Skip directly to search Skip directly to A to Z list Skip directly to site content
CDC Home

The content, links, and pdfs are no longer maintained and might be outdated.

  • The content on this page is being archived for historic and reference purposes only.
  • For current, updated information see the MMWR website.

Syringe Exchange Programs --- United States, 2008

Persons who inject drugs should use a new, sterile needle and syringe for each injection (1). Syringe exchange programs (SEPs) provide free sterile syringes and collect used syringes from injection-drug users (IDUs) to reduce transmission of bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus (HCV). As of March 2009, a total of 184 SEPs were known to be operating in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2009). Of these, 123 (67%) SEP directors participated in a mail/telephone survey conducted by NASEN and Beth Israel Medical Center (New York, New York) that covered program operations for the calendar year 2008. To characterize SEPs in the United States, this report summarizes the findings from that survey and compares them with previous SEP survey results from the period 1994--2007 (2--3). In 2008, the 123 SEPs reported exchanging 29.1 million syringes and had budgets totaling $21.3 million, of which 79% came from state and local governments. Most of the SEPs reported offering preventive health and clinical services in addition to basic syringe exchange: 87% offered HIV counseling and testing, 65% offered hepatitis C counseling and testing, 55% offered sexually transmitted disease screening, and 31% offered tuberculosis screening; 89% provided referrals to substance abuse treatment. Providing comprehensive prevention services and referrals to IDUs, such as those offered by many SEPs, can help reduce the spread of bloodborne infections and should increase access to health care and substance abuse treatment, thus serving as an effective public health approach for this population.

In March 2009, staff members from Beth Israel Medical Center and NASEN mailed surveys to directors of all 184 SEPs registered with NASEN at that time. The surveys included closed-ended questions regarding the number of syringes* exchanged, the types of services provided, budgets, and funding sources during 2008. Follow-up telephone interviews were conducted with the program directors by research staff members to clarify unclear or missing responses received on hard copy surveys. To protect participant confidentiality, many SEPs do not collect client-level data (e.g., number of persons who exchanged syringes or used other services); thus, the survey did not ask for such information. The data collection and analysis methods for this report are similar to those used in previous SEP surveys (2--3). The analyses for this report are limited to frequencies. To assess changes in funding over time, budgets from previous years were adjusted to 2008 dollars.

Data were compiled to show the numbers of programs known to NASEN, numbers of programs completing the surveys, syringes exchanged, and budget information for the surveys conducted from 1994--1995 through 2008 (Table 1). Rapid growth occurred in the number of SEPs in the United States in the 1990s and early 2000s, followed by more incremental growth through 2008. The 123 SEPs participating in the 2008 survey reported operating in 98 cities in 29 states and in DC.§ A total of 120 SEPs reported budget information for 2008. The reported 2008 budgets for these 120 SEPs totaled $21.3 million; individual program budgets ranged from $300 to $2.3 million, with a median of $63,258. Approximately one third (32%) of SEPs operated with a budget of <$25,000, 34% with $25,000--$100,000, and 37% with >$100,000. SEPs reported multiple sources of financial support in 2008, including private (individuals and foundations) and public (state and local government); 71% of the 120 SEPs that provided budget information received public funding, totaling nearly $16.8 million. The proportion of the SEP budgets coming from public sources increased from 62% during 1994--1995 to 79% in 2008 (Table 1).

SEPs were categorized as small, medium, large, or very large based on the number of syringes exchanged during 2008 (Table 2); SEPs reported exchanging a total of 29 million syringes in 2008. The 15 largest programs exchanged approximately 18 million syringes (62% of all syringes exchanged).

In 2008, many SEPs operated multiple sites, including fixed sites and mobile units. The total number of hours that clients were served by SEPs was summed for all sites operated by each program. The total number of scheduled hours per week ranged from <1 to 168 (mean: 29 hours per week; median: 24 hours per week). Delivery of syringes and other risk-reduction supplies to residences or meeting spots was reported by 41% of SEPs. A total of 111 (90%) SEPs allowed persons to exchange syringes on behalf of other persons (i.e., secondary exchange).

In addition to exchanging syringes, SEPs provided various supplies, services, and referrals in 2008; the percentage of programs providing each type of service was similar for the period 2005--2008 (Table 3). In 2008, all SEPs provided alcohol pads, and nearly all (98%) provided male condoms. Most (89%) provided referrals to substance abuse treatment. Other services also offered by SEPs included counseling and testing for HIV (87%) and HCV (65%), and screening for sexually transmitted diseases (55%) and tuberculosis (31%). Vaccinations for hepatitis A and B were provided by nearly half the programs (47% and 49%, respectively).

