1. Syringe Access Services
A hepatitis C and HIV
Prevention Intervention
Narelle Ellendon, RN
Katie Burk, MPH
www.harmreduction.org

2. Harm Reduction Coalition
2
 Founded in 1994 to work with individuals and communities
at risk for HIV infection due to drug use and high-risk sexual
behaviors.
 The Harm Reduction Coalition is a national advocacy and
capacity-building organization that promotes the health and
dignity of individuals and communities impacted by drug use.

3. HRC Programs & Services
 The Institute @HRC
 Capacity Building for Syringe Access Services Mobilization
 HIV Prevention Capacity Building Initiative for CBOs
 Harm Reduction Training Institute
 Overdose Prevention Programs (SKOOP/DOPE)
 LGBT Project
 Policy Advocacy
 National and Regional Conferences
 Next National Conference: Portland, Oregon in Nov. 2012
 Harm Reduction in The South; NC Sept 2011

4. Training Agenda
 Introductions
 Harm Reduction Definition
 Defining the problem
 The National Context of Syringe Access Programs
 Benefits of Syringe Access Services
 Getting Started: Program Models
 Practicing Drug User Cultural Competency

5. Working Definition of Harm Reduction
Harm Reduction:
A set of practical, public health
strategies designed to reduce
the negative consequences of
drug use and promote healthy
individuals and communities.

6. Goals of Harm Reduction
 Increased Health and well-being
 Increased self-esteem/self-efficacy
 Better living situation
 Reduced isolation and stigma
 Safer drug use
 Reduced drug use and/or abstinence

7. What’s the Problem?
18000 Newly infected each year in
16000 the USA due to syringe and
14000 equipment sharing:
12000
10000  8,000 people with HIV
8000  17,000 with Hep C
6000
4000 Overdose is the second
2000 leading cause of accidental
0 death in the US.
Source: The Center for Disease Control and Prevention, AIDS United.
HIV Hep C
http://www.aidsunited.org/policy-advocacy/issues/syringe-exchange/
http://www.cdc.gov/idu/hepatitis/viral_hep_drug_use.htm
http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/brief_full_page.htm

8. What’s the Problem?
IDUs tend to have…
 High prevalence of other health problems
 High prevalence of mental health issues
 High prevalence of trauma
 Poor social supports
 Higher level of homelessness
 Higher level of previous incarceration
Poor relationship with healthcare system

9. What’s the Problem?
Drug Treatment is not
always a viable option.
 Limited availability
 Research demonstrates
that drug dependence is a
chronic condition (ie:
relapse is a part of the
process)
 Oftentimes people may
not be ready to quit or
may choose not to

10. Who are IDUs?
 Estimate of current number of
IDUs in the USA in 2003: 1.4
million.
 IDU occurs in every
socioeconomic and racial/ethnic
group and in urban, suburban, and
rural areas.
 Males are twice as likely to report
injecting drugs than females.
Source: Baciewicz GJ, et al. Injecting Drug Use. Medscape Reference: Drugs, Diseases and
Procedures. http://emedicine.medscape.com/article/286976-overview#a0199

11. Meeting people where they are
Syringe access programs
 Started in Holland in the 1980s
in response to a hep B outbreak
 First US SAP started in Tacoma
in 1988 in response to the AIDS
crisis

12. SAPs: 211 Programs in 32 States

13. SAPs: The National Context
Significant shifts toward support of syringe access
programs on a federal level:
 Lift of the federal ban in 2009
 Federal funds can now be used to directly support syringe
access programs (reinstated in 2011)
 National HIV/AIDS Strategy (NHAS) 2010
 Calls for minimizing HIV infection among IDUs
 Specifically sites syringe exchange as an intervention that
will reduce the HIV infection rate among IDUs
 National Hepatitis plan 2011
 Call to enhance IDU access to sterile syringes
Sources:
http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf, http://www.hhs.gov/ash/initiatives/hepatitis/actionplan_viralhepatitis2011.p
df

14. Benefits of SAPs:
Reduction in HIV incidence
 Syringe access programs are the most
effective, evidence-based HIV prevention tool for
people who use drugs
 Seven federally funded research studies found that
syringe exchange programs are a valuable resource
 In cities across the nation, people who inject drugs
have reversed the course of the AIDS epidemic by
using sterile syringes and harm reduction practices.
Source: Office of the Surgeon General (2000): Evidence-based Findings on the Efficacy of Syringe Exchange Programs: An Analysis of the Scientific Research Completed
Since April 1998. US Department of Health and Human Services: Washington DC.

