Current State of Syringe Exchange in the Known Universe

Don C. Des Jarlais, Vivian Guardino,

Kamyar Arasteh, Courtney McKnight,

Judith Milliken and David Purchase

This work was funded by amfAR, The Foundation for AIDS Research, with support from the Elton John AIDS

Foundation and the Irene Diamond Foundation-Tides Foundation.

NASEC 2010, Austin, TX November 17, 2010

Three Eras of Syringe Exchange in the US

• Homeric age: heroes, demigods, villains and wars

• The Greek city-state era and the ideal of the rational

• The Roman empire era: central administration and resources

Homeric Age: mid to late 1980s

• Heroes, demigods, villains and wars

• Activist initiated exchanges

• Some support from local and state governments

• Intense opposition from some political/community leaders

• Court cases “Public health necessity”

Homeric Age

• Strom Thurmond Catch 22 on federal funding

• International and US research and practical experience indicating programs effective

Greek City-state Era. The ideal of the rational: mid 1990s to mid

2000s

Growth of SEPs in many different areas, but without national plan

• Programs evolved with minimum bureaucratic regulation, maximum input from front line staff and participants

• Occasional compromises with receipt of state/local funding, often “workarounds”

Characteristics of SEP’s Participating in BIMC/NASEN Surveys

United States, 1994-2009Numbers of 1994-

951996 1997 1998 2000 200

22004 2005 2006 2007 2008 2009

SEPs known to NASEN

68 101 113 131 154 148 174 166 188 186 184 201

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%)

149(74%)

Cities with SEP’s participating

44 69 78 77 98 97 88 90 113 100 98 115

States with SEP’s participating *

21 29 33 33 36 32 32 29 32 31 30 33

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 33.1

Total of SEP budgets ($, millions)

6.3 7.3 8.4 8.6 12.0 13.0

11.6 14.5 17.4 19.6 21.3 21.6

Total of SEP budgets in 2009-adjusted $ (millions)

10.6 11.4 12.7 12.6 16.5 16.3

13.3 16.0 18.4 19.9 20.9 21.6

Public funding as % of total SEP budgets

62% 62% 67% 69% 74% 67% 76% 74% 79% 73% 79% 80%

* This category includes the District of Columbia and/or Puerto Rico.

National Survey of Syringe Exchange Programs Methodology

2008 Survey •184 SEPs contacted in first quarter 2009•123 SEPs (67%) submitted completed

surveys by early summer.2009 Survey

•201 SEPs contacted in first quarter 2010•149 SEPs (74%) submitted completed

surveys by early summer.

SEP Budget Dollars2008 2009

Total $$$ $21,307,337

$21,686,788

City Gov $ $5,041,332 $5,381,142 County Gov $ $2,402,678 $2,261,688 State Gov $ $9,417,053 $9,768,293 Foundation $ $3,440,558 $3,233,266 Individual Donations

$458,685 $536,333

Out-of-pocket $ $57,911 $41,959 NASEN $ $ 65,170 $45,609 CBO Donation $ $19,000 $2,059 Corporate Donation $

$85,832 $38,084

Other $ $319,118 $378,355

Budget Status 2009 vs. 2008

Increased Budget, 26

Decreased Budget, 53

Same Budget, 60

Didn't Answer, 10

n = 149

SEPs That Participated in 2008 & 2009 Surveys Total Budget $$

2008 $19,427,22

8(as reported by 103 SEPs)

2009$18,001,37

7(as reportedby 100 SEPs)

Types of Areas SEPs Are Located in

United States, 2009

Rural: 31 SEPs 21%

Suburban 17 SEPs

11%Urban: 98 SEPs 66%

Didn't Answer: 3 SEPs 2%

n = 149

Gender Distribution Frequency of SEP Participants in 2009

<25%

<50%

<75%

75%

or more

Didn’t Answer

Male 2(1.34%

)

12(8.05

%)

113(75.84

%)

21(14.09

%)

1(0.67

%)Female 22

(14.77)

112(75.17

%)

13(8.72%

)

1(0.67

%)

1(0.67

%)Transgender

145(97.32

%)

1(0.67

%)

1(0.67%

)

1(0.67

%)

1(0.67

%)

Ethnic Distribution Frequency of SEP Participants in 2009

<25% <50% <75% 75% or more

Didn’t Answer

AfricanAmerican

103(69.13%)

