Update: Syringe Exchange Programs—United States, 1997 FREE

MMWR. 1998;47:652-655

1 table omitted

AS OF DECEMBER 1997, more than one third (36%) of the 641,086 cases of acquired immunodeficiency syndrome (AIDS) reported to CDC were directly or indirectly associated with injecting-drug use.¹ Syringe exchange programs (SEPs) are one of the strategies employed to prevent infection with human immunodeficiency virus (HIV) among injecting-drug users (IDUs). The goal of SEPs is to reduce the transmission of HIV and other bloodborne infections associated with reuse of blood-contaminated syringes* for drug injection by providing sterile syringes in exchange for used, potentially contaminated syringes. This report summarizes a survey of U.S. SEP activities during January-December 1997 and compares the findings with those of two previous surveys during 1994-1995 and 1996.^2- 3 The findings indicate continued expansion in the number, geographic coverage, and activity of SEPs in the United States.†

In November 1997, the Beth Israel Medical Center (BIMC) in New York City, in collaboration with the North American Syringe Exchange Network (NASEN), mailed questionnaires to the directors of 113 SEPs in the United States that were members of NASEN. From December 1997 through March 1998, BIMC contacted SEP directors to conduct structured telephone interviews based on the mailed questionnaires. SEP directors were asked about their program's legal status, number of syringes exchanged during 1997, program operations, services provided, budgets, and community and law enforcement relations.

Of the 113 SEPs, 100 (89%) participated in the survey. Of these, 54 began operating before 1995; 20, in 1995; 18, in 1996; and eight, in 1997. One SEP closed in 1997. These 100 SEPs reported operating in 80 cities in 30 states, the District of Columbia, and Puerto Rico‡; 52 (52%) of the SEPs were located in four states (California [19], New York [14], Washington [11], and Connecticut [eight]). Nine cities had at least two SEPs§ (31 SEPs in the nine cities). In the 1996 survey, 87 SEPs reported operating in 71 cities in 26 states, the District of Columbia, and Puerto Rico and during 1994-1995, a total of 60 SEPs reported operating in 46 cities and in 21 states.^2- 3

In 1997, a total of 96 of the 100 SEPs provided information about the number of syringes and reported exchanging approximately 17.5 million syringes (median: 57,343 syringes per SEP). The 10 largest volume SEPs (i.e., those that exchanged ≥500,000 syringes) exchanged approximately 10.3 million (59%) of all syringes exchanged.∥ The SEP in San Francisco reported exchanging the largest number of syringes (1.9 million) in 1997. During 1996, a total of 84 SEPs reported exchanging approximately 14 million syringes (median: 36,017) and in 1994, a total of 55 SEPs exchanged 8 million syringes (median: 39,014).

Most of the 100 SEPs provided other public health and social services: 99% offered instruction in the use of condoms and dental dams to prevent sexual transmission of HIV and other sexually transmitted diseases (STDs); 96% provided IDUs with information about safer injection techniques and/or use of bleach to disinfect injection equipment; and 94% referred clients for substance abuse treatment programs. Health-care services offered on site included HIV counseling and testing (64%), tuberculosis skin testing (20%), STD screening (20%), and primary health care (19%).

In this survey, SEPs were defined as legal if they operated in a state that had no law requiring a prescription to purchase a hypodermic syringe (i.e., a prescription law) or had an exemption to the state prescription law allowing the SEP to operate; illegal-tolerated if they operated in a state with a prescription law but had received a formal vote of support or approval from a local elected body (e.g., city council); and illegal-underground if the SEP operated in a state with a prescription law but had not received formal support from local elected officials. In 1997, a total of 52 SEPs were legal, 16 were illegal-tolerated, and 32 were illegal-underground.

SEPs reported receiving financial support from various sources including foundations, individuals, and state and local governments. Current federal law prohibits the use of federal funds to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drug.

