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 , New York , Washington , 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).
CDC,HIV/AIDS surveillance report, 1997. Atlanta, Georgia US Department of Health and Human Services, Public Health Service1997;Vol 9
CDC, Syringe exchange programs—United States, 1994-1995. MMWR. 1995;44684- 5691
CDC, Update: Syringe exchange programs—United States, 1996. MMWR. 1997;46565- 8
J A sterile syringe for every drug user injection: how many injections take place annually and how might pharmacists contribute to syringe distribution? J Acquir Immune Defic Syndr Hum Retrovirol.
S126- S132Link to Article
et al. Injection behaviors in HIV seroconversion among IV drug users in Montreal. Geneva, Switzerland Presented at the XII International Conference on AIDS June 28-July 3, 1998(Abstract 23221).
et al. Harm reduction, not harm production: needle exchange does not promote HIV transmission among injection drug users in Vancouver, Canada. Geneva, Switzerland Presented at the XII International Conference on AIDS June 28-July 3, 1998(Abstract 33379).
J Syringe use and re-use: effects of needle exchange programs in three cities. J Acquir Immune Defic Syndr Hum Retrovirol.
S37- S44Link to Article
et al. HIV incidence among injecting drug users in New York City syringe-exchange programs. Lancet.
1996;348987- 91Link to Article
D Drug abuse treatment success among needle exchange participants. Public Health Rep. 1998;113
D Use of sterile syringes and aseptic drug preparation are important components of HIV prevention among injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol.
S1- S5Link to Article