Amid an epidemic of opioid abuse in the United States that has contributed to a 150% rise in acute HCV infections in recent years and is blamed for nearly 1 in 10 new HIV infections, there is evidence that people who inject drugs are visiting syringe service programs at a higher rate than they were a decade ago, according to a new report by the CDC.
However, there has not been much of an overall decrease in the percentage of people who admit sharing needles, and large decreases in HIV infections among black and Latino persons who inject drugs are contrasted by a leveling-off among the white community since 2012, the CDC found.
Thomas R. Frieden
Better access to syringe service programs, or SSPs, is needed to limit infections, particularly in white rural areas where such services are rare, top CDC officials said during a teleconference on Tuesday.
The programs save money and lives, but not without controversy, the officials said.
“We understand that when people first hear about syringe exchange programs, they think, ‘Why would we do that? Why would we help people do something that’s harmful and illegal?’ ” CDC Director Thomas R. Frieden, MD, MPH, said during the call. “But what we’ve found over and over is … they help people get on treatment, they prevent the spread of infection and they serve as a link to get people into services that save lives and save money.”
Among people who inject drugs (PWID), SSPs contributed to a 90% decline across all races and ethnicities in AIDS diagnoses since a peak in 1993, but the opioid epidemic is threatening that progress, Frieden said.
“We risk stalling or reversing decades of progress in HIV prevention and the science shows that syringe services programs work,” he said.
According to a CDC Vital Signs report, in 2015, 54% of PWID reported using SSPs at least once in the prior year compared with 36% in 1995. However, only 25% of these people reported receiving all their syringes from sterile sources compared with 22% in 2005. Some 33% said they shared a syringe within the past year — not much different than the 36% who reported sharing them in 2005.
“SSPs recognize that we have to deal with the problems of the world as they are and not as we wish they were,” Frieden said. “We wish drug use were far less common than it is, but in fact it is common and, sadly, it has been increasing.”
There has been success in HIV prevention among black and Latino PWID over the past decade. Among black people, the percentage who reported getting all their syringes from a sterile source increased by 48% between 2005 and 2015, while the percentage who reported sharing syringes declined by 34% over the same period, according to the CDC report. HIV diagnoses among black PWID declined by approximately 60% from 2008 to 2014.
Among Latino PWID, syringe sharing declined 12% from 2005 to 2015 and the number of HIV diagnoses declined by almost half from 2008 to 2014.
In whites, however, the percentage of PWID who shared syringes declined just 45% in 2005 to 43% in 2015, and the percentage who reported receiving all their syringes from sterile sources remained unchanged at 22%. Despite declining by approximately 27% from 2008 to 2014, the rate of HIV diagnoses among white PWID was stable at the tail end of that period, between 2012 and 2014.
“These different diagnosis trends could be due in part to changing risk behaviors by race and ethnicity,” Jonathan Mermin, MD, MPH, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, said during the call.
Less than 1% of federal HIV funding is spent on SSPs, but 15 states have been approved to use federal HIV funds for SSPs, which not only provide patients access to sterile needles and syringes, but also link them with services including HIV and hepatitis testing and treatment, condoms, substance use treatment, and pre-exposure prophylaxis, according to Mermin.
At present, only 17 states and Washington, D.C., have laws explicitly allowing SSPs, the CDC noted.
“The result is an uneven patchwork of access to clean syringes across the country,” Mermin said. “To make further progress against HIV and hepatitis, the CDC encourages states and local communities to evaluate whether these barriers can be removed, identify where additional steps can be taken to expand access to critical services, particularly in many communities that struggle with higher levels of opioid injection.”
Local barriers to such solutions received national attention earlier this year when Indiana Gov. Mike Pence — now the Vice President-elect — approved a temporary needle exchange program in Scott County, Indiana, in the midst of an HIV outbreak associated with injection drug use. Until then, needle exchange programs had been illegal in the state.
According to Frieden, Vital Signs topics are picked months in advance and this one was selected in January, long before Donald Trump was elected president with Pence as his running mate.
“CDC stands ready to work with the administration, to support progress protecting Americans from health threats,” Frieden said.
According to Mermin, the CDC has identified areas that are more susceptible to HIV and hepatitis outbreaks among injection drug users and found that more than half of them were in a core region of Appalachia encompassing parts of Kentucky, Tennessee and West Virginia, highlighting the need for expanded access to SSPs.
“Life while injecting drugs is hard,” he said. “Avoiding HIV and hepatitis shouldn’t be.”– by Gerard Gallagher
Wejnert C, et al. MMWR Morb Mortal Wkly Rep. 2016;doi:10.15585/mmwr.mm6547e1.
Disclosures: Frieden, Mermin and the researchers report no relevant financial disclosures.