Syringe Exchange Programs -- United States, 1994-1995

As of December 1994, approximately one third (35.3%) of the 435,319 cases of acquired immunodeficiency syndrome (AIDS) reported among adults to CDC were associated with injecting-drug use (1). In addition, injection of illegal drugs is the risk behavior most frequently associated with heterosexual and perinatal transmission of human immunodeficiency virus (HIV) in the United States. The goal of syringe exchange programs (SEPs) is to reduce HIV transmission associated with drug injection by providing sterile syringes in exchange for used, potentially HIV-contaminated syringes. This report presents data from a recent survey of U.S. SEPs about their activities during January 1994-April 1995 and compares the findings with those of a 1993 survey (2). *

In April 1995, the North American Syringe Exchange Network (NASEN), in collaboration with the U.S. Conference of Mayors and Beth Israel Medical Center (New York City), mailed questionnaires to the directors of each of the 68 U.S. SEPs that were members of NASEN. Directors of SEPs from which a completed questionnaire was not returned within 3 weeks were contacted by telephone. Data collected included information about the SEP operations, legal status, services offered, number of syringes exchanged in 1994, and outreach efforts.

In the April 1995 survey, 60 (88%) SEPs provided data (47 {78%} by mail and 13 {22%} by telephone). These 60 SEPs reported operating in 46 cities in 21 states **. Forty-two (70%) of the SEPs were located in five states (California, New York, Washington, Connecticut, and Hawaii); in nine cities, at least two SEPs reported operating. In the 1993 survey, a total of 33 SEPs reported operating in 29 cities in 12 states (2).

The 55 SEPs operating in 1994 reported exchanging approximately 8 million new, sterile syringes for used syringes during January-December 1994 (median: 39,014 syringes per SEP; mean: 145,914). The seven most active SEPs (i.e., those that exchanged greater than or equal to 500,000 syringes; two SEPs in New York City and one each in Chicago; Philadelphia; San Francisco; and Seattle and Tacoma, Washington) exchanged nearly 5.5 million syringes, representing 68% of all syringes exchanged by SEPs in 1994 (Table_1). The San Francisco SEP reported exchanging the largest number of syringes (1.5 million) in 1994. Some SEPs reported exchanging relatively small numbers of syringes in 1994: 31 SEPs (56%) exchanged less than or equal to 55,000 syringes each while 12 SEPs (22%) exchanged less than 10,000 syringes each. In comparison, approximately 2.4 million syringes were exchanged by U.S. SEPs in 1992 (2).

In addition to syringe exchange, services provided by SEPs included provision of latex condoms (45 SEPs), HIV counseling and testing (23), tuberculin skin testing (12), primary health care (10), and directly observed tuberculosis therapy (six). Most (45 {85%} of 53) SEPs reported counseling injecting-drug users (IDUs) to follow medical hygiene standards when injecting illegal drugs (i.e., prepare the injection site with an alcohol swab; use a new, sterile needle and syringe for each injection; avoid reuse of syringes {even by the same person}; use clean {ideally sterile} water to prepare drugs for injection; and return used syringes to the SEP for safe disposal).

In both the 1993 and 1995 surveys, the legal status of SEPs was categorized as legal, illegal-but-tolerated, and illegal/underground. An SEP was defined as legal if it operated in a state that had no law requiring a prescription to purchase a hypodermic syringe (i.e., a "prescription law") or had an exemption to the state prescription law allowing the SEP to operate; illegal-but-tolerated if the program operated in a state with a prescription law and had received a formal vote of support or approval from a local elected body (e.g., a city council); and illegal/underground if the program operated in a state with a prescription law but had no formal support from local elected officials. Of the 60 SEPs in the 1995 survey, a total of 33 (55%) reported that they were legal; 19 (32%), illegal-but-tolerated; and eight (13%), illegal/underground.

Reported by: D Paone, EdD, DC Des Jarlais, PhD, J Clark, Q Shi, MS, A Orris, Beth Israel Medical Center; M Krim, PhD, M Reinfeld, American Foundation for AIDS Research; SR Friedman, PhD, National Development and Research Institutes, New York. D Purchase, H Smith, North American Syringe Exchange Network, Tacoma, Washington. P Jones, US Conference of Mayors, Washington, DC. P Lurie, MD, Univ of California, San Francisco. Div of HIV/AIDS Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Practices associated with injection of heroin, cocaine, methamphetamine, and other drugs can be linked to transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) (1,3). During intravenous injection, IDUs usually draw blood into the needle and syringe to verify the needle is in a vein. If that blood contains HIV, HBV, HCV, or other bloodborne pathogens, subsequent use of the syringe by another drug injector may result in transmission of these pathogens (4). To assist in reducing transmission of HIV, HBV, HCV, and other bloodborne pathogens (5), SEPs provide new, sterile syringes for IDUs and collect used, blood-contaminated syringes. In addition, nearly all SEPs provide alcohol swabs, latex condoms, and counseling services to clients, and many assist clients in obtaining health and social services (e.g., HIV counseling and testing, tuberculin skin testing, or admission to drug-treatment centers) either on-site or by referral (2).