Reported by

V Guardino, DC Des Jarlais, PhD, K Arasteh, PhD, Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center; R Johnston, PhD, amfAR (Foundation for AIDS Research), New York, New York. D Purchase, A Solberg, North American Syringe Exchange Network, Tacoma, Washington. A Lansky, D Lentine, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Editorial Note

The findings in this report indicate that, in 2008, the number of SEPs and the number of syringes exchanged remained similar to recent years, in contrast to a period of rapid growth from the mid-1990s through the early 2000s. Budgets for SEPs increased from 1994--1995 through 2008, with the majority of funds coming from public sources. SEP budgets support syringe exchange and various prevention services, clinical care, and referral to substance abuse treatment. SEPs contribute to a comprehensive approach to the prevention of bloodborne infections among IDUs and can serve as a frontline source of health services for IDUs (4). The need for a comprehensive approach to HIV prevention for IDU is reflected in the implementation guidance for syringe services programs issued by the U.S. Department of Health and Human Services** and the National HIV/AIDS Strategy.††

Multiple reviews have concluded that syringe exchange leads to reductions in injecting risk behaviors among IDUs (5,6). HIV incidence among IDUs declined by approximately 80% from 1988--1990 to 2003--2006 in the United States (7). Injection-related transmission is the only adult transmission category to show a reduction of this magnitude. Despite that overall decline, IDUs continue to represent a substantial proportion of persons with new HIV diagnoses, accounting for approximately 8,700 (15%) new infections in 2006 (7); moreover, injection-drug use is the most common risk factor for HCV infection (8). Economic evaluations have concluded that SEPs are cost-effective in preventing HIV infection (9). Additional services offered by SEPs, such as prevention of HCV infection and referrals to substance abuse treatment, should confer even greater benefits (10); additional research is needed on the role of SEPs in the prevention of HCV infection.

The findings in this report are subject to at least four limitations. First, the extent of SEP activity in the United States is almost certainly underestimated because 61 (33%) of the SEPs known to NASEN did not complete the survey. Other SEPs might exist that are not known to NASEN. Second, certain SEPs operating within larger, community-based organizations were not able to report exact budget information because of difficulties in allocating shared costs across administrative units. Third, client-level information on the extent and use of preventive health services is not available. Finally, data collected were based on self-reports by program directors and were not verified independently.

The data in this report are from program operations during 2008, in the midst of an economic downturn in the United States. State and local governments continue to experience budget difficulties, which might impact public health adversely. However, the ban on federal funding of SEPs was modified for fiscal year 2010 funds, so that SEPs are now eligible for federal support, subject to provisions regarding the location of these programs. Ongoing, systematic data collection and evaluation are important for monitoring changes in the variety and volume of SEP services in the context of these types of political and economic changes.

Acknowledgments

The findings in this report are based, in part, on contributions by amfAR (the Foundation for AIDS Research), the Elton John AIDS Foundation, the Irene Diamond Foundation, and the Tides Foundation, New York, New York.

References

  1. National Institute on Drug Abuse. Principles of HIV prevention in drug-using populations: a research based guide. Bethesda, MD: National Institutes of Health; 2002. NIH publication no. 02-4733. Available at http://www.nida.nih.gov/pohp/faq_1.html. Accessed November 10, 2010.
  2. CDC. Syringe exchange programs---United States, 2005. MMWR 2007;56:1164--7.
  3. Des Jarlais D, McKnight C, Goldblatt C, Purchase D. Doing harm reduction better: syringe exchange in the United States. Addiction 2009;104:1441--6.
  4. Academy for Educational Development. Preventing blood-borne infections among injection drug users: a comprehensive approach. Atlanta, GA: US Department of Health and Human Services, CDC; 2000. Available at http://www.cdc.gov/idu/pubs/ca/comprehensive-approach.pdf. Accessed November 10, 2010.
  5. Institute of Medicine. Preventing HIV infection among injecting drug users in high risk countries: an assessment of the evidence. Washington, DC: The National Academies Press; 2006.
  6. Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D. Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews. Addiction 2010;105:844--59.
  7. Hall HI, Song R, Rhodes P, et al. HIV Incidence Surveillance Group. Estimation of HIV incidence in the United States. JAMA 2008;300:520--9.
  8. CDC. Surveillance for viral hepatitis---United States, 2007. MMWR 2009;58(No. SS-3).
  9. Belani HK, Muennig PA. Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New York City. J HIV AIDS Soc Serv 2008;7:229--40.
  10. Des Jarlais DC, Perlis T, Arasteh K, et al. Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990--2001. AIDS 2005;19(Suppl 3):S20--5.

* For this report, the term "syringes" refers to both syringes and needles.

Cities with more than one SEP: Los Angeles, Redwood City, Sacramento, and San Francisco, California; Detroit, Michigan; Minneapolis, Minnesota; New York, New York; Portland, Oregon, Seattle and Tacoma, Washington; and Madison and Milwaukee, Wisconsin.

§ States with SEPs: California (30); Washington (16); Wisconsin (14); New York (11); Connecticut (five); Illinois (five); Oregon (five); Maine, Michigan and Minnesota (three each); Alaska, DC, Louisiana, New Jersey, North Carolina, Pennsylvania, Texas, and Vermont (two each); Arizona, Colorado, Delaware, Indiana, Maryland, Massachusetts, Missouri, Montana, Ohio, and Oklahoma (one each). New Mexico and Hawaii have integrated statewide programs that operate in multiple cities/counties but were considered as single programs in this survey.

Some SEPs received funding from a common source, and specific allocations of those funds to individual programs was not always possible.

** Available at http://www.cdc.gov/hiv/resources/guidelines/syringe.htm.

†† Available at http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf.


What is already known on this topic?

Injection-drug users (IDUs) account for 15% of new human immunodeficiency virus (HIV) infections in the United States. Persons who inject drugs should use a new, sterile syringe for each injection to prevent transmission of HIV and other bloodborne infections.

What does this report add?

In 2008, 123 of 184 syringe exchange programs (SEPs) surveyed reported exchanging 29.1 million syringes; 120 SEPs reported budgets totaling $21.3 million, of which 79% came from state and local governments. Most SEPs offered preventive health services in addition to basic syringe exchange.

What are the implications for public health practice?

Given the number of SEPs providing preventive health services, as well as provision of sterile syringes, these programs contribute to a comprehensive approach to the prevention of HIV and other bloodborne infections among IDUs.


TABLE 1. Characteristics of syringe exchange programs (SEPs) --- United States, 1994--2008

Characteristic

1994--1995

1996

1997

1998

2000

2002

2004

2005

2006

2007

2008

No. of SEPs known to NASEN*

68

101

113

131

154

148

174

166

188

186

184

No. of known SEPs participating in survey (%)

60 (88)

87 (86)

100 (88)

110 (84)

127 (82)

126 (85)

109 (63)

118 (71)

150 (80)

131 (70)

123 (67)

No. of cities with known SEPs participating in survey

44

69

78

77

98

97

88

90

113

100

98

No. of states with known SEPs participating in survey

21

29

33

33

36

32

32

29

32

31

30

No. of syringes exchanged (millions)

8.0

13.9

17.5

19.4

22.6

24.9

24.0

22.5

27.6

29.5

29.1

Total of SEP budgets (in millions of dollars)

6.3

7.3

8.4

8.6

12.0

13.0

11.6

14.5

17.4

19.6

21.3

Total of SEP budgets (in millions of dollars, adjusted to 2008 standard)

10.8

11.6

13.0

12.9

16.8

16.6

13.6

16.3

18.8

20.3

21.3

% of total budget from public funding

62

62

67

69

74

67

76

74

79

73

79

* North American Syringe Exchange Network.

Includes the District of Columbia and/or Puerto Rico.


TABLE 2. Number of syringes exchanged by syringe exchange programs (SEPs), by program size --- United States, 2008

SEP size

No. of syringes exchanged per SEP

No. of SEPs

Total no. of syringes exchanged

% of total syringes exchanged

Small

<10,000

20

67,593

0.2

Medium

10,000--55,000

33

982,317

3.4

Large

55,001--499,999

54

9,894,182

34.1

Very large

≥500,000

15

18,113,914

62.3

Total

122*

29,058,006

100.0

* One of 123 programs responding to the survey did not track the number of syringes exchanged in 2008.


TABLE 3. Services and supplies provided by syringe exchange programs (SEPs) --- United States, 2005--2008

Survey year (No. of SEPs)

Supplies and services

2005 (n = 118)

2006 (n = 150)

2007 (n = 131)

2008 (n = 123)

No.

(%)

No.

(%)

No.

(%)

No.

(%)

Prevention supplies

Male condoms

115

(97)

148

(99)

130

(99)

121

(98)

Female condoms

98

(83)

115

(77)

112

(85)

97

(79)

Alcohol pads

117

(99)

148

(99)

131

(100)

123

(100)

Bleach

82

(69)

89

(59)

77

(59)

69

(56)

On-site medical screenings and services

HIV counseling and testing

96

(81)

126

(84)

115

(88)

107

(87)

Hepatitis C counseling and testing

66

(56)

94

(63)

72

(55)

80

(65)

Hepatitis B counseling and testing

44

(37)

71

(47)

30

(23)

30

(24)

Hepatitis A counseling and testing

28

(24)

57

(38)

22

(17)

22

(18)

Hepatitis B vaccination

46

(39)

77

(51)

58

(44)

60

(49)

Hepatitis A vaccination

43

(36)

74

(49)

59

(45)

58

(47)

Sexually transmitted disease (STD) screening

57

(48)

75

(50)

64

(49)

67

(55)

Tuberculosis screening

33

(28)

39

(26)

31

(24)

38

(31)

On-site medical care

34

(29)

50

(33)

43

(33)

47

(38)

Referrals

Substance-abuse treatment

102

(86)

133

(89)

120

(92)

110

(89)

Education

HIV/AIDS prevention/STD prevention

116

(98)

139

(93)

124

(95)

118

(96)

Hepatitis A,B, and C prevention

114

(97)

148

(99)

127

(97)

119

(97)

Safer injection practice

113

(96)

129

(86)

126

(96)

116

(94)

Abscess care/vein care

107

(91)

141

(94)

123

(94)

113

(92)

Male condom use

112

(95)

145

(97)

125

(95)

120

(98)

Female condom use

97

(82)

119

(79)

104

(79)

91

(74)



Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.


All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

 
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Road Atlanta, GA 30329-4027, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
A-Z Index
  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
  27. #