Public Funding of Syringe Exchange in the US: The Challenges of Failures and Successes and the New Heroin Injectors Don Des Jarlais 1, Heidi Bramson 1, Vivian Guardino 1, Kamyar Arasteh 1, Nancy Nugent 1 1 The Baron Edmond de Rothschild Chemical Dependency Institute, Mount Sinai Beth Israel

SYRINGE EXCHANGE IN THE UNITED STATES Public funding of needle and syringe exchange programs (NSP) in the United States has been limited due to a ban on federal funding for NSP that has been in place since1988 The responsibility of implementing and permitting NSP programs fall to the state level, but there is wide variation in NSP availability in each state, with some states having multiple NSP locations and services, while other states do not offer any services Funding for and availability of NSP for drug users is very important in reducing morbidity and mortality while reducing new cases of HIV and other blood-borne infection

OBJECTIVES Assess the current status of needle/syringe exchange (NSP) programs and over the counter (OTC) syringe sales in the United States Examine trends in estimated state level HIV incidence among persons who inject drugs (PWID) Report the number of syringes exchanged Report provisions of other NSP based health services available for PWID Report on the current number of absolute newly reported/diagnosed cases of HIV among PWID

METHODS NSP operations collected from surveys of directors of programs located in the United States as part of the North American Syringe Exchange Network (NASEN) HIV data collected from publicly available surveillance reports from health departments in the United States Estimated number of PWID gathered from estimates from metropolitan statistical areas (MSA) published by Templaski et al* in 2009 (data aggregated to the state level) Trends in annual HIV incidence were calculated by dividing number of newly diagnosed HIV cases by estimated state level PWID population, and classified HIV incidence for each state as high (>2/1000 person years) or low (≤2/1000 person years) *Tempalski B, Lieb S, Cleland CM, Cooper H, Brady JE, Friedman SR. HIV prevalence rates among injection drug users in 96 large US metropolitan areas, Journal of Urban Health. Jan 2009;86(1):

RESULTS OF SURVEY AND DATA AVAILALBLE FOR ANALYSIS Data obtained in 2012 from 142 NSP in the United States Syringes exchanged nationally in 2012: 39.2 million NSP budget allocation: $19.4 million (81% of this budget came from state and local governments) HIV incidence was able to be estimated from 24 states and the District of Columbia 32 states had laws regarding provision of NSP or OTC sales; 26 states had data on state laws and public funding of NSP available

NSP INCREASES BY YEAR IN THE UNITED STATES

STATES WITH EXPLICIT OR IMPLICIT AUTHORIZATION OF NSP OR OVER THE COUNTER (OTC) SYRINGE SALES

PUBLIC FUNDING FOR STATES WITH AND WITHOUT STATE LAWS AUTHORIZING NSP

STATES WITH HIGH LEVEL OF NEWLY REPORTED HIV CASES There were four states that reported more than 140 newly reported cases of HIV in their most recent reporting year: Texas, with 307 cases reported in 2011 Florida, with 195 cases reported in 2012 New York, with 159 cases reported in 2010 Louisiana, with 140 cases reported in 2011

ESTIMATED HIV INCIDENCE TREND GROUP AND PUBLIC FUNDING

HIV INCIDENCE PERCENTAGES FOR FIRST AND LAST YEARS AVAILABLE FOR EACH STATE Categories: LL=Low-Low; HL=High-Low; HH=High-High

DISCUSSION Public funding was strongly associated with trends in HIV incidence at the state level 8 states had continuously low HIV incidence; 5 had public funding for NSP 11 states had trends from high to low HIV incidence, of which 9 had public funding of NSP. 5 states had HIV incidence that remained high while 1 state went from low to high HIV incidence, 0 had public funding

DISCUSSION Public funding was strongly associated with several factors: Numbers of syringes exchanged by programs The number of on-site services provided Whether NSP providing HIV counseling or testing to individuals Estimated HIV incidence remaining low over time and/or reductions in estimated HIV incidence The NSP programs reported considerable funding pressures; 72% reported a lack of resources or an overall lack of funding Although OTC sales contribute to reductions in injecting risk behavior, NSP make a much larger contribution

LIMITATIONS There is a delay in reporting of newly diagnosed HIV cases in each state, and this delay can vary from state to state depending on reporting methods HIV incidence estimates came from aggregate PWID populations from MSA, which would have missed PWID living outside of MSA Other factors outside of NSP and OTC could have influences HIV epidemics among PWID, including density and turnover of injecting networks, types of drugs injected, availability of substance use treatment programs, and sexual transmission of HIV

CONCLUSIONS With the long term band on funding for needle/syringe exchange programs in the United States, funding of these programs has become primarily a state and local government responsibility Continued high HIV incidence is occurring only in those states not providing public funding for needle/syringe exchange programs HIV prevention funding is being reallocated from successful needle/syringe exchange programs as the number of new injectors are increasing

CONCLUSIONS Reducing HIV transmission among PWID involves a two step legal and political process, which includes changing laws regarding needle/syringe access, and providing public funding for NSP There are variations in the complex laws regarding access to sterile injection equipment, and whether NSP and OTC sales are permitted in each state There still exist over 4000 new HIV infections per year among PWID in the United States Increased public funding of NSP especially in states with high numbers of newly identified HIV cases, would be a very important approach towards attaining an “AIDS free generation” in the United States

REFERENCES 1.WHO, UNAIDS. WHO, UNODC, UNAIDS Technical Guide For Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. Geneva: WHO; Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet. Jul ;376(9737): Des Jarlais D, Arasteh K, Mcknight C, et al. Combined HIV Prevention, the New York City Condom Distribution Program, and the Evolution of Safer Sex Behavior Among Persons Who Inject Drugs in New York City. AIDS and Behavior. 2013: Krisberg K. Funding ban repeal a step forward for needle exchange: Support could bolster HIV prevention. The Nation's Health. 2010;40(2): ONDCP. Needle Exchange Programs: Are They Effective? Executive Office of the President, Office of National Drug Control Policy; July NIDA. Drugs and violence: causes, correlates, and consequences. NIDA Research Monograph. 1990;103: Centers for Disease Control and Prevention. First report of AIDS. MMWR. Morbidity and mortality weekly report. 2001;50(21): Gallo RC, Montagnier L. The discovery of HIV as the cause of AIDS. New England Journal of Medicine. 2003;349(24): Normand J, Vlahov D, Moses LE. Preventing HIV Transmission: The Role of Sterile Needles and Bleach: National Academies Press; Hellinger FJ. The lifetime cost of treating a person with HIV. JAMA. 1993;270(4): Tempalski B, Lieb S, Cleland CM, Cooper H, Brady JE, Friedman SR. HIV prevalence rates among injection drug users in 96 large US metropolitan areas, Journal of Urban Health. Jan 2009;86(1):