Update on Syringe-Exchange Programs in the United States
As of December 1996, approximately one third (36%) of the 573,000 cases of acquired immunodeficiency syndrome (AIDS) among adults reported to CDC were directly or indirectly associated with injecting-drug use (1). Syringe-exchange programs (SEPs) are one of the strategies for preventing 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 drug injection by providing sterile syringes in exchange for used, potentially contaminated syringes. This report summarizes a survey of U.S. SEPs regarding their activities during 1995 and 1996 and compares the findings with those during 1994 and early 1995 (2). The findings indicate continued expansion in the number and activities of SEPs in the United States.*
In November 1996, 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 101 SEPs in the United States that were members of NASEN. Although the number of SEPs in the United States is unknown, most are believed to be members of NASEN. From November 1996 through April 1997, BIMC contacted SEP directors to conduct structured telephone interviews based on the mailed questionnaires. SEP directors were asked about when the SEP began; the number of syringes** exchanged during 1995; and, for 1996, legal status, services provided, and the number of syringes exchanged.
Of the 101 SEPs, 87 (86%) participated in this survey. Of these, 51 began operating before 1995; 22, in 1995; and 14, in 1996. These 87 SEPs reported operating in 71 cities in 28 states and one territory***; 44 (51%) of the SEPs were located in four states (California , Washington , New York , and Connecticut [six]). In eight cities, at least two SEPs were reported operating. In the 1994-1995 survey, 60 SEPs reported operating in 46 cities and in 21 states (2).
Of the 73 SEPs operating in 1995, 70 reported exchanging approximately 11 million syringes. In 1996, of the 87 SEPs that provided information about the number of syringes exchanged, 84 reported exchanging approximately 14 million syringes (median: 36,017 syringes per SEP) (Table 1). The 10 most active SEPs (i.e., those that exchanged greater than or equal to 500,000 syringes)**** exchanged approximately 9.4 million (69%) of all syringes exchanged. The SEP in San Francisco reported exchanging the largest number of syringes (1,461,096) in 1996. During 1996, a total of 50 SEPs (57%) reported exchanging less than or equal to 55,000 syringes each; of these, 23 (46%) exchanged less than 10,000 syringes each.
All 87 SEPs provided IDUs with information about safer injection techniques and/or use of bleach to disinfect injection equipment. Other services included referral of clients to substance-abuse treatment programs (84 [97%]), instruction in the use of condoms and dental dams to prevent sexual transmission of HIV and other sexually transmitted diseases (STDs) (84 [97%]), and STD-prevention education (70 [81%]). Health services offered on-site included HIV counseling and testing (35 [40%]), primary health care (15 [17%]), tuberculosis (TB) skin testing (23 [26%]), and STD screening (17 [20%]).
TABLE 1. Number and percentage of syringe-exchange programs (SEPs) and number and percentage of new syringes provided by SEPs, by size of program United States, 1996
|SEPs||Total syringes exchanged|
|Size of SEP*||No.||(%)||No.||(%)|
|< 10,000||23||( 27)||64,737||( <1)|
|10,000 - 55,000||27||( 32)||810,247||( 6)|
|55,001 - 499,999||24||( 29)||3,658,060||( 26)|
|> 500,000||10||( 12)||9,407,628||( 68)|
*Based on the number of syringes exchanged in 1996.
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-but-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 1996, a total of 46 (53%) SEPs were legal, 20 (23%) were illegal but tolerated, and 21 (24%) were illegal-underground. Legal SEPs were more likely than illegal ones to offer on-site HIV counseling and testing (29 [63%] of 46 legal versus eight [20%] of 41 illegal) and TB skin testing (19 [41%] of 46 versus three [7%] of 41). The three SEPs that did not refer clients to substance-abuse treatment were illegal-underground programs.
Reported by: D Paone, EdD, D Des Jarlais, PhD, J Clark, Q Shi, MS, Beth Israel Medical Center; M Krim, PhD, American Foundation for AIDS Research, New York. D Purchase, North American Syringe Exchange Network, Tacoma, Washington. Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, CDC.
Editorial Note: Among IDUs, multiperson use of syringes (i.e., "sharing") is the primary mechanism of transmission of HIV, hepatitis B and C, and other bloodborne infections related to injection of illicit drugs (3). Multiperson use occurs when an IDU prepares or injects drugs using a syringe borrowed, rented, and/or lent by another IDU. In addition, equipment and water used to prepare drugs for injection can become contaminated with blood remaining in previously used syringes.
In May 1997, the Public Health Service***** released provisional recommendations for persons who continue to inject drugs (4). These recommendations include advice that drug users who cannot stop injecting drugs use only sterile syringes to prepare and inject drugs and other steps to prevent bloodborne infection transmission. If IDUs adhere to these recommendations, the number of syringes required would be substantially greater than that currently provided through SEPs and other sources. Because of the costs of large-scale expansion of SEPs, these services alone probably could not meet the demand for sterile syringes (5).
The findings in this report indicate an expansion in the number of SEPs and in the scope of activities since 1994 (2). During 1994-1996, there were increases in the number of SEPs participating in the surveys (58% [from 55 to 87]) and in the numbers of cities (52% [from 46 to 71]) and states (38% [from 21 to 29]) with SEPs. Although the number of syringes exchanged increased by 75% (from 8 million to 14 million) from 1994 to 1996, most SEPs exchanged relatively small numbers of syringes, and the 23 least active SEPs exchanged a mean of 2815 syringes per program. If less active SEPs are located in communities with large numbers of IDUs, their impact on the overall availability of sterile syringes will probably be limited.
The findings in this report are subject to at least two limitations. First, the extent of SEP activity is probably underestimated because of incomplete participation in this survey of U.S. SEPs and the possible existence of SEPs that are not members of NASEN. Second, because the definition of legal status did not include the local status of drug paraphernalia laws, legal barriers to SEPs may be underestimated (6).
Existing laws and regulations in many U.S. communities substantially limit the sale of sterile syringes and needles and establish criminal penalties for possession of syringes for persons who inject illicit drugs (6) and may reduce the likelihood that IDUs will be able to obtain sterile syringes from legal sources (e.g., pharmacies). In May 1997, in efforts to prevent HIV transmission among IDUs, the legislatures in Maine and Minnesota removed criminal penalties for possession of less than or equal to 10 syringes to permit the legal operation of SEPs and increase IDUs' use of sterile syringes from legal sources.
Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health 1996;86:655-61.
CDC/Health Resources and Services Administration/National Institute on Drug Abuse/ Substance Abuse and Mental Health Services Administration. HIV prevention bulletin: medical advice for persons who inject illicit drugs. Atlanta: US Department of Health and Human Ser-vices, Public Health Service, 1997.
Gostin LO, Lazzarini Z, Jones TS, Flaherty K. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users: a national survey on the regulation of syringes and needles. JAMA 1997;277:53-62.
* Single copies of this report will be available until June 20, 1998, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023.
** For this report, the term "syringes" refers to both syringes and needles.
*** California (17 SEPs); Washington (11); New York (10); Connecticut (six); Illinois and Michigan (three each); Massachusetts, Puerto Rico, Texas, and Wisconsin (two each); and one each in Colorado, Florida, Indiana, Louisiana, Maryland, Minnesota, Missouri, New Hampshire, New Jersey, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, and Tennessee. Twenty-four SEPs asked that their location not be reported.
**** New York (two); Bridgeport, Connecticut; Chicago; Los Angeles; Oakland, California; Philadelphia; San Francisco; Seattle; and Tacoma, Washington (one each).
***** CDC, the Health Resources and Services Administration, the National Institute on Drug Abuse of the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration.