poll conducted in the same year by the Family Research Council, a conservative lobbying group, found 62% opposition to NEPs.(25) Vernick et al.(21) systematically reviewed all reported U.S. national surveys on syringe exchange programs between 1987 and 2000, and found that support for NEPs ranged from 29% to 66% over this period of time. They found that word choices such as “drug addicts” would decrease support for NEPs, whereas the words “those addicted to illegal drugs” would increase support. They concluded that there is no consensus in the U.S. public regarding support for NEPs due to the malleable nature of public opinion, and that it would be impossible to assess support over time unless polls and surveys were consistent in language and conducted by independent organizations. However, the findings and conclusions from this review should be interpreted with caution given that the data is from more than 10 years ago and based on public perception from the United States where views may, on average, differ from those in Canada.

The literature suggests there are many possible factors contributing to support for harm reduction programs. Most notably, those with higher income and education, who view people who use drugs as ‘ill’ people, and who agree that people who use drugs need public support, are more likely to have positive opinions towards these interventions.(16)

In a more nuanced analysis of public opinion in Quebec, Dubé et al. (23) found that support for harm reduction programs primarily came from individuals who have values based in solidarity, equity, universality and social justice. They concluded that Quebec residents tended to perceive social questions and problems, such as injection drug use, in the broader context of the community and societal wellbeing, irrespective of the traditional prohibitionist attitudes towards illicit drugs.

There were common themes that emerged from analyses of negative opinions and perceptions of harm reduction interventions. The most predominant theme is the perceived immorality of providing harm reduction services to people who use drugs.(13;19;26-29) Common arguments from opponents tend to argue that these programs promote drug use, attract more people who use drugs, and destroy communities.(27;29-31) There is also the ‘not in my back yard’ phenomenon where people might support the idea of harm reduction interventions, as long as they are not in their communities.(31) Those with moderate opposition towards harm reduction may argue these programs do not address broader social issues that cause addiction or incorporate comprehensive strategies to end drug addiction and re-integrate people who use drugs into the community.(31;32) More extreme opponents have suggested that these programs are a continuation of oppression on those most vulnerable to drug addiction and an act of genocide.(29;32)

With respect to needle exchange programs, people have expressed concern over finding discarded needles in the streets.(32;33) However, many of these fears and concerns can be resolved through education and efforts to increase awareness, as support for harm reduction has consistently grown in communities where SIFs and NEPs have been established.(15;17;18)

Changing negative opinions and perceptions

Despite majority support for harm reduction interventions, it remains important to educate the public and address fears and concerns that could lead to opposition to scale-up efforts. Through the documented experiences in Vancouver, the U.S., Australia and some countries in U.K., there are several strategies that have succeeded in the past to change the public culture and grow support for harm reduction:

1. Make (injection) drug use a public problem – In order to gain public attention and support, the first step for many successful programs was to convince the public that there is a public health crisis (HIV/HCV transmission, prostitution and promiscuity) and a growing public problem (crime and violence, public drug use, dirty needles) stemming from injection and illegal drug use,(22;34) and that this problem requires an official public solution.(35)

2. Ensure the public that supporting harm reduction is not equal to condoning or promoting drug addiction – In many unsuccessful experiences, studies have noted that there was insufficient education and consultation in the communities where the programs were being established.(22;27;32;36) Particularly, the messaging wasn’t targeted to their concerns and fears, such as whether harm reduction programs promote and attract illegal drug use, or whether they help people who use drugs stop and re-integrate into society. It is also important that this process involves local figures that the communities trust.(32;36)

3. Elicit public endorsement from respected (local) people and groups – In one American survey, the endorsement of NEPs by the American Medical Association directly altered the poll results positively.(19) Similarly, the endorsement by public figures (including politicians, bureaucrats and academics) and medical or human rights-based organizations has had similar effects in other communities and countries.(22;34)

4. Fend off bad press and watch out for negative portrayals in the media – In some studies and commentaries, the media has been blamed to be a significant part of the drug problem and for the lack of public support for harm reduction interventions.(19;26;32;37) In some successful experiences, there was direct engagement among harm reduction advocates with the media, including commentary writing and letters to the editors.(35;38) Furthermore, support from local newspapers can have an effect on public opinion.(35)

5. Claim the moral high ground – The arguments for harm reduction approaches should not be based solely on science and public health.(28) Confrontation with opponents of harm reduction interventions requires that supporters claim the moral high ground based on human rights— people who use drugs, much like other citizens, have equal rights to health and access to necessary health care and services, which include such interventions as NEPs and SIFs.(28;39)

6. Humanize– The public needs to feel connected to those who would benefit from harm reduction interventions. This means the gap between “us” and “them” must be bridged. Efforts should be made to ‘humanize’ people who use drugs – they are someone’s parent, son, daughter, brother or sister, just like everyone else (22;23;35;39)

Factors That May Impact Local Applicability

Although there have been common themes emerging in the opposition against harm reduction interventions, it is important that attempts to counter it should be tailored towards the context of each community.(36) For example, many strategies that worked in Vancouver, B.C., might not work in Ontario. The drug problem in Vancouver is highly visible in its downtown area, and thus, it is not difficult to convince the public that this is a growing public problem. However, the problem is not as visible in Ontario, which could create different challenges for advocates here. Furthermore, the overall public opinion in Ontario is not as supportive towards harm reduction strategies as in British Columbia, as shown by the 2012 TOSCA report.(24) The TOSCA report also showed that different stated goals of establishing SIFs garner different amounts of public support, thus, it is important that the goals are properly tailored and communicated to the community.

