Limited availability on the part of the program…very difficult to find slots of poor and homeless folks. Also limited ability for people to go (work, childcare, pets)
People inject for many reasons—Pleasure, Dependence, Exposure to injecting practices, Purity of the drug, Type of drug, Supply of drug, Cost of drug, Law enforcement practices, love of the ritualIt’s not just people injecting heroin, speed or cocaine--People inject hormones (transgender community) and steroids (weightlifters)
Second syringe access program opened in Seattle WA shortly after Tacoma’s program opened. It’s important to note that these are programs that are born of activists’ response to a crisis. The late 80s and early 90s were a very scary time in America. People were disappearing because of AIDS.
Many of the remaining states without SAPs have low rates of HIV attributable to IDU (ie: WY)Source: AmFAR, Foundation for AIDS Research (using NASEN and Beth Israel Hospital data)
Researchers say that this is the great success story of HIV Prevention. The biggest successes we have managed to have in HIV transmission is with perinatal transmission and transmission among IDUs
HIV Seroprevalence among Intravenous Drug Users in New York is down from 50% to 18% in 10 yearsThere has been an 80% reduction in HIV transmission.
Again, the data is very clear on this…they do reduce HIV infections, reduce risk of HCV infection, and connect difficult to reach populations to much needed services
A meeting of experts on SAP policy and programs convened in NY in August of 2009 to compile a report on best practices
Other pros: Other cons: can be difficult to stay attuned to drug use patterns in the neighborhood
Van can have high overhead, need off-site storageOther examples include Boulder, CO
Presentation + Participant input: discuss each with examplesBlame: “just say no”, your own fault for getting HIV, HCV, weak-willed, don’t care, etc.; contrast to “pity” Ex. Someone who is born without a hand vs. someone who loses their hand because of an injection-related infectionCriminalize: War on drugs (drugs = bad, get tough, punish). Stigma (investment in prisons, incarcerating drug users for non-violent crimes vs. resources into supportive services). Result: causes more harm to drug users than drugs:Increases stigma (external + internalized—”criminal”)HCV/HIV rates increaseInterruptions in services/txRacial profiling (social stigma increases – i.e. people of color are the ones who are causing problem…use/deal drugs/create crime in community.Pathologize: sick, diseased, mentally ill, self-medicating “sickness” in mind/character; something is wrong with drug users; they can not help themselves;Not the same as a public health approach to drug use.Patronize: language (ie, the way that information is communicated); also in the presumption that others know what is best for drug users; people are very often telling drug users what they should do, or what they need, as opposed to seeking input and involving drug users in the decisions that matter most to them. Fear and Isolate: people can’t talk about it (drug use, HIV, HCV) – outed.People are isolated; Drug users as “scary”; fear-based public education campaigns;
Sas overview logo
Syringe Access ServicesA hepatitis C and HIVPrevention Intervention Narelle Ellendon, RN Katie Burk, MPH www.harmreduction.org
Harm Reduction Coalition2 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.
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
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
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.
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
What’s the Problem?18000 Newly infected each year in16000 the USA due to syringe and14000 equipment sharing:1200010000 8,000 people with HIV8000 17,000 with Hep C60004000 Overdose is the second2000 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
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
What’s the Problem?Drug Treatment is notalways 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
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 andProcedures. http://emedicine.medscape.com/article/286976-overview#a0199
Meeting people where they areSyringe 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
SAPs: The National ContextSignificant shifts toward support of syringe accessprograms 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
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 CompletedSince April 1998. US Department of Health and Human Services: Washington DC.
Successful outcomesHIV 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
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/Centerfor 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
Benefits of Syringe Access:It’s not just syringes!SAPs connect difficult-to-reach populations tomuch 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
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
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 SAPsSources: Lorenz J, et al. Occupational Needlestick Injuries in aMetropolitan Police Force. American Journal of PreventativeMedicine, 2000. 18:146-150.Groseclose SL, et al. Impact of Increased Legal Access toNeedles and Syringes on Practices of Injecting Drug Usersand Police Officers—Connecticut 1992-1993. Journal of AIDSand Human Retrovirology. 10(1): 71-72.
Debunking Myths about SAPsSyringe Access Programs DO NOT:X .. encourage drug useX .. increase crime ratesX .. Increase inappropriately discarded syringesX .. increase needlestick injuries
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 SAPsSource: Recommended Best Practices for Effective Syringe Exchange Programs in the in the United States: Reports from a Consensus Meeting, 2009. Available athttp://www.harmreduction.org/downloads/Best%20Practices%20for%20Syringe%20Exchange%20Programs%20consensus%20statement.pdf
Getting Started: Core Elements of aNeeds 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?
Getting Started: Equipment Needles & Syringes Sterile water in various sizes containers Cookers Alcohol swabs Condoms Cottons/Filters Tourniquets/Ties Health education literature
Getting Started: EquipmentIf Budget allows… Powdered Citric /Ascorbic acid Gauze pads and band aids Twist ties Bleach kits Fit packs Baggies Crack kits
Getting Started:What do SAPs look like? Storefront Street-based Secondary or peer-delivered Underground programs Pharmacy access
Storefront SAPsCase Study: Lifepoint, Tucson, AZPros 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
Street-Based SAPsCase Study: The CHOW Project, HawaiiPros 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
Peer-Delivered SAPsCase Study: Southern Tier AIDS Program, NYPros 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
Underground SAPs:Case Study: Austin, TXPros Cons No restrictions on Legal vulnerability practice More limited reach Potential to be more Difficult to fund, staff participant-driven
Pharmacy AccessCase Study: NevadaPros 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
Why is there a need for Drug User Cultural Competency?Demonstrating More More cultural meaningful effective competency engagement interventions
The Principles of Drug User CulturalCompetency: 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
Key Elements of Drug-Related StigmaBlame and moral judgmentCriminalizePathologizePatronizeFear and Isolate
Implications for ProvidersWillingness to access services Relationships and trust Assumptions Participant risk and behaviors Participant self-worth Funding
Multiple Social Inequalities Homelessness Sexism/ Trauma Homophobia/ Transphobia Injection Drug User Medical and Incarceration Mental Health Issues Racism/ Nationalism
Practicing Drug User CulturalCompetencySupporting consumer involvement Community advisory boards Secondary exchangers Focus groups Peer education trainings Volunteering Leadership
Ensuring that the communities served have a real voice in the creation of programs and policies. Respectful Relevant Responsive
Embracing a Multi-Tiered Model Service Provider Community (IDU)
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/
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 retentionCollaboration & interventionsService Integration •Core competencies •Social marketing Process and Outcome Monitoring and Evaluation