The 100 SEPs operated in various settings, including home visits (37%) (syringe pick-up/drop-off sites), storefront locations (35%), vans (35%), sidewalk tables (23%), on-foot outreach (23%), cars (19%), locations where IDUs gather to inject drugs (i.e., shooting galleries) (17%), and health clinics (11%). Sixty-nine (69%) SEPs operated in multiple settings. Ninety-five SEPs reported data on the hours of program operation each week; they reported providing 2078.5 hours (median: 18 hours; range: 1-112 hours) of SEP services each week.

D Paone, EdD, DC Des Jarlais, PhD, MP Singh, MPH, D Grove, Q Shi, PhD, Beth Israel Medical Center, New York; M Krim, PhD, American Foundation for AIDS Research, New York, New York. D Purchase, North American Syringe Exchange Network, Tacoma, Washington. RH Needle, PhD, P Hartsock, PhD, Community Research Br, Div of Epidemiology and Prevention, National Institute on Drug Abuse, National Institutes of Health. Div of HIV/AIDS Prevention-Intervention, Research, and Support, National Center for HIV, STD, and TB Prevention, CDC.

The findings in this survey indicate continued growth in the number, geographic coverage, and activity of SEPs in the United States. From 1994-1995 to 1997, there were increases in the number of SEPs participating in these surveys (67% [from 60 to 100]), the number of cities with SEPs (74% [from 46 to 80]), and the number of syringes exchanged (119% [from 8 million to 17.5 million]). However, the scope of SEP activity may be underestimated because some of the known SEPs in the United States did not participate in this survey and some may not be members of NASEN.

The 10 largest volume SEPs are responsible for approximately half of all syringes exchanged in 1997, and the 24 smallest volume SEPs (i.e., those that exchanged <10,000 syringes) reported exchanging only <1% of total syringes (mean: 3431.5 syringes per program). An IDU makes approximately 1000 illicit drug injections per year.⁴ Larger volume SEPs could have greater community impact in allowing IDUs to use a sterile syringe for every injection.

Many IDUs who participate in SEPs are high-risk drug users, suggesting that SEPs can reach persons at risk for bloodborne infections (including HIV and hepatitis C) and other public health problems.^5- 6 IDUs who participate in SEPs increase the proportion of drug injections in which a syringe is used only once, thereby reducing the reuse of potentially contaminated syringes.⁷ In addition, IDUs using syringes obtained from SEPs have lower rates of HIV incidence (compared to IDUs using syringes obtained from the illicit market).⁸ Compared with clients referred to substance abuse treatment programs from other sources, IDUs referred by SEPs have comparably good short-term treatment outcomes.⁹

SEPs are one component of a community's comprehensive approach currently used to prevent HIV infection among IDUs, their sexual partners, and their children. Access to sterile syringes for drug users who continue to inject also can be provided through the sale of syringes in pharmacies. In addition to SEPs, comprehensive programs for reducing the spread of HIV and other bloodborne infections should include community outreach programs, substance abuse treatment programs, HIV-prevention programs in jails and prisons, prevention of initiation of drug injection, health care for HIV-infected IDUs, and HIV risk-reduction counseling and testing for IDUs and their sexual partners.¹⁰

*For this report, the term "syringes" refers to both syringes and needles.

†Single copies of this report will be available until August 14, 1999, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 519-0459.

‡California (19 SEPs); New York(14); Washington (11);Connecticut (eight); Massachusetts (five); New Jersey, Oregon, and Puerto Rico (three each); Arizona, Colorado, Illinois, Michigan, Minnesota, Ohio, Pennsylvania, Texas, and Wisconsin (two each); and one each in Alaska, District of Columbia, Florida, Georgia, Hawaii, Indiana, Kansas, Louisiana, Maryland, Missouri, Montana, New Hampshire, North Carolina, Rhode Island, and Tennessee. Staff of one SEP asked its location not be reported.

§The following cities have multiple SEPs: New York (12); Los Angeles, Portland, and Seattle (three each); and Boston, Cleveland, Minneapolis, New Haven, and Sacramento (two each).

