The capacity of rural and suburban syringe service programs is limited compared with those established in urban areas, according to recent MMWR data.
Because of the high population of persons who inject drugs (PWID) outside of major urban areas, expanding the reach of these programs outside of cities could limit the transmission of HIV and HCV.
“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 analgesic and transitioned to injecting,” Don C. Des Jarlais, PhD, director of research for the Edmond de Rothschild Chemical Dependency Institute of Mount Sinai Beth Israel Medical Center, and colleagues wrote. “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.”
Don C. Des Jarlais
Disparities in SSP funding, performance
Des Jarlais and colleagues conducted a mail and telephone survey of syringe service programs (SSPs) operating in the U.S. in 2013. SSP directors were asked to provide their best estimates of client demographics and behaviors, as well as questions concerning their operating characteristics, location and budgets.
Survey responses were collected from 153 SSP directors, accounting for 75% of the 204 U.S. SSPs known to exist in 2014. SSPs were primarily located in the West (n = 61) and Northeast (n = 43), with relatively few operating in the South (n = 14). Twenty percent of all respondents reported operation in rural locations, 69% reported urban locations, and 9% reported suburban locations.
Due to their higher prevalence, the number of syringes exchanged by urban SSPs (31,486,507) was much greater than that reported by suburban (4,389,770) and rural (2,654,551) programs. In addition, rural SSPs exchanged a mean of 91,536 syringes, which was lower than that reported by suburban (mean = 313,555) and urban (mean = 305,694) programs. More than four-fifths of budgeted funds were allocated to urban SSPs, which also had greater average annual budgets.
Men and whites were the most frequent SSP users, although urban programs reported a higher proportion of black and Hispanic participants. A majority of SSPs in all location types reported funding and resource shortages in 2013, but suburban programs were most likely to report participant recruitment difficulties. Most SSPs in all locations encouraged attendees to exchange needles on behalf of peers who did not participate, and all reported similar rates of counseling and testing for HIV and HCV.
“The modest number of rural and suburban SSPs participating in this survey raise concerns that many rural and suburban areas with PWID might not have access to SSPs,” the researchers wrote. “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.”
Experts advocate increased implementation of exchange programs
Calls by Des Jarlais and colleagues to increase SSPs in these underserved region come from a body of academic work highlighting the benefits of needle exchange.
Among the most recent data is an analysis from Monica S. Ruiz, PhD, MPH, assistant research professor in the department of prevention and community health at George Washington University’s Milken Institute School of Public Health, and colleagues that examined the effectiveness of a needle exchange program implemented in Washington, D.C., in 2008. The city had been prohibited from operating these programs due to a Congressional ban on federal funding in 1998.
According to the researchers, there were 176 injection drug use (IDU)-associated HIV infections in the 2 years after the policy change. Had the ban remained in place, 296 IDU-related infections would have occurred during the same time period, they said — a difference of 120 new cases and approximately $44 million in health costs.
“The evidence is abundant: needle exchanges save lives and they save money,” Ruiz told Infectious Disease News.
Similar arguments and government action have come in the wake of IV drug use-related HIV outbreaks. After Indiana Gov. Mike Pence declared a public health disaster emergency in Scott County in late March allowing the temporary provision of needle exchange programs, a commentary published in the New England Journal of Medicine advocated permanent implementation of the Indiana program and others like it.
“Legislation allowing Scott County to operate needle-exchange programs is a step in the right direction,” the experts wrote. “However, the current provision extends for only 1 year, a limit that ignores the reality that three interrelated chronic diseases — addiction, HIV and HCV — will continue to challenge this community and others like it for decades unless a very aggressive, multipronged public health prevention strategy is implemented.”
On Dec. 18, 2015, an omnibus bill approved by Congress lifted the funding ban on needle exchange programs, allowing state and local governments to once again support certain components of these programs with federal funding.
“Outbreaks in Indiana and elsewhere have been powerful reminders that people who inject drugs can be at very high risk for HIV and hepatitis C, and studies have shown that syringe services programs are cost saving, and can reduce the risk of infection without increasing drug use,” Jonathan Mermin, MD, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention, said in a statement following the bill’s passage. “Along with other tools proven to reduce the risk of infection and strategies to prevent and treat substance abuse itself, syringe services programs can be a valuable component of a comprehensive prevention strategy for people who inject drugs and their partners.” – by Dave Muoio
Des Jarlais EC, et al. MMWR Morb Mortal Wkly Rep. 2015; 64:1337-1341.
Ruiz MS, et al. AIDS Behav. 2015;doi:10.1007/s10461-015-1143-6.
Strathdee SA, et al. N Engl J Med. 2015;doi:10.1056/NEJMp1507252.
Disclosure: The researchers report no relevant financial disclosures.