Syringe Exchange Programs --- United States, 2005

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Syringe exchange programs (SEPs) provide free sterile syringes* in exchange for used syringes to reduce transmission of bloodborne pathogens among injection-drug users (IDUs) (1). SEPs in the United States began as a way to prevent the spread of human immunodeficiency virus (HIV) and other bloodborne infections such as hepatitis B and hepatitis C. The National Institute on Drug Abuse recommends that persons who continue to inject drugs use a new, sterile syringe for each injection (2). Monitoring syringe exchange activity is an important part of assessing HIV prevention measures in the United States. As of November 2007, a total of 185 SEPs were operating in 36 states, the District of Columbia (DC), and Puerto Rico (North American Syringe Exchange Network [NASEN], unpublished data, 2007). This report summarizes a survey of SEP activities in the United States during 2005 and compares the findings with previous SEP surveys (3--7; Beth Israel Medical Center [BIMC], unpublished data, 2000 and 2004). The findings indicated an increase in overall funding for SEPs, including an increase in public funding, and a stabilization in both the number of SEPs operating and the number of syringes exchanged since 2004. This report also documents an expansion of services offered by SEPs, a trend that resulted from an increase in state and local funding. These expanded services are helping protect IDUs and their communities from the spread of bloodborne pathogens and are providing access to health services for a population at high risk. Monitoring of syringe exchange activity should continue.

In March 2006, staff members from BIMC and NASEN mailed surveys to directors of all 166 SEPs registered with NASEN at that time (compared with 68 known SEPs for the 1994--1995 survey, 101 for 1996, 113 for 1997, 131 for 1998, 154 for 2000, 148 for 2002, and 174 for 2004) (3--7; BIMC, unpublished data, 2000 and 2004). Registration with NASEN provides important benefits to SEPs and does not involve any cost; thus, nearly all SEPs in the United States are likely to be registered. The surveys included questions regarding the number of syringes exchanged, the types of services provided, and budgets and funding during 2005. Data for 2005 were collected during March--August 2006. Telephone interviews were conducted to clarify responses received on surveys. The methods were similar to those used in previous SEP surveys, except for an Internet-based option that was used in the 2002 survey only.

Of the 166 SEPs contacted, 118 (71%) completed the survey. These 118 SEPs reported operating in 91 cities in 28 states/territories^§ and in DC. A total of 79 (67%) SEPs were operating in six states: 22 in California, 17 in New Mexico, 15 in Washington, 10 in Wisconsin, nine in New York, and six in Connecticut.

SEP size was determined by the number of syringes exchanged during 2005 (Table 1); 117 SEPs reported exchanging a total of 22,472,168 syringes (one SEP did not track the number of syringes exchanged in 2005). The 12 largest programs exchanged 11,863,932 (53% of all the syringes exchanged).^¶

In addition to exchanging syringes, SEPs provided various supplies, services, and referrals in 2005 (Table 2). Nearly all SEPs provided alcohol pads (117 [99%]), male condoms (115 [97%]), and referrals to substance-abuse treatment 102 (86%). Certain medical services also were offered by SEPs, including counseling and testing for HIV (96 [81%]) and hepatitis C (66 [56%]). Vaccinations for hepatitis B were provided by 46 (39%) SEPs, and hepatitis A vaccinations were provided by 43 (37%). Thirty-four (29%) SEPs offered other on-site medical care.

In 2005, many SEPs operated multiple sites, including fixed sites and mobile van routes. The total number of hours that clients were served by SEPs was summed for all sites operated by each program. This total number of hours per program ranged from 1 to 168 hours per week (mean: 26 hours per week; median: 20 hours per week). Delivery of syringes and other risk-reduction supplies to residences or meeting spots was reported by 56 (47%) SEPs. A total of 110 (93%) SEPs allowed persons to exchange syringes on behalf of other persons (i.e., secondary exchange).

A total of 114 SEPs reported budget information for 2005; four SEPs lacked budget information for this period. The reported budgets for these 114 SEPs totaled $15.2 million (Table 3). Some SEPs received funding from a common source, and allocating funds from the common source to individual programs was not always possible. For the 97 SEPs for which individual budget information could be generated, the 2005 budgets ranged from $648 to $1,516,375. The mean SEP budget increased from $131,301 in 2004 to $133,450 in 2005. In 2005, a total of 30 (31%) SEPs operated with a budget of <$25,000, 29 (30%) with $25,000--$100,000, and 38 (39%) with >$100,000. SEPs reported multiple sources of financial support in 2005, including individuals, foundations, and state and local governments. In 2005, a total of 72 (61%) of the 118 SEPs that responded to the survey received public funding totaling nearly $11.3 million from city, county, and state governments,** accounting for approximately 74% of total funding. The total amount of public funding increased by nearly $2 million in 2005, and the mean public funding budgets increased by nearly $10,000 ($145,633 in 2004 versus $157,273 in 2005). Federal law prohibits the use of federal funds to support SEPs.

