1. Current State of Syringe Exchange in the Known Universe Don C. Des Jarlais, Vivian Guardino, Kamyar Arasteh, Courtney McKnight, Judith Milliken and David Purchase This work was funded by amfAR, The Foundation for AIDS Research, with support from the Elton John AIDS Foundation and the Irene Diamond Foundation-Tides Foundation. NASEC 2010, Austin, TX November 17, 2010

2. Three Eras of Syringe Exchange in the US Homeric age: heroes, demigods, villains and wars The Greek city-state era and the ideal of the rational The Roman empire era: central administration and resources

3. Homeric Age: mid to late 1980s Heroes, demigods, villains and wars Activist initiated exchanges Some support from local and state governments Intense opposition from some political/community leaders Court cases “Public health necessity”

4. Homeric Age Strom Thurmond Catch 22 on federal funding International and US research and practical experience indicating programs effective

5. Greek City-state Era. The ideal of the rational: mid 1990s to mid 2000s Growth of SEPs in many different areas, but without national plan Programs evolved with minimum bureaucratic regulation, maximum input from front line staff and participants Occasional compromises with receipt of state/local funding, often “workarounds”

6. Characteristics of SEP’s Participating in BIMC/NASEN Surveys United States, 1994-2009 Numbers of 1994-9519961997199820002002200420052006200720082009 SEPs known to NASEN 68101113131154148174166188186184201 SEPs Participating in survey (%) 60 (88%) 87 (86% 100 (88% 110 (84%) 127 (82%) 126 (85% 109 (63%) 118 (71%) 150 (80%) 131 (70%) 123 (67%) 149 (74%) Cities with SEP’s participating 446978779897889011310098115 States with SEP’s participating * 212933 3632 2932313033 Syringes exchanged (millions) 8.013.917.519.422.624.924.022.527.629.529.133.1 Total of SEP budgets ($, millions) 6.37.38.48.612.013.011.614.517.419.621.321.6 Total of SEP budgets in 2009-adjusted $ (millions) 10.611.412.712.616.516.313.316.018.419.920.921.6 Public funding as % of total SEP budgets 62% 67%69%74%67%76%74%79%73%79%80% * This category includes the District of Columbia and/or Puerto Rico.

7. National Survey of Syringe Exchange Programs Methodology 2008 Survey 184 SEPs contacted in first quarter 2009 123 SEPs (67%) submitted completed surveys by early summer. 2009 Survey 201 SEPs contacted in first quarter 2010 149 SEPs (74%) submitted completed surveys by early summer.

8. SEP Budget Dollars 20082009 Total $$$$21,307,337$21,686,788 City Gov $ $5,041,332 $5,381,142 County Gov $ $2,402,678 $2,261,688 State Gov $ $9,417,053 $9,768,293 Foundation $ $3,440,558 $3,233,266 Individual Donations $458,685 $536,333 Out-of-pocket $ $57,911 $41,959 NASEN $ $ 65,170 $45,609 CBO Donation $ $19,000 $2,059 Corporate Donation $ $85,832 $38,084 Other $ $319,118 $378,355

9. Budget Status 2009 vs. 2008 n = 149

10. SEPs That Participated in 2008 & 2009 Surveys Total Budget $$ 2008 $19,427,228 (as reported by 103 SEPs) 2009 $18,001,377 (as reported by 100 SEPs)

11. Types of Areas SEPs Are Located in United States, 2009 n = 149

12. Gender Distribution Frequency of SEP Participants in 2009 <25%<50%<75%75% or more Didn’t Answer Male 2 (1.34%) 12 (8.05%) 113 (75.84%) 21 (14.09%) 1 (0.67%) Female 22 (14.77) 112 (75.17%) 13 (8.72%) 1 (0.67%) 1 (0.67%) Transgender 145 (97.32%) 1 (0.67%) 1 (0.67%) 1 (0.67%) 1 (0.67%)