∥States with the 10 largest volume SEPs were: California (three SEPs); New York and Washington (two each); and one each in Illinois, Maryland, and Pennsylvania. The largest volume SEPs were San Francisco AIDS Foundation, California (1.9 million syringes exchanged); Chicago Recovery Alliance, Illinois (1.6 million); Clean Needles Now, Los Angeles, California (1.0 million); Point Defiance AIDS Project, Tacoma, Washington (1.0 million); Seattle-King County Department of Public Health Needle Exchange Program (NEP), Seattle, Washington (0.9 million); Alameda County SEP, Oakland, California (0.8 million); Prevention Point, Philadelphia, Pennsylvania (0.8 million); Baltimore City NEP, Maryland (0.8 million); Lower East Side NEP, Manhattan, New York (0.8 million); and New York Harm Reduction Educators, Bronx, New York (0.7 million).

MMWR. 1998;47:493-497

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SYPHILIS is an acute and chronic sexually transmitted disease (STD) caused by infection with Treponema pallidum. The disease is characterized by skin and mucous membrane lesions in the acute phase (primary and secondary [P&S] syphilis) and lesions of the bone, viscera, and cardiovascular and neurologic systems in the chronic phase. Because syphilis enhances transmission of human immunodeficiency virus (HIV), prevention of syphilis is important for controlling HIV.¹ During 1986-1990, an epidemic of syphilis occurred throughout the United States.² Syphilis rates began to decline in 1991 and have declined each year since that time. To determine whether this decline is reflected in changes in the epidemiology of syphilis, CDC analyzed notifiable disease surveillance data for 1997. This report summarizes the findings of the analysis, which indicate that 8551 cases of primary and secondary (P&S) syphilis were reported in 1997, an 83% decline in cases from the peak of the epidemic in 1990, and that syphilis remains substantially more common in non-Hispanic blacks than in other racial/ethnic groups and continues to be concentrated in the Southern region of the United States.

Summary data for syphilis cases reported to state health departments for 1997 were sent quarterly and annually to CDC. Data from states included the total number of syphilis cases by county, sex, stage of disease, racial/ethnic group, and 5-year age group. Data on reported cases of syphilis in the P&S stages were analyzed for this report because those cases best represent incident cases (i.e., newly acquired infections within the evaluated time period). P&S syphilis rates were calculated per 100,000 persons using population denominators from the Bureau of Census.²

In 1997, the incidence of P&S syphilis in the United States was 3.2 per 100,000 population. Rates of P&S syphilis were higher in the South (6.6 per 100,000 population) than in the Midwest (2.0), Northeast (1.1), and West (1.0).* The South is the only region that has not achieved the revised national health objective for 2000 (HP2000) of four cases per 100,000 population (objective 19.3).² In 1997, a total of 41 (82%) states had P&S syphilis rates below the HP2000 objective, and 21 states (42%) reported 10 or fewer cases of P&S syphilis. Montana, New Hampshire, North Dakota, Vermont, and Wyoming reported zero cases of P&S syphilis. No cases of P&S syphilis were reported in 1997 from 2324 (75%) of 3115 counties. Rates of P&S syphilis were below the HP2000 objective in 2698 (86%) counties. A total of 31 (1.0%) counties accounted for 50% of P&S syphilis cases, and 186 (6%) counties accounted for 85% of all reported P&S syphilis cases.

P&S syphilis rates for blacks remained substantially higher than those for non-Hispanic whites and Hispanics. In 1997, the P&S syphilis rate for blacks was 22.0 per 100,000, compared with 1.6 for Hispanics and 0.5 for non-Hispanic whites. The overall male-to-female P&S syphilis rate ratio was 1.2; this rate ratio was higher for Hispanics (2.1) than for blacks (1.3) and non-Hispanic whites (1.2). P&S syphilis rates were highest for Hispanic women aged 15-19 years (2.7), for black women aged 20-24 years (47.9), and for non-Hispanic white women aged 25-39 years (1.2). P&S syphilis rates were highest for Hispanic men aged 25-29 years (5.5) and for black and non-Hispanic white men aged 35-39 years (50.6 and 1.2, respectively).

