Syringe Services Programs

STATEMENT OF POLICY

Syringe Services Programs

Policy The National Association of County and City Health Officials (NACCHO) supports a comprehensive, evidence- based approach to syringe services programs, also known as syringe or needle exchange programs, in order to support the health of people who inject drugs and to curb transmission of HIV, viral hepatitis, and other blood- borne diseases. NACCHO urges state and local policy makers to do the following:

• Support syringe services program development and operation in accordance with the peer-reviewed evidence base, best practices, and local health department and other expert recommendations;

• Remove legal barriers to accessing and safely disposing sterile needles, syringes, and other injecting equipment;

• Modify state and local statutes to permit over-the-counter pharmacy sales and purchase of syringes; • Revise paraphernalia laws to decriminalize syringe possession; • Increase the availability of drug treatment and overdose prevention, including Medication-Assisted

Treatment and naloxone training and distribution; • Ensure education of law enforcement, criminal justice personnel, health department staff, healthcare

providers, pharmacists, and other relevant professional and community partners regarding the benefit of syringe services programs, as well as other harm reduction strategies, and relevant laws, policies, and processes; and

• Assure adequate resources to support health department surveillance, program planning, and program evaluation capacity to assess disease and risk behavior trends and the impact of syringe services programs, as well as other disease prevention and health promotion interventions for persons who inject drugs, on local health outcomes.

Furthermore, NACCHO urges Congress to remove the ban on the use of federal funds to support syringe services programs. Justification Injection drug use is a major route of transmission for HIV, viral hepatitis, and other blood-borne pathogens. Over the past 25 years, syringe services programs have proven to be highly effective at reducing HIV transmission among people who inject drugs and are an essential strategy to prevent hepatitis C virus (HCV) infection. In addition to providing sterile syringes and other injecting equipment, many syringe service programs also provide medical and social services, including HIV and viral hepatitis testing, overdose prevention training, referrals to social services and housing, and linkages to medical care, mental health care, and substance use treatment, to individuals who are not often served by traditional healthcare providers.1

2

In the United States, HIV incidence among people who inject drugs declined by approximately 80% from 1988 to 2006 following the adoption of syringe service programs in a number of states.2 Despite that overall decline, people who inject drugs continue to represent a substantial proportion of persons with new HIV diagnoses, accounting for approximately 8% of new HIV infections in 2010 and 15% of those living with HIV in 2011.3 Since the epidemic began, approximately 186,728 people with AIDS who inject drugs have died.4 The sharing of drug injection paraphernalia is the primary risk factor for HCV infection. The rate of reported new hepatitis C infections has risen rapidly nationwide, more than doubling from 2010 to 2013.5 An estimated 3-4 million people in the United States are living with chronic hepatitis C, which is at least 10 times more infectious than HIV. In 2007, the number of U.S. deaths associated with hepatitis C surpassed those from HIV for the first time. After receiving reports of approximately 800-1,000 cases of acute hepatitis C each year from 2006-2010, there was a significant increase of 151.5% in reported cases of acute hepatitis C infection from 2010 to 2013. Based on surveillance data and epidemiologic studies, new cases of HCV are highest among young persons who are white, live in non-urban areas, and have a history of injection drug use.6 The number of cases reported represent only a fraction of the total number of new hepatitis C infections. Additional capacity for surveillance to detect these new infections and additional prevention capacity to link persons to services and medical care that can stop transmission are needed, particularly for states already reporting increases in transmission. A comprehensive public health response that includes expanded syringe access is necessary to reduce the transmission of HCV, HIV, and other blood-borne pathogens. Numerous federally funded studies, including studies conducted by the Centers for Disease Control and Prevention (CDC) and the Institute of Medicine (IOM), have established that syringe exchange is an effective HIV prevention intervention and does not promote drug use.7-10 Rather, studies show that people who inject drugs who participate in syringe services programs are more likely to enroll and complete substance use treatment. A study in Seattle found that new syringe services program participants are five times more likely to enter a drug treatment program than nonparticipants.11 Drug treatment programs, such as Medication-Assisted Treatment for opiate dependence, have been shown to substantially reduce the frequency of drug use, other risk behaviors, and new infections.12 In 2011, the U.S. Surgeon General determined that syringe services programs reduce both drug abuse and the risk of HIV infection.13 Syringe services programs may also provide the overdose reversal medication naloxone. Drug overdose is the leading cause of injury-related death in the United States, killing more people every year than auto accidents. Opioids (both prescription painkillers and heroin) are responsible for most of these deaths. The death rate from prescription opioid-caused overdose nearly quadrupled from 1999 to 2013, while deaths from heroin overdose rose 270% between 2010 and 2013.14Most opioid overdose deaths can be prevented by the timely administration of naloxone. In the event of an overdose, witnesses such as injecting partners, friends and family, and first responders (e.g., law enforcement, Emergency Medical Services) should be trained to administer naloxone and have access to this life-saving medication. Syringe services programs have unique access to people at risk of overdose prevention, making them important points of naloxone distribution and training. In the United States, public funding of syringe services programs has been limited due to a ban on the use of federal funding for syringe service programs, which was first enacted in 1988. In December 2009, the 111th Congress ended the nearly 20 year prohibition of using federal funds to support syringe service programs; however, in December 2011, the 112th Congress reinstated the ban through the Labor, Health and Human Services, and Education Appropriations bill included in the FY2012 Consolidated Appropriations Act (P.L.