The strategies for changing public opinions and perceptions found in this review were similar to those identified by the HomeComing Community Choice Coalition in their 2005 guide for Ontario’s supportive housing provider, Yes, in my backyard.(40) Although harm reduction interventions and their facilities are distinct from supportive and social housing, the challenges and opposition presented by introducing these amenities into a community are quite similar. In their guide, the Coalition identified several main strategies for changing local communities’ opinions and perceptions of new social housing developments: “enlist the support of the local councilor and planner at the outset”; “explain the human rights issues to supporters”; “never accuse opponents of being “not in my backyarders” or bigots”; “answer all questions with cheerful confidence”; and “stick to your principles”. The advice in their guide could be translated into applicable strategies for inducing cultural change towards harm reduction in Ontario.

Given the inherent differences between communities and countries, it is vital to consult with the community and assess what the prevailing concerns, fears and perceptions are, before developing a comprehensive strategy to change the culture.

What We Did

We conducted a search in Medline (without date limits) using the following combination of search terms: MeSH terms: (“Harm Reduction” OR “Needle-Exchange Programs” OR “Syringes” OR “Substance Abuse, Intravenous”) AND title terms: (“opinion” OR “perception” OR “supervised injection” OR “safe injection”). We also searched the Cochrane Library for any potentially relevant systematic reviews using the following text terms: “harm reduction” OR “needle exchange” OR “methadone clinic” OR “safe injection” OR “supervised injection”) AND (“opinion” OR “attitude” OR “perception” OR “public”). Lastly, we reviewed references in the studies found. Only studies in English and French were included.

References

1) UNAIDS. The Warsaw Declaration: A Framework for Effective Action on HIV/AIDS. Warsaw, Poland: UN-AIDS; 2003.

2) Strathdee S, Pollini RA. A 21-st Lazarus: the role of safer injection sites in harm reduction and recov-ery. Addiction 2007;102(6):848-9.

3) Public Health Agency of Canada. Epidemiology of Acute Hepatitis C Infection in Canada: Results from the Enhanced Hepatitis Strain Surveillance System (EHSSS). Pub-lic Health Agency of Canada 2009;Available from: URL: http://www.phac-aspc.gc.ca/sti-its-surv-epi/hcv-epi-eng.php

4) Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA et al. Global epidemi-ology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 2008;372(9651):1733-45.

5) Public Health Agency of Canada. HIV/AIDS Epi Updates. Ottawa, Canada: Centre for Infectious Dis-ease Prevention and Control, Public Health Agency of Canada; 2010.

6) Canadian Centre on Substance Abuse. Canadian Addiction Survey: A national survey of Canadians' use of alcohol and other drugs. Ottawa: Canadian Centre on Substance Abuse; 2004.

7) Maher L, Salmon A. Supervised injecting facilities: how much evi-dence is enough? Drug & Alcohol Review 2007;26(4):351-3.

8) Strike C, Watson T, Lavigne P, Hop-kins S, Shore R, Young D et al. Guidelines for better harm reduc-tion: evaluating implementation of best practice reccommendations for needle and syringe programs (NSPs). Drug and Alcohol Review 2011;26:351-3.

9) Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug and Alcohol Review 2006;25(6):611-24.

10) (Small D. Fools rush in where an-gels fear to tread Playing God with Vancouver's Supervised Injection Facility in the political borderland. International Journal of Drug Policy 2007;18(1):18-26.

11) Woods A. Ottawa ignores support for injection sites. The Vancouver Sun 2006 Nov 6.

12) (Broadhead RS, van HY, Hecka-thorn DD. The impact of a needle exchange's closure. Public Health Reports 1999;114(5):439-47.

13) Tempalski B, Flom PL, Friedman SR, Des J, Friedman JJ, McKnight C et al. Social and political factors predicting the presence of syringe exchange programs in 96 US met-ropolitan areas. American Journal of Public Health 2007;97(3):437-47.

14) Wells P. Harper swings and misses on Insite. Maclean's 2011 Oct 10.

15) Dolan, K., MacDonald, M., Silins, E., and Topp, L. Needle and syrings programs: A review of the evidence. Canberra: Australian Government Department of Health and Ageing; 2005.