From 1990 to 1997, P&S syphilis rates declined 84% in the United States, in all regions (95% in the Northeast, 91% in the West, 80% in the South, and 73% in the Midwest), and in all but two states (Indiana and Kentucky). Rates in Indiana and Kentucky peaked in 1993 and have declined steadily since that time. Rates of P&S syphilis were below the revised HP2000 objective in 86% of all counties in 1997, compared with 69% in 1990.

P&S syphilis rates have declined for all racial/ethnic groups; the largest decline occurred among Hispanics (90%) followed by blacks (85%) and non-Hispanic whites (81%). The P&S syphilis male-to-female rate ratio has remained stable for all races.

Div of Sexually Transmitted Diseases Prevention, National Center for HIV, STD, and TB Prevention, CDC.

The findings in this report document substantial progress in the control and prevention of infectious syphilis in the United States. P&S syphilis is at its lowest level since reporting began in 1941. Although syphilis remains an endemic disease in parts of the South, rates in this region have declined 80% since 1990. The South has had the highest syphilis rates since the 1940s, in part because of limited access to health care in many parts of the South. Despite substantial declines in P&S syphilis in all racial/ethnic groups, syphilis continues to disproportionately affect blacks. Reporting of syphilis has presumably been biased toward over-reporting of infections in persons of minority races/ethnicities who attend public STD clinics; the degree to which this bias influences disease rates across racial/ethnic groups is unknown. Reasons for these reported racial disparities require further investigation.

At least four factors may have contributed to the recent decline in syphilis. First, after recognition of the epidemic in the mid-1980s, increased state and federal resources were invested in syphilis control programs.³ These resources were used for both traditional (e.g., partner notification and clinical services) and nontraditional (e.g., community-based screening and outreach and risk-reduction counseling) activities.³ Second, since the mid-1980s, a variety of HIV prevention activities have been implemented throughout the United States. Although these activities probably contributed to declines in all STDs, it is unknown how these activities contributed to the prevention of specific bacterial STDs. Third, a decline in crack cocaine use⁴ may have resulted in a decline in the incidence of syphilis. Use of crack cocaine and exchange of sex for drugs were major contributors to the recent syphilis epidemic.⁵ Finally, the presence of acquired immunity in the population at risk following the epidemic may have contributed to the decline.^6- 7

A concerted effort while rates are low and disease is focal could contribute to the possible elimination of domestic transmission of syphilis in the United States.⁸ In 1996, the Council of State and Territorial Epidemiologists proposed that syphilis surveillance systems be evaluated and strengthened, that treatment and prevention efforts be enhanced in areas of substantial ongoing transmission, that a national workgroup be convened to evaluate the possibility of elimination of domestic syphilis transmission, and that ongoing support for syphilis control be maintained or enhanced until domestic syphilis is eliminated. A recent Institute of Medicine report on STDs in the United States suggests that STD surveillance systems use new information technology, be accurate and timely enough to identify national and local trends in STD incidence, and provide the data necessary to direct local activities.⁹ CDC is working toward improving syphilis surveillance on a national level by encouraging state and local health departments to discontinue aggregate syphilis reporting and to collect, analyze, take action on, and report line-listed case reports of syphilis electronically to CDC. These line-listed data will provide an opportunity to analyze case reports at the county level by a variety of demographic characteristics and other potential risk factors for STD.

Syphilis is increasingly manifested as an epidemic rather than an endemic disease in the United States; focal outbreaks are still occurring.⁵ Optimal combinations of several different prevention and control strategies may be useful for areas with different levels of morbidity (i.e., to prevent importation into those areas without disease and to intensify detection and control in those areas with substantial morbidity). Several state and local health departments have developed enhanced syphilis control and elimination plans (e.g., California, Florida, Massachusetts, and San Diego County). Components of such a plan could include an evaluation and enhancement of the surveillance system, a review of the epidemiology of syphilis in the local area and development of targeted interventions if applicable, and enhancement of screening for syphilis in high-risk populations (e.g., correctional and drug-treatment facilities and emergency departments).

*Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.