15. Successful outcomes
HIV Seroprevalence among IDU’s in NY
50
45
40
35
30
25
20
15
10
5
0
1990-92 1993-95 1996-98 1998-2002
Don C Des Jarlais Beth Israel Medical Center, New York, NY

16. Benefits of SAPs:
Reduction in HCV Transmission Risk
 More than half of IDUs acquire syringes from a
potentially unsterile source in NYC*
 Almost 1/3 of IDUs (31.8%) report “sharing”
syringes and other equipment**
 Many participants of SAPs have been injecting for
some time
 Large number of IDUs already infected with HCV
*Source: HIV Prevalence and Risk among IDUs in NYC: Results from NHBS. HIV Epidemiology Program of NYC Dept of Health and Mental Hygiene/Center
for Drug Use and HIV Research. Available at http://www.nyc.gov/html/doh/downloads/pdf/dires/epi-resupdates-riskdrugusers.pdf
**Source: HIV-Associated Behaviors among Injecting Drug Users—23 Cities, United States, May 2005-Feb 2006. The CDC. MMWR. April 10, 2009 /
58(13);329-33 Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5813a1.htm

17. It’s All About the Blood …..

18. Benefits of Syringe Access:
It’s not just syringes!
SAPs connect difficult-to-reach populations to
much needed services:
 Detox and drug treatment programs
 Medical, Dental & Mental health services
 Counseling and referral
 Case Management
 HIV/HCV services
 Housing services
 Community building
 Overdose prevention
 Prevention for non-injectors

19. Benefits of SAPs:
Cost Effectiveness
 The lifetime cost of medical care for each
new HIV infection is $385,200-$618,000.
 For hepatitis C, the lifetime cost of
medical care exceeds $100,000.
 The equivalent amount of money spent
on syringe access could prevent dozens of
new HIV infections annually.
Sources:.
Press Release. Schackman B. The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States. Medical
Care, Nov 2006; vol 44: pp 990-997.
Press Release. San Francisco Hep C Task Force Releases Recommendations for Fighting Epidemic. Available at
http://www.natap.org/2010/newsUpdates/012611_04.htm

20. Benefits of SAPs:
Reduction of Needle Stick Injuries
 30% of law enforcement
officers have experienced
a needle stick injury (NSI).
 66% reduction in NSIs
among law enforcement
officers following the
implementation of SAPs
Sources: Lorenz J, et al. Occupational Needlestick Injuries in a
Metropolitan Police Force. American Journal of Preventative
Medicine, 2000. 18:146-150.
Groseclose SL, et al. Impact of Increased Legal Access to
Needles and Syringes on Practices of Injecting Drug Users
and Police Officers—Connecticut 1992-1993. Journal of AIDS
and Human Retrovirology. 10(1): 71-72.

21. Debunking Myths about SAPs
Syringe Access Programs DO NOT:
X .. encourage drug use
X .. increase crime rates
X .. Increase inappropriately discarded
syringes
X .. increase needlestick injuries

22. Characteristics of Effective SAPs
 Ensure low threshold access to services
 Promote secondary syringe distribution
 Maximize responsiveness to the local IDU
population
 Provide or coordinate provision of health and
other social services
 Include diverse community stakeholders in
creating social and legal environment supportive of
SAPs
Source: Recommended Best Practices for Effective Syringe Exchange Programs in the in the United States: Reports from a Consensus Meeting, 2009. Available at
http://www.harmreduction.org/downloads/Best%20Practices%20for%20Syringe%20Exchange%20Programs%20consensus%20statement.pdf

23. Getting Started: Core Elements of a
Needs Assessment Process
 Identifying relevant stakeholders
 Where are IDUs getting services?
 Review of existing data, policies, resources, and
services
 Existing services, HCV/HIV prevalence, OD rates
 Getting to know the IDU Community
 Who is injecting drugs?
 What drugs are being injected?
 Where does drug purchase and injection take place?