28(18.79%)

5(3.36%)

10(6.71%)

3(2.01%)

AsianPacific Islander

144(96.64)

1(0.67%)

0 1(0.67%)

3(2.01%)

Caucasian

25(16.78%)

22(14.77%)

47(31.54%)

52(34.90%)

3(2.01%)

Latino/a 114(76.51%)

21(14.09%)

6(4.03%)

4(2.68%)

4(2.68%)

Native American

145(97.32%)

1(0.67%)

0 0 3(2.01%)

% of Injected Substances and Substance Combinations

< 25% < 50% < 75% > 75%‘08 ‘09 ‘08 ‘09 ‘08 ‘09 ‘08 ‘09

Heroin by itself 14% 12%

30%

27%

30%

28%

26%

32%

Heroin & Cocaine 75% 77%

16%

15%

6% 4% 2% 1%

Heroin mixed with another drug (not cocaine)

93% 89%

3% 3% -- 3% 3% 3%

Cocaine by itself (including Crack) 82% 77%

15%

17%

2% 3% 1% 1%

Cocaine mixed with another drug (not heroin)

96% 94%

-- 2% 1% 1% 2% 1%

Methamphetamine (crystal meth/ice/crank)

63% 68%

24%

22%

8% 7% 4% 1%

Other Amphetamines (uppers/Dexedrine)

98% 94%

-- 3% -- 1% 1% --

Other Opiates (OxyContin, Percodan, Vicodin, etc.)

80% 75%

13%

16%

2% 4% 3% 3%

Steroids 97% 96%

-- -- -- 1% 2% --

HIV meds and/or insulin 96% 97%

1% 1% -- -- 2% --

Downers (benzodiazepines, tranquilizers)

96% 91%

1% 4% 2% 1% 1% 1%

Silicone 98% 96%

-- -- -- 1% 1% --

Any other substances 97% 95%

-- -- 1% 1% 1% 1%

Type of Heroin Used in 2009As Reported by SEPs

Primarily White Powder: 52

35%Primarily Black Tar: 5537%

Both White Powder & Black

Tar: 3423%

Don't Know: 32%

Didn't Answer: 53%

Type of Exchange Conducted by SEPs in 2009

Variation No. (%)Allowed receipt of more syringes than brought in

126 (84.56%)

Used Start-up Packs

91 (61.07%)

Used A Minimum 48 (32.21%)Used A Distribution Model

83 (55.70%)

Had a Limit on Syringes Exchanged

34 (22.82%)

Weekly Exchange Hours @ Regular, Scheduled Times &

Places •2008

Total of 3,625 hours per week averaging 29.47 hours per SEP (n = 123)•2009 Total of 4,063 hours per week averaging 27.83 hours per SEP (n = 146)

Number of Syringes Distributed by Syringe Exchange Programs (SEPs), by

Program Size: 2008 & 2009

SEP Size(Syringes

Distributed)

No. of

SEPs

2008

Total syringes

exchanged 2008

No. of

SEPs2009

Total syringes

exchanged 2009

Small(< 10,000)

20 67,593 (0.2%)

25 94,611(0.3%)

Medium(10,000-55,000)

33 982,317 (3.4%)

39 1,129,493(3.4%)

Large(55,001-499,999)

54 9,894,182 (34.1%)

70 13,011,703(39.3%)

Very Large(500,000)

15 18,113,914 (62.3%)

14 18,879,383(57.0%)

Total 122*

29,058,006 148* 33,115,190* In 2008 & 2009 one program responding to the survey did not track the number of syringes exchanged.

Returned/Collected Syringes

26,401,034

30,569,003

2008 2009

Disposal Methods of Collected Used Syringes in 2009

Private Sanitation: 9

SEPs6%

Arrangement with Local

Facility: 140 SEPs94%

Syringes Exchanged By 106 Programs That

Participated in Both 2008 & 2009 Surveys2008 (n =

106)•26,834,186

syringes distributed

•24,409,879 syringes collected

2009 (n = 105)•29,257,618

syringes distributed

•27,731,430 syringes collected

SEP Usage of Unique Identifiers for Tracking

Individuals in 2009

Used Unique Identifier: 91

SEPs61%

Did Not Use Unique

Identifier: 58 SEPs39%

Secondary (Satellite) Exchange & Methods of Encouragement Used

by SEPs in 2009Secondary Exchange No. (%)