16) Cruz MF, Patra J, Fischer B, Rehm J, Kalousek K. Public opinion to-wards supervised injection facilities and heroin-assisted treatment in Ontario, Canada. International Journal of Drug Policy 2007;18(1):54-61.

17) Salmon AM, Thein HH, Kimber J, Kaldor JM, Maher L. Five years on: what are the community percep-tions of drug-related public amenity following the establishment of the Sydney Medically Supervised Inject-ing Centre? International Journal of Drug Policy 2007;18(1):46-53.

18) Thein H, Kimber J, Maher L, Mac-Donald M, Kaldor J. Public opinion towards supervised injecting cen-tres and the Sydnewy Medically Supervised Injecting Centre. Inter-national Journal of Drug Policy 2005;16(4):275-80.

19) Blendon RJ, Young JT. The public and the war on illicit drugs. Journal of the American Medical Associa-tion 1998;79(11):827-32.

20) Treloar C, Fraser S. Public opinion on needle and syringe pro-grammes: avoiding assumptions for policy and practice. Drug & Alcohol Review 2007;26(4):355-61.

21) Vernick J, Burris S, Strathdee S. Public opinion about syringe ex-change programmes in the USA: An analysis of national surveys. Inter-national Journal of Drug Policy 2003;14(5):431-5.

22) Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injec-tion in the city of Vancouver. Inter-national Journal of Drug Policy 2008;19(1):11-6.

23) Dubé E, Massé R, Noël L. Accepta-bilité des interventions en réduc-tion des méfaits: contributions de la population aux débats éthiques de santé publique. Canadian Jour-nal of Public Health 2009;100(1):24-8.

24) Bayoumi, A. M., Strike, C., Jairam, J., Watson, T., Enns, E., Kolla, G., Lee, A., Shepherd, S., Hopkins, S., Millson, M., Leonard, L., Zaric, G., Luce, J., Degani, N., Fischer, B., Glazier, R., O'Campo, P., Smith, C., Penn, R., and Brandeau, M. Report of the Toronto and Ottawa Super-vised Consumption Assessment Study, 2012. Toronto: St. Michael's Hospital and the Dalla Lana School of Public Health, University of To-ronto.; 2012.

25) Two polls, two different views on needle exchanges. AIDS Policy & Law 1997;12(18):8.

26) McArthur M. Pushing the drug debate: the media's role in policy reform. Australian Journal of Social Issues 1999;34(2):149-65.

27) Kimber J, Dolan K, van B, I, Hedrich D, Zurhold H. Drug consumption facilities: an update since 2000. Drug & Alcohol Review 2003;22(2):227-33.

28) Buchanan D, Shaw S, Ford A, Sing-er M. Empirical science meets moral panic: an analysis of the politics of needle exchange. Journal of Public Health Policy 2003;24(3-4):427-44.

29) Heller D, Paone D. Access to sterile syringes for injecting drug users in New York City: politics and percep-tion (1984-2010). Substance Use & Misuse 2011;46(2-3):140-9.

30) Cusick L, Kimber J. Public percep-tions of public drug use in four UK urban sites. International Journal of Drug Policy 2007;18(1):10-7.

31) Smith C. Socio-spatial organization and the contested space of addic-tion treatment: remapping strate-gies of opposition to the disorder of drugs. Social Science & Medicine 2010;70(6):859-66.

32) Shaw SJ. Public citizens, marginal-ized communities: the struggle for syringe exchange in Springfield, Massachusetts. Medical Anthropol-ogy 2006;25(1):31-63.

33) Lawrence Thompson Strategic Consulting. A review of needle exchange programs in Saskatche-wan, prepared for the Population Health Branch of Saskatchewan Ministry of Health. Saskatoon: Lawrence Thompson Strategic Consulting; 2008.

34) Csete J, Grob PJ. Switzerland, HIV and the power of pragmatism: lessons for drug policy develop-ment. International Journal of Drug Policy 2012;23(1):82-6.

35) Small D, Palepu A, Tyndall M. The establishment of North America's first state sanctioned supervised injection facility: A case study in cultural change. International Jour-nal of Drug Policy 2006;17(2):73-82.

36) Downing M, Riess TH, Vernon K, Mulia N, Hollinquest M, McKnight C et al. What's community got to do with it? Implementation models of syringe exchange programs. AIDS Education & Prevention 2005;17(1):68-78.

37) Korner H, Treloar C. Needle and syringe programmes in local media: 'needle anger' versus 'effective education in the community'. Inter-national Journal of Drug Policy 2003;15(1):46-55.

38) Farfard P. Public health under-standings of Policy and Power: lessons from INSITE. Journal of Urban Health 2012;May 2012.

39) Ben-Ishai E. Responding to vulnera-bility: the case of injection drug use. International Journal of Femi-nist Approaches to Bioethics 2012;5(2):39-63.

40) HomeComing Community Choice Coalition. Yes, in my backyard. Toronto: HomeComing Community Choice Coalition; 2005

This article first appeared on the OHTN webisie here.