24. Getting Started: Equipment
 Needles & Syringes  Sterile water
in various sizes containers
 Cookers
 Alcohol swabs
 Condoms
 Cottons/Filters
 Tourniquets/Ties
 Health education
literature

25. Getting Started: Equipment
If Budget allows…
 Powdered Citric /Ascorbic
acid
 Gauze pads and band aids
 Twist ties
 Bleach kits
 Fit packs
 Baggies
 Crack kits

26. Getting Started:
What do SAPs look like?
 Storefront
 Street-based
 Secondary or peer-delivered
 Underground programs
 Pharmacy access

27. Storefront SAPs
Case Study: Lifepoint, Tucson, AZ
Pros Cons
 House other services  Limited access
 Shelter from steet- (hours, location)
based activities  Participants must
come to you
 Increased privacy
 High overhead and
 On site storage space upkeep
 Creating “safe space”  Potential focus of
community opposition

28. Street-Based SAPs
Case Study: The CHOW Project, Hawaii
Pros Cons
 Flexibility if drug  Hard to include
scene changes ancillary services
 More acceptable to  Inclement weather
neighborhood can be a deterrant
 Informal or low-
threshold  Privacy concerns
 Meeting people  Hard to supervise
where they are outreach staff

29. Peer-Delivered SAPs
Case Study: Southern Tier AIDS Program, NY
Pros Cons
 Taps into peer  Cost of training and
knowledge supervising peers
 Can reach groups  Managing boundary
unlikely to access SAPs issues
 Empowers peers to  Peers may need to
take ownership collect and transport
 Increased volume others’ equipment

30. Underground SAPs:
Case Study: Austin, TX
Pros Cons
 No restrictions on  Legal vulnerability
practice  More limited reach
 Potential to be more  Difficult to fund, staff
participant-driven

31. Pharmacy Access
Case Study: Nevada
Pros Cons
 Mainstream location  Pharmacists often
refuse to sell syringes
 May have more without a prescription
extended hours  Cost can be prohibitive
 Could be located  No counseling services
closer to where  Other injection
injectors live or hang equipment not available
out  No disposal options

32. Why is there a need for Drug User
Cultural Competency?
Demonstrating More More
cultural meaningful effective
competency engagement interventions

33. The Principles of Drug User Cultural
Competency:
 Understand the role of stigma in the lives of drug users
 Recognize the vast diversity within IDU communities
 Nonjudgmental and non-coercive provision of services
 Compassionate pragmatism vs. absolutism
 Ensuring that the communities served have a real
voice in the creation of programs and policies
 Embracing a multi-tiered, collaborative model

34. Key Elements of Drug-Related Stigma
Blame and moral judgment
Criminalize
Pathologize
Patronize
Fear and Isolate

35. Implications for Providers
Willingness to access services
 Relationships and trust
 Assumptions
 Participant risk and behaviors
 Participant self-worth
 Funding

36. Multiple Social Inequalities
Homelessness
Sexism/
Trauma Homophobia/
Transphobia
Injection
Drug
User
Medical and
Incarceration Mental Health
Issues
Racism/
Nationalism

37. Practicing Drug User Cultural
Competency
Supporting consumer involvement
 Community advisory boards
 Secondary exchangers
 Focus groups
 Peer education trainings
 Volunteering
 Leadership

38. Ensuring that the communities served have a real
voice in the creation of programs and policies.
 Respectful
 Relevant
 Responsive

39. Embracing a Multi-Tiered Model
Service
Provider
Community
(IDU)

40. For more information
 The Harm Reduction Coalition www.harmreduction.org
 Guide to Developing and Managing Syringe Access
Programs http://www.harmreduction.org/
 Understanding Drug User Stigma Training materials
http://www.harmreduction.org/
 Foundation for AIDS Research (amFAR) www.amFAR.org
 North American Syringe Exchange Network (NASEN)
http://www.nasen.org/

41. What Can CBA Do For You?
Organizational Program Community
Development Development Mobilization for
SAS
•Strategic Planning •DEBIs and Public
Health Strategies •Community
•Board Development assessment
•Program adaptation
•Grant Readiness •Coalition building
•Recruitment and
•Program •Community-level
retention
Collaboration & interventions
Service Integration •Core competencies
•Social marketing
Process and Outcome Monitoring and Evaluation

42. Contact
Syringe Access Community Mobilization
Narelle Ellendon (NYC)
ellendon@harmreduction.org
212 213 6376 x16
Katie Burk (Oakland)
burk@harmreduction.org
510 444 6969 x13