Syringe Services Programs: A Proven Public Health Strategy

With the recent federal policy change allowing use of federal funds for needle exchange programs, there is renewed focus on cost-effective public health syringe services programs to prevent HIV and hepatitis C infections and to reduce disparities. State law modifications to allow syringe services programs are described.

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In December 2009, President Obama signed the Consolidated Appropriations Act of 2010, which modified provisions regarding the use of funds for needle exchange programs. This modification allows states to fund syringe services programs using federal funds, although no specific federal funds were appropriated for this purpose. Syringe service programs provide clean needles to injection drug users at no cost.

Nationally, nearly one-third of all HIV and hepatitis C infections are directly or indirectly linked to injection drug use.1,2 Sharing contaminated syringes or other drug injection tools puts injection drug users at a risk of infection of these diseases. Individuals who engage in sexual activity with injection drug users are also at increased risk of HIV infection. In addition, babies born to mothers who may have contracted HIV through sharing drug injection equipment or having sex with an injection drug user are also at risk. Providing sterile syringes is a critical part of a comprehensive strategy to reduce the risk of transmission of HIV and other blood-borne pathogens among injection drug users and their partners.

Racial and ethnic minority populations in the U.S. are most heavily affected by injection drug user-associated AIDS. In 2000, injection drug user associated AIDS accounted for 26 percent of all AIDS cases among African-American adults and adolescents and 31 percent among Hispanic adults and adolescents, compared with 19 percent of all cases among white adults and adolescents.3  Injection drug use was the second-leading cause of HIV infection for African-Americans living with HIV/AIDS in 2007.4 African-Americans account for 48 percent of all people in the United States living with HIV/AIDS in 34 states with long-term, confidential name-based HIV reporting, although they comprise only about 12 percent of the population.4,5  In 2007, injection drug use was the second most common method of transmission of HIV/AIDS among Hispanic men and women.6 Hispanics comprised 15 percent of the U.S. population but accounted for 17 percent of new AIDS cases in 2006.5,6  HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35 to 44.6.

What are Syringe Services Programs?

Syringe services programs encompass a range of services, including the exchange of used syringes for new sterile syringes in an effort to decrease the spread of HIV/AIDS, hepatitis C and other bloodborne pathogens. In addition to providing new, sterile syringes, many programs provide health education and counseling, immunizations, access to substance abuse and mental health treatment, screening for tuberculosis, hepatitis and HIV, and condom distribution, as well as referrals for social and medical programs.

Needle exchange programs first began in 1983 in Amsterdam in response to a hepatitis B outbreak and later spread to other European countries after the emergence of HIV/AIDS.7  Syringe services programs now operate in 77 countries.8

Syringe services programs first appeared in the U.S. in 1987 in New Haven, Conn. The program was operated underground because possession of drug paraphernalia was illegal, and remains illegal in many states. The first publicly funded syringe services program was started in Tacoma, Wash., in 1988.7 In 1990, then-Hawaii Gov. John Waihee signed into law the first state-approved syringe services program.9 According to the North American Syringe Exchange Network, more than 200 syringe services programs operate in 36 states, Washington, D.C., and the territories.10

Syringe Services Program Examples

Hawaii

The Community Health Outreach Work (CHOW) to Prevent AIDS Project was established by the State Department of health in 1989. The CHOW Project is a statewide, nonprofit organization providing HIV prevention services for injection drug users. Hawaii was the first state to start a syringe exchange program in 1990 and remains the only state with a fully state-funded, coordinated, statewide program. The program exchanges syringes with clients on a one-for-one basis and also provides sterile injection equipment. The Hawaii syringe services program operates through six mobile van routes on four major islands and one fixed exchange site near downtown Honolulu. It also offers individually scheduled exchange services. It conducts outreach in high-risk areas, provides harm reduction education and information, offers HIV counseling and testing, distributes condom packages, and makes referrals to drug treatment and other needed social and health services.

New York

AIDS Center of Queen’s County (ACQC) is one of 13 programs in New York City where injection drug users can come to receive clean syringes in exchange for used ones, along with testing for HIV, hepatitis, and other sexually transmitted infections. AXCQC has a “return plus ten” rule, where a person can receive ten more syringes on top of the number they bring back. Syringe Exchange Programs (SEPs) were legalized in New York State in 1992, after a slew of underground operations were formed to combat the spread of HIV through needle sharing. All of the 13 New York City organizations that do syringe exchange outreach have some form of peer outreach program that uses trained former drug users to help distribute sterile syringes.

Puerto Rico

Community Initiative is the U.S. island territory’s only needle-exchange program. It has operated since 1992, and has since developed into a full-service organization that helps both injection drug users and AIDS patients. It not only provides treatment, but also teaches clients how to navigate the health care system to improve their benefits. The initiative is funded through a mix of state and local government grants and private donations. Currently, possession of syringes still can be an “aggravating circumstance” under Puerto Rico’s drug laws, but the community initiative is legally allowed to provide syringes. Recently, the program began testing a vending machine to provide drug users with clean syringes after-hours to fight the spread of HIV and hepatitis C. The vending machine program targets young addicts reluctant to seek help.