SEPs have been widely implemented as an HIV-prevention intervention in Australia, Canada, Netherlands, and the United Kingdom. In the United States, the first SEP was established in Tacoma, Washington, in 1988 (2). Based on the survey in April 1995, the number of SEPs operating in the United States increased 82% over that in 1993; in addition, the number of syringes exchanged by SEPs increased threefold from 2.4 million in 1992 (2) to 8 million in 1994.

The findings in this report are subject to at least two limitations. First, the extent of SEP activities probably is underestimated because of incomplete participation in the survey by known SEPs and because some operational SEPs may be unknown to the NASEN. Second, some SEPs that participated in the 1995 survey included in their reported data information from separate, independent SEPs.

Previous studies demonstrate the effectiveness of SEPs and other interventions that increase access to sterile syringes in preventing HIV infection. For example, participation by IDUs in SEPS in Tacoma was associated with substantially lower risk for hepatitis B and hepatitis C among IDUs (sixfold and sevenfold lower, respectively) (6). The National Academy of Sciences recently reviewed research on SEPs and, in a September 1995 report, concluded that SEPs should be regarded as an effective component of a comprehensive strategy to prevent infectious disease (7). In addition, in Connecticut, simultaneous partial repeal during 1992 of a law that required a prescription to purchase syringes and a law that specified possession of syringes as illegal was followed by increased purchasing of syringes from pharmacies by IDUs and decreased sharing of injection equipment (6,8).

References

1. CDC. HIV/AIDS surveillance report, 1994. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1995:11-2. (Vol 6, no. 2).

2. Lurie P, Reingold AL, Bowser B, et al. The public health impact of needle exchange programs in the United States and abroad. Vol I. San Francisco, California: University of California, October 1993.

3. Alter MJ. Epidemiology of hepatitis C in the west. Seminars in Liver Disease 1995;15:5-14.

4. Jose B, Friedman SR, Curtis R, et al. Syringe-mediated drug-sharing (back loading): a new risk factor for HIV among injecting drug users. AIDS 1993;7:1653-60.

5. Haverkos HW, Jones TS. HIV, drug-use paraphernalia, and bleach. J Acquir Immune Defic Syndr 1994;7:741-2.

6. Valleroy LA, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales -- Connecticut, 1992-1993. J Acquir Immune Defic Syndr 1995;10:73-81.

7. Normand J, D Vlahov, LE Moses, eds. Preventing HIV transmission: the role of sterile needles and bleach. Washington, DC: National Academy Press, 1995.

8. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers -- Connecticut, 1992-1993. J Acquir Immune Defic Syndr 1995;10:82-89.

• Single copies of this report will be available until September 22, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023. ** California (18 SEPs), New York (nine), Washington (eight), Connecticut (four), Hawaii (three), Illinois and Minnesota (two each), and one each in Alasaka, Colorado, Indiana, Louisiana, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New Mexico, Oregon, Pennsylvania, Texas, and Wisconsin.

+------------------------------------------------------------------- -------+ |             | | Erratum: Vol. 44, No. 37 | | ======================== | | SOURCE: MMWR 44(40);759 DATE: Oct 13, 1995 | |             | | In the report "Syringe Exchange Programs -- United States, | | 1994-1995," the following limitation should have been included in the | | second full paragraph on page 691: "Because of incomplete reporting, the | | total number of syringes exchanged in 1992 is underestimated." In the | | next paragraph, the referencecited for the Tacoma hepatitis study is | | incorrect. The correct reference is "Hagan H, Des Jarlais DC, Friedman | | SR, et al. Reduced risk of hepatitis B and hepatitis C among injecting | | drug users participating in the Tacoma syringe exchange program. Am J | | Public Health (in press)." All subsequent references in the paragraph | | should be renumbered accordingly (i.e., references 7, 6, and 8 should | | become 7, 8, and 9). | +------------------------------------------------------------------- --------+
Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Number and percentage of syringe exchange programs (SEPs)
and number and percentage of new syringes provided by SEPs, by size
of program -- United States, 1994
=====================================================================
                              SEPs         Total syringes exchanged
                        --------------    ---------------------------
Size of SEP *             No.    (%)           No.          (%)
---------------------------------------------------------------------
       < 10,000           12    ( 22)        20,057       (< 1)
10,000-- 55,000           19    ( 35)       472,771       (  6)
55,001--499,999           17    ( 31)     2,075,511       ( 26)
      >=500,000            7    ( 13)     5,456,915       ( 68)

Total                     55    (100)     8,025,254       (100)
---------------------------------------------------------------------
* Based on number of syringes exchanged during 1994.
=====================================================================

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