SEPs allowing secondary exchange 135 (90.60%)

SEPs encouraging secondary exchange 119 (79.87%)

Methods of Encouragement

Talked about it 108 (72.48%)

Had no limit on syringes exchanged 96 (64.43%)

Gave extra supplies 110 (73.83%)

Provided sharps containers 103 (69.13%)

Enrolled people receiving syringes from secondary exchange

34 (22.82%)

Peer education 79 (53.02%)

Gift certificates/Other incentives 20 (13.42%)

Risk Reduction Education Provided by SEPs in

2008 & 2009 2008 No. (%)

2009 No. (%)

Condom Use 120 (97.56%)

146 (97.99%)

Hepatitis (A,B,C) Prevention

119 (96.75%)

142 (95.30%)

OD Prevention with Narcan

62 (50.41%)

76 (51.01%)

OD Prevention without Narcan

59 (47.97%)

78 (52.35%)

Safer Crack Use 65 (52.85%)

81 (54.36%)

STD and HIV Prevention (other than condom use)

118 (95.93%)

138 (92.62%)

Dental Dam/Female Condom Use

91 (73.98%)

105 (70.47%)

Use of Bleach 85 (69.11%)

97 (65.10%)

Safer Injection Techniques

116 (94.31%)

140 (93.96%)

Abscess/Wound and/or Vein Care

113 (91.87%)

134 (89.93%)

Weekly On-Site Medical Services

•200847 SEPs reported providing on-site medical care totaling 1,516 hours per week

•2009 46 SEPs reported providing on-

site medical care totaling 1,360 hours per week

Supplies Provided by SEPs

2008No. (%)

2009No. (%)

Containers for carrying syringes

102 (83%)

135 (91%)

Cookers 119 (97%)

144 (97%)

Crack Kits 47 (38%)

61 (41%)

Cotton 120 (98%)

146 (98%)

Alcohol Pads 123 (100%)

148 (99%)

Bleach 69 (56%)

83 (56%)

Supplies Provided by SEPs2008

No. (%)2009

No. (%)

Water bottles 94 (76%) 116 (78%)Ties 111

(90%)135 (91%)

Antibiotic Ointment

97 (79%)

117 (79%)

Wound Kits 63 (51%)

86 (58%)

Band-aids 105 (85%)

124 (83%)

Suboxone 11 (9%) 10 (7%)Buprenorphine 7 (6%) 10 (7%)Narcan 54 (44%) 66(44%)

Supplies Provided by SEPs

2008No. (%)

2009No. (%)

Condoms 121 (98%)

148 (99%)

Female Condoms

97 (79%)

129 (87%)

Dental Dams 88 (72%)

99 (66%)

Lubricant 112 (91%)

143 (96%)

Supplies Provided by SEPs

2008No. (%)

2009No. (%)

Hygiene Items 104 (85%)

124 (83%)

Clothes 79 (64%) 88 (59%)Food 84 (68%) 103 (69%)Gift Certificates / Vouchers / Travel

46 (37%)

54 (36%)

Other 24 (20%)

28 (19%)

Selected On-Site Services Provided by SEPs

2008No. (%)

2009No. (%)

HIV Counseling & Testing

107 (87%) 129 (87%)

Hepatitis C Counseling & Testing

80 (65%) 93 (62%)

Hepatitis B Counseling & Testing

30 (24%) 29 (19%)

Hepatitis A Counseling & Testing

22 (18%) 22 (15%)

Hepatitis B Vaccination

60 (49%) 57 (38%)

Hepatitis A Vaccination

58 (47%) 56 (38%)

Selected On-Site Services Provided by SEPs

2008No. (%)

2009No. (%)

STD Screening

67 (55%) 69 (46%)

Tuberculosis Screening

38 (31%) 38 (26%)

Substance Abuse Treatment Referrals

110 (89%)

128 (86%)

Additional Program Characteristics

2008 No. (%)

2009 No. (%)

Did not operate for two months or more

2 (1.63%)

13 (8.72%)

Any full-time (paid) staff

86 (69.92%)

97 (65.10%)

Operated by city, county or state health department

35 (28.46%)

35 (23.49%)

501-C3 Status 96 (78.05%)

117 (78.52%)

Additional Program Characteristics

2008 No. %)

2009 No. (%)

Operated a Delivery Service

51 (41.46%)

78 (52.35%)

Had Referral Tracking System

65 (52.85%)

68 (45.64%)

Was involved in formal external evaluation

24 (19.51%)

28 (18.79%)

Problems SEPs Encountered in 2008 & 2009

Problems 2008 No. (%) 2009 No. (%)

Operations disrupted by government or law enforcement official

20 (16.26%) 18 (12.08%)

Lack of resources/Lack of funding

83 (67.48%) 103 (69.13%)

Staff shortage 63 (51.22%) 77 (51.68%)

Staff burnout 38 (30.89%) 44 (29.53%)

Lack of political support 21 (17.07%) 29 (19.46%)

Lack of community support 25 (20.33%) 28 (18.79%)

Lack of outreach 28 (22.76%) 31 (20.81%)

Legal status 9 (7.32%) 12 (8.05%)

Police harassment of participants (at/near site)

27 (21.95%) 30 (20.13%)

Police harassment of staff / program

10 (8.13%) 8 (5.37%)

Reaching or recruiting participants

31 (25.20%) 38 (25.50%)

Retaining participants 12 (9.76%) 20 (13.42%)

Any type of problem due to gentrification?

15 (12.20%) 15 (10.07%)

Other 18 (14.63%) 15 (10.07%)

Quality of Relationship Between SEPs and Police as Reported by SEPs in 2008

& 2009Quality of Relationship

2008No. (%)

2009No. (%)

Very Good 24 (19.51%)

33 (22.15%)

Somewhat good

37 (30.08%)

45 (30.20%)

Neutral 45 (36.59%)

45 (30.20%)

Somewhat poor

5 (4.07%)

7 (4.70%)

Very poor 2 (1.63%)

4 (2.68%)

Non-existent 10 (8.13%)

12 (8.05%)

Quality of Relationship Between SEPs and Local Health Officials in

2008 & 2009Quality of Relationship

2008No. (%)

2009No. (%)

Very Good 71 (57.72%)

103 (69.13%)

Somewhat good

32 (26.02%)

28 (18.79%)

Neutral 11 (8.94%)

8 (5.37%)

Somewhat poor

1 (0.81%)

2 (1.34%)

Very poor 2 (1.63%)

2 (1.34%)

Non-existent 6 (4.88%) 4 (2.68%)

Strategies SEPs Used in 2009 to Gain

Law Enforcement SupportStrategy # of

SEP’s%

None 34 22.81%

Meetings 72 48.32%

Trainings 44 29.53%

Invitation to exchange 23 15.43%

Street demonstrations 6 4.02%

Coalition work w/other public health activists

39 26.17%

Officer Liasons 35 23.48%

Didn’t have capacity/resources for strategy

17 11.40%

Other 16 10.73%

•Any favorable or unfavorable media attention in 2009

–YES •42 programs (28.19%)

–NO

•106 programs (71.14%)

The Roman Empire Era: 2010 onward

Need for a national plan

Need for national resources

Will rationality and best practices be retained?

Federal FundingSEPs … Yes No Don’t

KnowDidn’t

AnswerBelieve Eligible

65 (43.62%

)

16 (10.74%

)

68 (45.64

%)

0

Have or expect to apply

73 (48.99%

)

28 (18.79%

)

47 (31.54

%)

1 (0.67%

)

Expect to receive funds

34 (22.82%

)

15 (10.07%

)

78 (52.35

%)

22 (14.77

%)

If Federal Funding Received Programs Anticipate …

Maintaining

Present Services

Expanding

Present Services

Adding New

Services

Don’t Know

Didn’t Answer

27 (18.12

%)

58 (38.93

%)

23 (15.44

%)

10 (6.71%)

31 (20.81

%)

Three Eras of Syringe Exchange in the US

• Homeric age: heroes, demigods, villains and wars

• The Greek city-state era and the ideal of the rational

• The Roman empire era: central administration and resources

Other Parts of Known Universe

• Canada: expansion of syringe access in Vancouver and Montreal led to decreased HIV incidence

• China: Scaling up, but not sure how to measure effectiveness

• Russia: scaling down

• Estonia: scaled up, preliminary evidence of decreased HIV incidence

Thank You!

Special Thanks to Alisa Solberg and Kay Borba for their help in reaching out to SEPs

Many Thanks to EVERYONE who contributed to a survey submission. KEEP THEM COMING!