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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!