13. Ethnic Distribution Frequency of SEP Participants in 2009 <25%<50%<75%75% or more Didn’t Answer African American 103 (69.13%) 28 (18.79%) 5 (3.36%) 10 (6.71%) 3 (2.01%) Asian Pacific Islander 144 (96.64) 1 (0.67%) 01 (0.67%) 3 (2.01%) Caucasian 25 (16.78%) 22 (14.77%) 47 (31.54%) 52 (34.90%) 3 (2.01%) Latino/a 114 (76.51%) 21 (14.09%) 6 (4.03%) 4 (2.68%) 4 (2.68%) Native American 145 (97.32%) 1 (0.67%) 003 (2.01%)

14. % of Injected Substances and Substance Combinations < 25%< 50%< 75%> 75% ‘08‘09‘08‘09‘08‘09‘08‘09 Heroin by itself 14%12%30%27%30%28%26%32% Heroin & Cocaine 75%77%16%15%6%4%2%1% Heroin mixed with another drug (not cocaine) 93%89%3% --3% Cocaine by itself (including Crack) 82%77%15%17%2%3%1% Cocaine mixed with another drug (not heroin) 96%94%--2%1% 2%1% Methamphetamine (crystal meth/ice/crank) 63%68%24%22%8%7%4%1% Other Amphetamines (uppers/Dexedrine) 98%94%--3%--1% -- Other Opiates (OxyContin, Percodan, Vicodin, etc.) 80%75%13%16%2%4%3% Steroids 97%96%-- 1%2%-- HIV meds and/or insulin 96%97%1% -- 2%-- Downers (benzodiazepines, tranquilizers) 96%91%1%4%2%1% Silicone 98%96%-- 1% -- Any other substances 97%95%-- 1%

15. Type of Heroin Used in 2009 As Reported by SEPs

16. Type of Exchange Conducted by SEPs in 2009 VariationNo. (%) Allowed receipt of more syringes than brought in 126 (84.56%) Used Start-up Packs91 (61.07%) Used A Minimum48 (32.21%) Used A Distribution Model 83 (55.70%) Had a Limit on Syringes Exchanged 34 (22.82%)

17. Weekly Exchange Hours @ Regular, Scheduled Times & Places 2008 Total of 3,625 hours per week averaging 29.47 hours per SEP (n = 123) 2009 Total of 4,063 hours per week averaging 27.83 hours per SEP (n = 146)

18. Number of Syringes Distributed by Syringe Exchange Programs (SEPs), by Program Size: 2008 & 2009 SEP Size (Syringes Distributed) No. of SEPs 2008 Total syringes exchanged 2008 No. of SEPs 2009 Total syringes exchanged 2009 Small (< 10,000) 2067,593 (0.2%) 2594,611 (0.3%) Medium (10,000-55,000) 33982,317 (3.4%) 391,129,493 (3.4%) Large (55,001-499,999) 549,894,182 (34.1%) 7013,011,703 (39.3%) Very Large (  500,000) 1518,113,914 (62.3%) 1418,879,383 (57.0%) Total122*29,058,006148*33,115,190 * In 2008 & 2009 one program responding to the survey did not track the number of syringes exchanged.

19. Returned/Collected Syringes

20. Disposal Methods of Collected Used Syringes in 2009

21. Syringes Exchanged By 106 Programs That Participated in Both 2008 & 2009 Surveys 2008 (n = 106) 26,834,186 syringes distributed 24,409,879 syringes collected 2009 (n = 105) 29,257,618 syringes distributed 27,731,430 syringes collected

22. SEP Usage of Unique Identifiers for Tracking Individuals in 2009

23. Secondary (Satellite) Exchange & Methods of Encouragement Used by SEPs in 2009 Secondary ExchangeNo. (%) SEPs allowing secondary exchange135 (90.60%) SEPs encouraging secondary exchange119 (79.87%) Methods of Encouragement Talked about it108 (72.48%) Had no limit on syringes exchanged 96 (64.43%) Gave extra supplies110 (73.83%) Provided sharps containers103 (69.13%) Enrolled people receiving syringes from secondary exchange 34 (22.82%) Peer education 79 (53.02%) Gift certificates/Other incentives 20 (13.42%)

