SYRINGE EXCHANGE IN THE UNITED STATES: DOING THE SIMPLE THINGS BETTER?
The good news
The good news, as reported by Des Jarlais and colleagues , is that over the last 13 years the number of syringe exchange programmes (SEP) and the number of syringes exchanged in the United States has expanded from 68 to 186 and 8 to 29.5 million per annum, respectively. The expansion of SEPs (and pharmacy-based programmes) has been accompanied by substantial declines in human immunodeficiency virus (HIV) prevalence and incidence in injecting drug users (IDU) . In 2007 89% of SEPs surveyed permitted secondary exchange and 76% encouraged it. This is in contrast to the situation in Australia, where secondary distribution is not encouraged because of laws prohibiting the unauthorized distribution of syringes. As with programmes elsewhere, SEPs in the United States also provide a range of other services, including condoms, referrals and blood-borne virus (BBV) screening, with most programmes reporting provision of HIV (88%) and hepatitis C virus (HCV) (55%) counselling and testing and one-third providing on-site medical care .
The not-so-good news
The bad news is that the US Congress continues to maintain a prohibition on the use of federal funds for SEPs. This is despite evidence indicating that needle syringe programmes (NSPs) are the single most important and cost-effective strategy in reducing drug-related harms among people who inject drugs, with an estimated 25 000 HIV infections and 21 000 HCV infections averted in Australia alone between 1991 and 2000 . Almost a third of US programmes surveyed still adhered to a ‘one-for-one’ policy and only 7% provided clients with the number of syringes requested, regardless of the number returned. Acknowledging the critical importance of coverage other countries, such as Australia, have moved away from restrictive syringe ‘exchange’ to syringe ‘distribution’ programmes .
Margin or mainstream?
Des Jarlais et al. identify two key strategies responsible for the growth of SEPs in the United States: (1) utilizing secondary exchange to increase coverage and (2) providing health and social services beyond syringe exchange. There is an inherent tension between these two strategies, in that a focus on the latter comes potentially at the expense of the former. While syringe exchange is relatively cheap and cost-effective, providing other health and social services can be resource-intensive. The most common problem, identified by more than half the programmes in the North American Syringe Exchange Network (NASEN) survey, was ‘lack of resources/lack of funding’ (p. 6). Thus, it is important to ensure that the provision of ancillary services does not limit inadvertently the further development or expansion of SEP services.
Injection coverage is core business for SEPs and provides a strong argument for focusing upon the simple things and doing them well. As noted by the authors, there is huge variation in coverage in the United States . Interestingly, both Australia (population 20 million) and the United States (population 300 million), distribute around 30 million syringes each year. While Des Jarlais et al. acknowledge that many areas lack adequate coverage, they shy away from this important issue, noting that complexities in assessing coverage mean it is ‘not possible to make an overall assessment’. In the absence of coverage data, we are unable to assess how well SEPs are doing in relation to this key indicator. Crucial policy questions, such as the increase in syringe distribution necessary to control or reduce HIV or HCV incidence in IDUs, are neither asked nor answered.
Alternative health-care provision
The potentially contentious issue in this paper is the role of American SEPs as alternative health-care providers for people who inject drugs. While the diminishing HIV imperative may make it increasingly difficult to maintain current levels of services and programming, some SEPs are well placed to provide low threshold health services to IDUs. However, while many ancillary services, including condom distribution and hepatitis B immunization, also impact on BBVs, others, such as referral to drug treatment, may not be strongly related to health outcomes. A recent study of IDUs attending a Supervised Injecting Facility in Sydney found that approximately 12% of clients received a written referral to drug treatment and only 16% of these presented to the specified service .
Obvious advantages of the alternative health-care model include responsiveness to client needs, organizational flexibility and provision of health care within a harm reduction framework. However, within the current funding climate it may also be unreasonable to place expectations on SEPs, and those who work in them, that they are somehow responsible for the wide range of social and other health issues affecting people who inject drugs. An alternative to providing a separate, and potentially unequal, health system is to work towards better integration of the SEP sector with existing primary health-care services—to move SEPs from the margins to the mainstream—and away from HIV/AIDS exceptionalism. This would ensure that the broader health sector takes a more active role in the health and wellbeing of people who inject drugs. Mainstreaming also has resonance for some developing countries where harm reduction, including SEP, is driven by donor dollars and replete with examples of perennial pilot projects and programmes that are unsustainable or never brought to scale.
However, as Des Jarlais et al. note, the need for an alternative reflects the sad reality of widespread stigma and discrimination against drug users in American society. In places where IDUs are shunned or turned away from health services, SEPs may be the only source of primary care. Integration and sustainability may be achieved more easily in countries such as Australia which, if not always in practice, at least in principle provides access to universal health care. Regardless of the setting, the value of SEPs as an evidence-based public health response to BBVs and injection-related injuries is overwhelming. We know what works and we have the evidence. However, if we are serious about increasing access to health care for people who inject drugs then we need to confront the stigma and discrimination that IDUs continue to encounter in mainstream health-care settings around the world.
Lisa Maher is supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship. The National Centre in HIV Epidemiology and Clinical Research is core-funded by the Australian Government Department of Health and Ageing.
Declarations of interest