3

112-74). As long as the ban on federal funding to support syringe services programs is law, the responsibility of permitting, funding, and implementing such programs falls to the state and local level, which has resulted in a wide variation in syringe services program availability. Additional resources, as well as the removal of the ban on the use of federal funds to support syringe services programs, are needed to fully plan, implement, evaluate, and expand the inclusion of syringe services programs in comprehensive HIV and HCV prevention efforts and to address the health of people who inject drugs. The cost savings of infections averted by syringe services programs are significant. Lifetime treatment of an HIV-positive person is estimated to cost $326,500 on average, whereas a sterile syringe costs less than a dollar.15 An analysis conducted in 2015 calculated that the capacity of existing syringe services programs to provide a new syringe for each injection is estimated to be sufficient to meet only 3% of the need, and that expanding syringe services program coverage to meet even 10% of injections would avert nearly 500 new HIV infections annually.16 Additional savings will be incurred by preventing the transmission of HCV and other blood-borne diseases, as well as supporting the overall health and well-being of people who inject drugs through linkage to substance use treatment, preventive medicine, and other health and supportive services offered by syringe services programs. References 1. Centers for Disease Control and Prevention. (2012). Integrated prevention services for HIV infection, viral hepatitis, sexually

transmitted diseases, and tuberculosis for persons who use drugs illicitly: summary guidance from CDC and the U.S. Department of Health and Human Services. Morbidity and Mortality Weekly Report, 61(No. RR-5). Retrieved June 1, 2015, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm

2. Centers for Disease Control and Prevention. (2015). HIV in the United States: At A Glance. Retrieved June 1, 2015, from http://www.cdc.gov/hiv/pdf/statistics_basics_ataglance_factsheet.pdf

3. Ibid. 4. Ibid. 5. Centers for Disease Control and Prevention. (2015). Increases in hepatitis C virus infection related to injection drug use among

persons aged ≤30 years — Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. Morbidity and Mortality Weekly Report, 64(17). Retrieved June 1, 2015, from http://www.cdc.gov/MMWr/preview/mmwrhtml/mm6417a2.htm

6. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance, United States, 2013. (2013). Retrieved June 1, 2015, from http://www.cdc.gov/hepatitis/statistics/2013surveillance/index.htm

7. National Commission on Acquired Immune Deficiency Syndrome. (1991). The twin epidemics of substance use and HIV. Retrieved June 22, 2015, from http://harmreduction.org/wp-content/uploads/2012/01/NationalCommissiononAIDS1991

8. U.S. General Accounting Office. (1993). Needle exchange programs: research suggests promise as an AIDS prevention strategy. HRD-93-60. Retrieved June 25, 2015, from http://www.gao.gov/products/HRD-93-60

9. Office of Technology Assessment, Congress of the United States. (1995) The effectiveness of AIDS prevention efforts. Retrieved June 22, 2015, from http://ota.fas.org/reports/9556.pdf

10. National Research Council and Institute of Medicine. (1995). Preventing HIV transmission: the role of sterile needles and bleach. Retrieved June 22, 2015, from http://www.nap.edu/catalog/4975/preventing-hiv-transmission-the-role-of-sterile-needles-and- bleach

11. Hagan, H., McGough, J.P., Thiede, H., Hopkins, S., Duchin, J., & Alexander, E.R. (2000). Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment, 19, 247–252.

12. Metzger, D.S., Woody, G.E., & O’Brien, C.P. (2010). Drug treatment as HIV prevention: a research update. Journal of Acquired Immune Deficiency Syndrome, 55(Suppl 1), S32-6.

13. Health and Human Services Department. (2011). Determination that a demonstration needle exchange program would be effective in reducing drug abuse and the risk of acquired immune deficiency syndrome infection among intravenous drug users (Federal Register Notice). Retrieved June 1, 2015, from https://www.federalregister.gov/articles/2011/02/23/2011- 3990/determination-that-a-demonstration-needle-exchange-program-would-be-effective-in-reducing-drug-abuse

14. Davis, C. (2015). Naloxone for community opioid overdose reversal. Public Health Law Research. Retrieved June 25, 2015, http://phlr.org/product/naloxone-community-opioid-overdose-reversal

4

15. amfAR, The Foundation for AIDS Research. (2015). Preventing HIV and Hepatitis C Among People Who Inject Drugs: Public Funding for Syringe Services Programs Makes the Difference. Retrieved June 25, 2015, from http://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/BIMC_SSP_IB-WEB-VERSION_041315.pdf

16. Nguyen, T.Q., Weir, B.W., Pinkerton, S.D., Des Jarlais, D.C., & Holtgrave, D. (2012, July). Increasing investment in syringe exchange is cost-saving HIV prevention: modeling hypothetical syringe coverage levels in the United States. Presented at the 19th International AIDS Conference, Washington, D.C.: Abstract no. MOAE0204. Retrieved June 25, 2015, from https://www.aids2014.org/Abstracts/A200746842.aspx

Record of Action Proposed by NACCHO HIV/STI Prevention Workgroup Approved by NACCHO Board of Directors December 11, 2005 Updated July 2010 Updated June 2015