24. Risk Reduction Education Provided by SEPs in 2008 & 2009 2008 No. (%) 2009 No. (%) Condom Use 120 (97.56%) 146 (97.99%) Hepatitis (A,B,C) Prevention 119 (96.75%) 142 (95.30%) OD Prevention with Narcan 62 (50.41%) 76 (51.01%) OD Prevention without Narcan 59 (47.97%) 78 (52.35%) Safer Crack Use 65 (52.85%) 81 (54.36%) STD and HIV Prevention (other than condom use) 118 (95.93%) 138 (92.62%) Dental Dam/Female Condom Use 91 (73.98%) 105 (70.47%) Use of Bleach 85 (69.11%) 97 (65.10%) Safer Injection Techniques 116 (94.31%) 140 (93.96%) Abscess/Wound and/or Vein Care 113 (91.87%) 134 (89.93%)

25. Weekly On-Site Medical Services 2008 47 SEPs reported providing on-site medical care totaling 1,516 hours per week 2009 46 SEPs reported providing on-site medical care totaling 1,360 hours per week

26. Supplies Provided by SEPs 2008 No. (%) 2009 No. (%) Containers for carrying syringes 102 (83%)135 (91%) Cookers119 (97%)144 (97%) Crack Kits 47 (38%) 61 (41%) Cotton120 (98%)146 (98%) Alcohol Pads123 (100%)148 (99%) Bleach69 (56%)83 (56%)

27. Supplies Provided by SEPs 2008 No. (%) 2009 No. (%) Water bottles94 (76%)116 (78%) Ties111 (90%)135 (91%) Antibiotic Ointment 97 (79%) 117 (79%) Wound Kits 63 (51%)86 (58%) Band-aids105 (85%)124 (83%) Suboxone11 (9%)10 (7%) Buprenorphine7 (6%)10 (7%) Narcan54 (44%)66(44%)

28. Supplies Provided by SEPs 2008 No. (%) 2009 No. (%) Condoms121 (98%)148 (99%) Female Condoms97 (79%)129 (87%) Dental Dams 88 (72%) 99 (66%) Lubricant112 (91%)143 (96%)

29. Supplies Provided by SEPs 2008 No. (%) 2009 No. (%) Hygiene Items104 (85%)124 (83%) Clothes79 (64%)88 (59%) Food84 (68%)103 (69%) Gift Certificates / Vouchers / Travel 46 (37%) 54 (36%) Other 24 (20%) 28 (19%)

30. Selected On-Site Services Provided by SEPs 2008 No. (%) 2009 No. (%) HIV Counseling & Testing 107 (87%)129 (87%) Hepatitis C Counseling & Testing 80 (65%)93 (62%) Hepatitis B Counseling & Testing 30 (24%) 29 (19%) Hepatitis A Counseling & Testing 22 (18%)22 (15%) Hepatitis B Vaccination60 (49%)57 (38%) Hepatitis A Vaccination58 (47%)56 (38%)

31. Selected On-Site Services Provided by SEPs 2008 No. (%) 2009 No. (%) STD Screening67 (55%)69 (46%) Tuberculosis Screening 38 (31%)38 (26%) Substance Abuse Treatment Referrals 110 (89%) 128 (86%)

32. Additional Program Characteristics 2008 No. (%) 2009 No. (%) Did not operate for two months or more 2 (1.63%)13 (8.72%) Any full-time (paid) staff 86 (69.92%) 97 (65.10%) Operated by city, county or state health department 35 (28.46%) 35 (23.49%) 501-C3 Status 96 (78.05%) 117 (78.52%)

33. Additional Program Characteristics 2008 No. %) 2009 No. (%) Operated a Delivery Service 51 (41.46%)78 (52.35%) Had Referral Tracking System 65 (52.85%) 68 (45.64%) Was involved in formal external evaluation 24 (19.51%)28 (18.79%)

