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in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2009).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.

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