receive during any one visit. The authors further noted that the ready availability of clean injecting equipment through pharmacies might have meant that the NSE attracted marginalized, high-risk individuals (Bruneau et al., 1997).

These early research results prompted the Montreal NSE to remove limits on the number of needles and syringes users could obtain, to provide access to other injection equipment, and to expand the number of distribution points to 25 (Personal communication, Carole Morissette and Pascale Leclerc, Health Protection Sector, Public Health Department, Agence de Santé et Des Services Sociaux de Montréal, June 6, 2006). In addition to syringes, NSEs began to provide alcohol swabs, individual disposal containers, sterile water vials, and “stericups” (kits containing a filter, cooker, and post-injection swab). Of 429 pharmacies in Montreal, injection equipment is available at roughly 40 percent, and some (n=70) sell kits containing four syringes, condoms, alcohol swabs, sterile water vials, stericups, and education material for $1.

Following these changes, HIV incidence among participants in the Montreal SurvUDI study dropped from 6.1 per 100 person-years in 1995 to 4.7 per 100 person-years in 2004. The SurvUDI study is a surveillance network that began in 1995 and targets hard-to-reach, mostly out-of-treatment IDUs in Eastern Central Canada (Hankins et al., 2002). HCV incidence—reported retrospectively among Montreal SurvUDI participants between 1997 and 2003—remains high, at about 26 per 100 person-years. (Personal communication, Carole Morissette and Pascale Leclerc, Health Protection Sector, Public Health Department, Agence de santé et des services sociaux de Montréal, June 6, 2006). The SurvUDI network also provides data on trends in syringe sharing in Montreal, including the proportion of participants injecting with a syringe used by someone else (at first study participation). That proportion fell from 45 percent in 1995 to 28 percent in 2004.

In Vancouver, Strathdee et al. (1997) also found that frequent NSE attendance was an independent predictor of HIV seroconversion. After adjusting for confounders, the authors found that the adjusted odds ratio for HIV infection status among NSE users compared with non-NSE users was 1.68. The authors noted that cocaine was the drug of choice among 72 percent of HIV-seropositive IDUs, and that cocaine puts IDUs at elevated risk because it is associated with more frequent injection (Anthony et al., 1991; Chaisson et al., 1989). A follow-up study by Schechter et al. (1999) in the same setting found no relationship between NSE use and HIV incidence, and a case-control study found borrowing of syringes to be the most significant behavior associated with seroconversion among IDUs (Patrick et al., 1997). After multivariate analysis controlling for confounders, the au-



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