Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas — United States, 2013

Don C. Des Jarlais, PhD1; Ann Nugent1; Alisa Solberg, MPA2; Jonathan Feelemyer, MS1; Jonathan Mermin, MD3; Deborah Holtzman, PhD4

Reducing human immunodeficiency virus (HIV) infection rates in persons who inject drugs (PWID) has been one of the major successes in HIV prevention in the United States. Estimated HIV incidence among PWID declined by approximately 80% during 1990–2006 (1). More recent data indicate that further reductions in HIV incidence are occurring in multiple areas (2). Research results for the effectiveness of risk reduction programs in preventing hepatitis C virus (HCV) infection among PWID (3) have not been as consistent as they have been for HIV; however, a marked decline in the incidence of HCV infection occurred during 1992–2005 in selected U.S. locations when targeted risk reduction efforts for the prevention of HIV were implemented (4). Because syringe service programs (SSPs)* have been one effective component of these risk reduction efforts for PWID (5), and because at least half of PWID are estimated to live outside major urban areas (6), a study was undertaken to characterize the current status of SSPs in the United States and determine whether urban, suburban, and rural SSPs differed. Data from a recent survey of SSPs† were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services§ were less available to PWID outside urban settings. Because increases in substance abuse treatment admissions for drug injection have been observed concurrently with increases in reported cases of acute HCV infection in rural and suburban areas (7), state and local jurisdictions could consider extending effective prevention programs, including SSPs, to populations of PWID in rural and suburban areas.

The basic service offered by SSPs allows PWID to exchange used needles and syringes for new, sterile needles and syringes. Providing sterile needles and syringes and establishing appropriate disposal procedures substantially reduces the chances that PWID will share injection equipment and removes potentially HIV- and HCV-contaminated syringes from the community. Many SSPs have become multiservice organizations, providing various health and social services to their participants (8). HIV and HCV testing and linkage to care and treatment for substance use disorders are among the most important of these other services. The availability of new and highly effective curative therapy for HCV infection increases the benefits of integrating testing and linkage to care among the services provided by SSPs.

During the last decade, an increase in drug injection has been reported in the United States, primarily the injection of prescription opioids and heroin among persons who started opioid use with oral analgesics and transitioned to injecting (9). Much of this drug injection has occurred in suburban and rural areas (6). Outbreaks of HCV infection, and more recently HIV infection, in these nonurban areas have been correlated with these injection patterns and trends (7).

The recent HIV outbreak in Scott County, Indiana (10), and the emerging HCV epidemics in multiple areas throughout the United States (11) have focused attention on the limited coverage of prevention services for both types of infections among PWID in rural and suburban areas. This report summarizes data from a survey of U.S. SSPs, and compares selected characteristics of these programs by urbanicity.

As of March 2014, 204 SSPs were known to be operating in the United States in 2013 (2). Directors of 153 (75%) of these programs participated in a mail/telephone survey covering program operations for 2013, conducted by the North American Syringe Exchange Network and Mount Sinai Beth Israel (New York, New York). Research personnel conducted follow-up telephone interviews with program directors for response clarification and completeness.

Because some SSPs do not collect individual client-level data (e.g., characteristics and behaviors of persons who exchanged syringes or used other services) to protect participant confidentiality, the survey asked program directors for their best estimates of demographic characteristics and behaviors of their client populations. In addition, when SSPs had multiple sites within their specific service area, the directors were asked to describe program and client characteristics for the entire population served, rather than for individual sites. Thus, the data in this report refer to each program as a whole. Program directors also were asked whether their main site of operations (including mobile operations if applicable) was located in an urban, suburban, or rural setting. The data collection and analysis for this report were conducted during the spring and summer of 2014 using methods similar to those used in previous SSP surveys (12). Program, client, and operating characteristics are reported as percentages by urban, suburban, and rural setting.

The West and Northeast had the highest numbers of SSPs, and the South had the lowest (Table 1). Nationally, 20% of SSPs reported primary rural locations, 9% reported primary suburban locations, and 69% reported primary urban locations with slightly less than 3% with missing location data. There was some variation in the percentage of rural, suburban, and urban programs among the geographic regions, with the West and Midwest having a higher percentage of rural programs, the South and Northeast having the highest percentage of urban programs, and the South having the lowest percentage of rural and suburban SSPs.

Rural SSPs exchanged fewer syringes than suburban and urban SSPs. Because there were many more urban SSPs, they dominated the total number of syringes exchanged (31.5 million by urban programs versus 4.4 million for suburban programs and 2.7 million for rural programs). Annual budgets for SSPs paralleled the number of syringes exchanged, with rural programs having modest budgets (mean = $26,023), suburban programs having much larger budgets (mean = $116,902), and the urban programs having the largest budgets (mean = $184,738). Urban programs dominated the total budgets for SSPs in the survey, accounting for 83% of budgeted funds. The percentage of SSPs receiving public funding (from local and state governments) was similar across SSP locations (60% for rural, 64% for suburban, and 60% for urban SSPs).

Although a greater percentage of SSP participants were male, a substantial minority (>30%) were female (Table 2). Compared with rural and suburban SSPs, urban SSPs reported considerably higher percentages of African American and Hispanic participants and smaller percentages of white participants, although whites were still the majority of participants in all SSPs. Heroin was the most frequently injected drug for all three types of SSP locations, with approximately two thirds of participants injecting heroin in suburban and urban SSPs, and approximately one half in rural SSPs. Rural SSPs reported higher percentages of participants injecting amphetamines and opioid analgesics.

Regardless of location, most SSPs encouraged secondary exchange, in which persons attending the program exchange used needles and syringes on behalf of peers who do not personally attend the program (Table 3). In addition, a majority of SSPs in all location types reported experiencing funding and resource shortages in 2013, although the percentage was slightly higher for rural exchanges. Suburban SSPs were most likely to report difficulties in reaching (e.g., making initial contact) and recruiting potential participants. Differences in personnel patterns also were apparent. Among rural SSPs, approximately 40% reported having full-time paid personnel, and approximately one half reported former drug users as program personnel. Conversely, among suburban and urban SSPs, most reported employing former drug users.

Despite differences in program size, operating budgets, and staffing among SSPs in rural, suburban, and urban locations, there were similarities in on-site services (Table 3). Most SSPs offered HIV counseling and testing (87% among rural SSPs, 71% among suburban SSPs, and 90% among urban SSPs) and HCV testing (67% among rural SSPs, 79% among suburban SSPs, and 78% among urban SSPs). A minority of SSPs reported having referral tracking systems for HCV-related care and treatment (33% of rural SSPs, 43% of suburban SSPs, and 44% of urban SSPs). Rural SSPs were less likely to provide naloxone (for reversing opioid overdoses) (37%) compared with suburban (57%) and urban (61%) programs that provided this service.

Discussion

A recent estimate of the geographic variation among PWID indicated that half lived outside of major metropolitan areas (6). Opiate overdoses and prescription opiate use have been increasing particularly in rural areas (13). The modest number of rural (20) and suburban (14) SSPs participating in this survey raise concerns that many rural and suburban areas with PWID might not have access to SSPs. Unmet needs for SSPs were recently documented in Kentucky, Tennessee, Virginia, and West Virginia. CDC reported large increases in HCV infection (primarily associated with injection drug use) in these four states during 2006–2012 (7). During the time of this increase, only one SSP was known to be operating in the four states combined, and state-supported SSPs were not officially authorized in any of the states (2). Kentucky and Indiana recently authorized SSPs, after the Indiana HIV outbreak (10).

The existence of an SSP in an area, however, will not necessarily prevent an outbreak of HIV or HCV infection; in addition to substance use prevention and treatment services, PWID need access to adequate numbers of sterile syringes. The Joint United Nations Programme on HIV/Acquired Immunodeficiency Syndrome (AIDS) (UNAIDS) recommends provision of 200 sterile syringes per injector per year for a high level of coverage.¶ Access to sterile syringes can be provided through SSPs and through pharmacy sales. Each of these settings has advantages and limitations. Pharmacies have many locations and longer hours of operation, but they usually do not collect used needles and syringes and typically do not ensure client confidentiality. SSPs can provide free sterile needles and syringes and certain additional services, including the collection of used needles and syringes, and they might be more effective in protecting confidentiality of injectors. Selected services are frequently provided by SSPs to improve the health of clients, prevent infectious diseases, and reduce drug use, and can be considered a minimum set for good quality service (Table 3) (8). Good practice also includes treating clients with respect and protecting client confidentiality.

The findings in this report are subject to at least four limitations. First, only 75% of SSPs in the United States participated in the survey, and some of the participating SSPs requested that their data (including their location) not be made public; however, based on previous surveys of SSPs (12), those that do not participate tend to be small programs. Therefore, the survey likely represents the majority of SSP activities nationally. Second, participant characteristics and drug use behaviors were estimated by program directors rather than abstracted or enumerated from program records. Third, the data on service provision considered whether each service was provided and did not assess quantity or quality of the specific service. Finally, some programs with multiple sites operated in more than one type of location, and there might be some misclassification of program location. The most likely direction of such misclassification would be nonurban operations that were part of programs with urban primary locations.

Despite these limitations, the survey data indicated distinct differences (location, size, budgets, staffing, and drugs injected) and some important similarities (offering HIV and HCV testing) among the programs. HIV prevention for PWID has been successful where it has been implemented in the United States. During the last decade, however, injection drug use has increased in many new areas, particularly rural and suburban communities, where HIV and hepatitis C prevention programs and services are often lacking. Providing all populations of PWID in the United States with access to sterile injection equipment as well as comprehensive treatment and prevention services for drug use and HIV and HCV infection could help prevent worsening of these epidemics.

1Mount Sinai Beth Israel, New York, New York; 2North American Syringe Exchange Network, Tacoma, Washington; 3National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 4Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Corresponding author: Don C. Des Jarlais, DDesJarlais@chpnet.org.

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