34. Problems SEPs Encountered in 2008 & 2009 Problems2008 No. (%)2009 No. (%) Operations disrupted by government or law enforcement official 20 (16.26%) 18 (12.08%) Lack of resources/Lack of funding83 (67.48%)103 (69.13%) Staff shortage63 (51.22%) 77 (51.68%) Staff burnout38 (30.89%) 44 (29.53%) Lack of political support21 (17.07%) 29 (19.46%) Lack of community support25 (20.33%) 28 (18.79%) Lack of outreach28 (22.76%) 31 (20.81%) Legal status 9 (7.32%) 12 (8.05%) Police harassment of participants (at/near site) 27 (21.95%) 30 (20.13%) Police harassment of staff / program10 (8.13%) 8 (5.37%) Reaching or recruiting participants 31 (25.20%) 38 (25.50%) Retaining participants12 (9.76%) 20 (13.42%) Any type of problem due to gentrification? 15 (12.20%) 15 (10.07%) Other 18 (14.63%) 15 (10.07%)

35. Quality of Relationship Between SEPs and Police as Reported by SEPs in 2008 & 2009 Quality of Relationship 2008 No. (%) 2009 No. (%) Very Good 24 ( 19.51%) 33 (22.15%) Somewhat good 37 (30.08%) 45 (30.20%) Neutral 45 ( 36.59%) 45 (30.20%) Somewhat poor 5 (4.07%) 7 (4.70%) Very poor 2 (1.63%) 4 (2.68%) Non-existent 10 (8.13%) 12 (8.05%)

36. Quality of Relationship Between SEPs and Local Health Officials in 2008 & 2009 Quality of Relationship 2008 No. (%) 2009 No. (%) Very Good 71 ( 57.72%) 103 (69.13%) Somewhat good 32 (26.02%) 28 (18.79%) Neutral 11 ( 8.94%) 8 (5.37%) Somewhat poor 1 (0.81%) 2 (1.34%) Very poor 2 (1.63%) 2 (1.34%) Non-existent 6 (4.88%) 4 (2.68%)

37. Strategies SEPs Used in 2009 to Gain Law Enforcement Support Strategy# of SEP’s% None3422.81% Meetings7248.32% Trainings4429.53% Invitation to exchange2315.43% Street demonstrations 64.02% Coalition work w/other public health activists 3926.17% Officer Liasons3523.48% Didn’t have capacity/resources for strategy1711.40% Other1610.73%

38. Any favorable or unfavorable media attention in 2009 –YES 42 programs (28.19%) –NO 106 programs (71.14%)

39. The Roman Empire Era: 2010 onward Need for a national plan Need for national resources Will rationality and best practices be retained?

40. Federal Funding SEPs …YesNoDon’t Know Didn’t Answer Believe Eligible 65 (43.62%) 16 (10.74%) 68 (45.64%) 0 Have or expect to apply 73 (48.99%) 28 (18.79%) 47 (31.54%) 1 (0.67%) Expect to receive funds 34 (22.82%) 15 (10.07%) 78 (52.35%) 22 (14.77%)

41. If Federal Funding Received Programs Anticipate … Maintaining Present Services Expanding Present Services Adding New Services Don’t Know Didn’t Answer 27 (18.12%) 58 (38.93%) 23 (15.44%) 10 (6.71%) 31 (20.81%)

42. Three Eras of Syringe Exchange in the US Homeric age: heroes, demigods, villains and wars The Greek city-state era and the ideal of the rational The Roman empire era: central administration and resources

43. Other Parts of Known Universe Canada: expansion of syringe access in Vancouver and Montreal led to decreased HIV incidence China: Scaling up, but not sure how to measure effectiveness Russia: scaling down Estonia: scaled up, preliminary evidence of decreased HIV incidence

44. Thank You!  Special Thanks to Alisa Solberg and Kay Borba for their help in reaching out to SEPs  Many Thanks to EVERYONE who contributed to a survey submission. KEEP THEM COMING!