Syringe Services Programs Work and are Cost-Effective

Studies show syringe exchange programs lower the rate of new HIV infections among injection drug users. A study conducted by Beth Israel Medical Center in Manhattan shows a two-thirds decrease in HIV infections among participants in five New York City syringe exchange programs. The programs also reduce significantly the infection rates of hepatitis B and C.11

Research shows that these programs do not appear to lead to increased drug use among current users or encourage initiation of drug use,12, 13or lead to a rise in crime.12, 14A study in Seattle found participants in syringe services programs were more likely than non-participants to reduce injection drug use and to remain in treatment programs.15

Economic studies also show syringe services programs are cost-effective. The projected lifetime cost of treating just one person with HIV in the U.S. is between $400,000 and $600,000,16 while a new, sterile syringe costs less than $1.17 Injection drug users shoot up an estimated 1,000 times a year.18

Syringe Services Programs Face Funding, Legal and Regulatory Barriers

The majority of syringe services programs function through state and local funding from a variety of non-governmental organizations, public health departments, state grants and private donations. The recent modification of provisions in the 2010 federal appropriations bill could bring much-needed additional resources to programs that work to prevent HIV transmission among injection drug users.

Many states have laws and regulations that prohibit possession, distribution or sale of new, sterile syringes. Most of these laws originated to combat illicit drug use, and were enacted before the HIV/AIDS epidemic. In order to take advantage of the availability of federal funding, states may need to review and amend existing laws and regulations.

Several states have initiated efforts to establish syringe services programs and make new, sterile syringes available, including changing laws and regulations, obtaining exceptions to state statutes, allowing health department waivers and implementing local states of emergency. Some examples include:

  • In 1992, Connecticut partially repealed its laws and regulations limiting pharmacy sales of syringes by allowing pharmacy sales of up to 10 syringes without a prescription and legalizing the possession of up to 10 syringes. Minnesota passed similar legislation in 1997.

  • In 2000, New York passed legislation allowing individuals 18 and older to purchase and/or possess up to 10 unused syringes at a time.

  • Other states have developed strategies to allow the legal operation of syringe services programs. For example, five states—Hawaii, Maryland, Massachusetts, New York and Rhode Island—and Washington, D.C., have given their health departments the power to establish syringe services programs and to exempt them from drug paraphernalia laws. Three states— Connecticut, Massachusetts and Rhode Island—have specifically exempted these programs from their prescription laws.

  • In some municipalities, public officials sought legal authority to provide syringe services programs by declaring a public health emergency. Since 2000, programs have been operating in San Diego under a provision in state law that decriminalizes syringe services programs, provided the city or county declares a public health emergency.

  •  In 2006, New Jersey passed legislation allowing the creation of syringe services programs.

  •  In 2007, Texas passed legislation authorizing a pilot syringe services program in Bexar County.

Conclusion:

Research shows syringe services programs work to reduce risk behaviors associated with the spread of HIV, hepatitis C and other blood-borne pathogens without increasing illegal drug use. But a lack of federal funding, along with legal barriers, have limited the expansion of these programs. States, cities, counties, nongovernmental organizations or private donors have funded these programs without federal support, creating a patchwork network of programs that provide sterile syringes in exchange for used ones. The number of syringe services programs could increase since the ban was modified under provisions in the 2010 appropriations bill. This move would allow federal funds to be used for such programs, as part of a comprehensive HIV prevention approach. Laws governing syringe services programs are generally the purview of the states and are driven by local considerations, and may require changes to existing laws to allow development and implementation of syringe services programs.

References:

1 Centers for Disease Control and Prevention (CDC).“HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2006.” Vol. 18. 2008.

2 CDC. “Surveillance for Acute Viral Hepatitis-U.S., 2007.” Morbidity and Mortality Weekly Report 2009; 58 (No 55-3). December 2005. 

3 CDC. “Drug-Associated HIV Transmission Continues in the United States.” May 2002.

4 CDC.“HIV / AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007.” Vol. 19. 2009. 

5 U.S. Census Bureau. “State and County Quick Facts.”

6 CDC. “HIV/AIDS among Hispanics/Latinos.” August 2009. 

7 Tempalski, Barbara. “Placing the Dynamics of Syringe Exchange Programs in the United States.” Health Place. 2007 June; 13(2): 417–431.

8 International Harm Reduction Association. “The Global State of Harm Reduction 2008: Mapping the Response to Drug-Related HIV and Hepatitis C Epidemics.” 2008.

9 Gostin, Lawrence. “Needle Exchange: Law and Policy.” In “Dimensions of HIV Prevention: Needle Exchange.” Henry J. Kaiser Foundation. 1993.

10 North American Syringe Exchange Network. “US Syringe Exchange Program Database.”

11 “Update: Syringe Exchange Programs -- United States, 2002.” Morbidity and Mortality Weekly Report. July 15, 2005, Vol. 54, No. 27.

12 Institute of Medicine, National Academies. “Preventing HIV Infection among Injecting Drug Users in High-Risk Countries. An Assessment of the Evidence." Washington, D.C.: National Academies Press; 2006.

13 Petrar, Steven, et al.“Injection Drug Users’Perceptions Regarding Use of a Medically Super- vised Safer Injecting Facility.” Addictive Behaviors. 2007; 32(5):1088–93.

14 Marx, MA, et al.“Trends in Crime and the Introduction of a Needle Exchange Program.” American Journal of Public Health. 2000; 90(12):1933–6.

15 Hagan, Holly, et al.“Reduced Injection Frequency and Increased Entry and Retention in Drug Treatment Associated with Needle-Exchange Participation in Seattle Drug Injectors.”Journal of Substance Abuse Treatment. 2000; (19)3: 247-252.

16 amfAR.“2008 Annual Report."

17 CDC.“Syringe Exchange Programs, December 2005.”

18 Lurie, P. et al.“A sterile syringe for every drug user injection: how many injections take place annually, and how might pharmacists contribute to syringe distribution?” Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;18(Suppl 1):S45-S51. Abstract available.


This publication was supported by Cooperative Agreement 1H25PS00138-02 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

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