Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas — United States, 2013

Reducing human immunodeficiency virus (HIV) infection rates in persons who inject drugs (PWID) has been one of the major successes in HIV prevention in the United States. Estimated HIV incidence among PWID declined by approximately 80% during 1990–2006 (1). More recent data indicate that further reductions in HIV incidence are occurring in multiple areas (2). Research results for the effectiveness of risk reduction programs in preventing hepatitis C virus (HCV) infection among PWID (3) have not been as consistent as they have been for HIV; however, a marked decline in the incidence of HCV infection occurred during 1992–2005 in selected U.S. locations when targeted risk reduction efforts for the prevention of HIV were implemented (4). Because syringe service programs (SSPs)* have been one effective component of these risk reduction efforts for PWID (5), and because at least half of PWID are estimated to live outside major urban areas (6), a study was undertaken to characterize the current status of SSPs in the United States and determine whether urban, suburban, and rural SSPs differed. Data from a recent survey of SSPs^† were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services^§ were less available to PWID outside urban settings. Because increases in substance abuse treatment admissions for drug injection have been observed concurrently with increases in reported cases of acute HCV infection in rural and suburban areas (7), state and local jurisdictions could consider extending effective prevention programs, including SSPs, to populations of PWID in rural and suburban areas.

The basic service offered by SSPs allows PWID to exchange used needles and syringes for new, sterile needles and syringes. 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. Many SSPs have become multiservice organizations, providing various health and social services to their participants (8). HIV and HCV testing and linkage to care and treatment for substance use disorders are among the most important of these other services. The availability of new and highly effective curative therapy for HCV infection increases the benefits of integrating testing and linkage to care among the services provided by SSPs.

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 analgesics and transitioned to injecting (9). Much of this drug injection has occurred in suburban and rural areas (6). Outbreaks of HCV infection, and more recently HIV infection, in these nonurban areas have been correlated with these injection patterns and trends (7).

TABLE 1. Program characteristics, by syringe service program location — United States, 2013
Program characteristic	SSP location
	Rural	Suburban	Urban	Missing data*	U.S. total
	No. (%)	No. (%)	No. (%)	No.	No.
Region
Midwest	6 (20)	1 (3)	23 (77)	0	30
Northeast	4 (9)	4 (9)	35 (81)	0	43
Puerto Rico	1 (20)	0 (0)	4 (80)	0	5
South	1 (7)	0 (0)	12 (86)	1	14
West	18 (30)	9 (15)	31 (51)	3	61
Total	30 (20)	14 (9)	105 (69)	4	153
Program size (no. of syringes distributed)
Small (1–9,999)	5 (17)	1 (7)	6 (6)	0	12
Medium (10,000–55,000)	10 (33)	4 (29)	21 (20)	0	35
Large (55,001–499,999)	14 (47)	6 (43)	60 (57)	2	82
Very large (≥500,000)	0 (0)	3 (21)	16 (15)	2	21
None/unknown/missing	1 (3)	0 (0)	2 (2)	0	3
Total	30 (100)	14 (100)	105 (100)	4	153
No. of syringes exchanged
No. of SSPs† reporting no. of syringes	29	14	103	4	150
Median no. of syringes per SSP	55,000	82,681	146,263	1,826,977	121,880
Mean no. of syringes per SSP	91,536	313,555	305,694	1,834,533	305,793
Total no. of syringes	2,654,551	4,389,770	31,486,507	7,338,132	45,868,960
Total SSP funding§
Mean cost per SSP	$26,023	$116,902	$184,738	$501,033	$155,466
Total cost for SSP location	$676,590	$1,636,630	$18,104,328	$1,503,100	$21,920,648
Public funding of SSP (city, county, and state funding)¶
Yes	18 (60)	9 (64)	63 (60)	3	93
No	8 (27)	5 (36)	35 (33)	0	48
Unknown/missing	4 (13)	0 (0)	7 (7)	1	12
Total	30 (100)	14 (100)	105 (100)	4	153
Source: Mount Sinai Beth Israel, New York, NY; North American Syringe Exchange Network. Abbreviation: SSP = syringe service program. * Data on location missing for four SSPs. † Two SSPs did not report the number of syringes distributed, and one SSP reported zero syringes distributed (not operational). § Twelve SSPs did not report total SSP funding. ¶ The use of federal funding for SSP implementation is prohibited.

TABLE 2. Reported client characteristics, by syringe service program location — United States, 2013
Client characteristic	SSP location
	Rural (n = 30)	Suburban (n = 14)	Urban (n = 105)
	Mean % of participants	Mean % of participants	Mean % of participants
Gender
Male	61	67	65
Female	39	32	31
Transgender	0	1	3
Race/Ethnicity
African American	2	7	16
Asian/Pacific Islander	1	1	1
White	80	72	56
Hispanic	11	12	22
Native American	4	5	2
Biracial/Mixed	2	2	2
Other	0	2	1
Types of drugs injected
Heroin by itself	48	69	63
Heroin and cocaine	9	6	21
Heroin mixed with other drug (not cocaine)	12	4	11
Cocaine by itself	10	6	13
Methamphetamine (crystal methamphetamine/ice/crank)	25	18	12
Other opiates (oxycodone)	25	13	15
Steroids	1	1	2
Source: Mount Sinai Beth Israel, New York, NY; North American Syringe Exchange Network. Abbreviation: SSP = syringe service program.

TABLE 3. Selected syringe service program operating characteristics and selected services, by syringe service program location — United States, 2013
Characteristic	SSP location
	Rural (n = 30)	Suburban (n = 14)	Urban (n = 105)
	%	%	%
Operating characteristic
Syringes estimated to be distributed via secondary exchange, peer delivery services, or both	30	28	20
SSPs encouraged secondary exchange	73	79	71
Mobile exchange	23	71	74
Experienced a lack of resources/funding	73	64	63
Experienced problems reaching, recruiting participants, or both	20	36	18
Full-time paid personnel	40	79	77
Former drug users as program personnel	50	86	70
Selected service
HIV counseling and testing	87	71	90
HCV testing	67	79	78
Sexually transmitted diseases screening	40	29	50
HCV referral tracking	33	43	44
Distribution of food	33	29	54
Distribution of naloxone	37	57	61
Referral to methadone, buprenorphine, maintenance or both	70	86	90
Source: Mount Sinai Beth Israel, New York, NY; North American Syringe Exchange Network. Abbreviations: HCV = hepatitis C virus; HIV = human immunodeficiency virus; SSP = syringe service program.

Full article at:  http://goo.gl/7lEkWK

By:  Don C. Des Jarlais, PhD1; Ann Nugent1; Alisa Solberg, MPA2; Jonathan Feelemyer, MS1; Jonathan Mermin, MD3; Deborah Holtzman, PhD4

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