From the period 1994--1995, when the first national survey of SEPs was conducted, to 2002, the number of SEPs and the number of syringes exchanged by these programs increased consistently. However, in 2005, a reduction was observed in the number of SEPs and syringes exchanged. In 2005, eight fewer SEPs were operating than previously indicated by results from the 2004 survey (BIMC, unpublished data, 2004), and two fewer states had SEPs operating. However, four additional cities had SEPs operating in 2005, compared with 2004. The number of syringes exchanged decreased from approximately 24.0 million in 2004 to 22.5 million in 2005.

Reported by: CA McKnight, MPH, DC Des Jarlais, PhD, T Perlis, PhD, K Eigo, Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center; M Krim, PhD, M Ruiz, PhD, American Foundation for AIDS Research, New York, New York. D Purchase, A Solberg, North American Syringe Exchange Network, Tacoma, Washington. TD Mastro, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Editorial Note:

Compared with data from previous national SEP surveys, the findings in this report indicate an overall stabilization in the number of SEPs operating in the United States. Total funding of SEPs increased in 2005 despite a reduction in the number of SEPs. Increases in funding, particularly public funding, provided opportunities for SEPs to expand the types of services they provide. As a result of these increases, many SEPs have evolved into larger, community-based organizations that provide numerous social and medical services to IDUs and their communities (e.g., testing for HIV and hepatitis A, hepatitis B, and hepatitis C; vaccinations for hepatitis A and hepatitis B; and general medical care). These more costly services have been added to many SEPs during the past several years, and continued increases in funding might make these services more available. By expanding such services, SEPs are becoming part of a comprehensive approach to the prevention of bloodborne infections among IDUs and their communities.

The findings in this report are subject to at least three limitations. First, the extent of SEP activity in the United States is likely underestimated because 48 (29%) of the SEPs known to NASEN did not complete the survey. Other SEPs might exist but are not known to NASEN. Second, certain SEPs operating within larger organizations were not able to report exact budget information because of difficulties in allocating shared costs across administrative units. Finally, data collected were based on self-reports by program directors and were not verified independently.

Although the number of SEPs in the United States has stabilized, many SEPs are providing a wider range of services than initially offered. On-site medical services are being provided by an increasing number of SEPs. IDUs often encounter problems in accessing health care, and offering these services in SEP locations increases the likelihood that IDUs will receive these services.

References

Cities with more than one SEP: Eureka, Los Angeles, Oakland, and San Francisco, California; Detroit, Michigan; Minneapolis, Minnesota; Albuquerque and Farmington, New Mexico; New York, New York; Burlington, Vermont; Bremerton, Seattle, and Tacoma, Washington; and Madison and Milwaukee, Wisconsin.

^§ States/territories with SEPs: California (22); New Mexico (17); Washington (15); Wisconsin (10); New York (nine); Connecticut (six); Illinois (four); Massachusetts, Michigan, Minnesota, Oregon, and Vermont (three each); Louisiana, Maine, and Texas (two each); and Alaska, Colorado, Georgia, Hawaii, Indiana, Kansas, Missouri, New Jersey, North Carolina, Oklahoma, Pennsylvania, Puerto Rico, and Utah (one each). In addition, DC has one SEP.

^¶ States with SEPs that exchanged >500,000 syringes in 2005: California (four SEPs); Washington (three); Illinois, New Mexico, Oregon, Pennsylvania, and Wisconsin (one each). The largest-volume SEPs were San Francisco AIDS Foundation HIV Prevention Project (2.3 million syringes exchanged per year); Chicago Recovery Alliance, Chicago, Illinois (2.3 million); Street Outreach Services, Seattle, Washington (1.0 million); HIV Education and Prevention Project of Alameda, Oakland, California (0.9 million); Public Health -- Seattle & King County Needle Exchange, Seattle, Washington (0.9 million); Point Defiance AIDS Project, Tacoma, Washington (0.8 million); San Diego Clean Needle Exchange Program, San Diego, California (0.8 million); SANA Needle Exchange Program/HIV Alliance, Eugene, Oregon (0.6 million); Prevention Point Pittsburgh, Pittsburgh, Pennsylvania (0.6 million); Lifepoint, Milwaukee, Wisconsin (0.5 million); Homeless Healthcare, Los Angeles, California (0.5 million); and Project De Sida, Albuquerque, New Mexico (0.5 million).

** State/territorial governments providing public funding: California, Connecticut, Georgia, Hawaii, Illinois, Massachusetts, New Mexico, New York, Oregon, Puerto Rico, Washington, and Wisconsin. County governments providing public funding: Clark, King, Pierce, and Skagit, Washington; Alameda, Humboldt, Los Angeles, and Santa Clara, California; Dane and Eau Claire, Wisconsin; Boulder, Colorado; Cook, Illinois; and Lane and Multnomah, Oregon. City governments providing public funding: Inglewood, Los Angeles, Reseda, and San Francisco, California; Seattle and Vancouver, Washington; Chicago, Illinois; Milwaukee and Madison, Wisconsin; New York, New York; and Bridgeport, Connecticut.

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