This document discusses harm reduction strategies and syringe exchange programs (SEPs). It provides evidence that SEPs are effective in preventing HIV and hepatitis C by allowing for safe disposal of used needles and connecting injection drug users to medical care. The document reviews how SEPs make communities safer by reducing improperly discarded syringes, protect first responders from needlestick injuries, and do not increase crime rates. SEPs are also cost-effective by saving millions in avoided healthcare costs from prevented infections. The discussion aims to increase support for SEPs by addressing common myths and concerns.

1. IHS - Oklahoma City Area Office
Hepatitis C Treatment & Updates
HCV and harm reduction: where the
rubber meets the road
MARY BETH LEVIN, MPH
ASSOCIATE PROFESSOR
DEPARTMENT OF FAMILY MEDICINE
GEORGETOWN UNIVERSITY SCHOOL OF MEDICINE

2. Conflict of Interest
Disclaimer
 No financial disclosures.
 Opinions expressed are exclusively my own and not
those of the HIS.

3. Objectives
 1. Understand the evidence that syringe exchange
programs are successful in preventing blood-borne illness
(including hepatitis C) and serving as a bridge to
treatment for substance use disorder.
 2. Understand the similarities and differences between
harm reduction and traditional medical models.
 3. Understand various scenarios in which syringe
exchange programs can operate.
 4. Understand the current federal and state legislative
environment for implementing syringe exchange.
 5. Understand the wide-ranging political support for
syringe exchange from law enforcement, faith
communities, and medical providers.

4. Why should anyone care?
• Here in the US, 8% of new HIV infections are due to IDU.
• That’s 11 people per day.
• People who inject are twice as likely to be unaware of their HIV status
than the general public.
• People inject all sorts of things: heroin, cocaine, methamphetamine, pain
meds, silicone, hormones.
• Outside of Sub-Saharan Africa, three out of ten new infections are due to
IDU.
• Here in the US, hep C is the leading cause of death among those living
with HIV.
• HCV is the leading cause of death by infectious disease in the US, more
than the next 30 combined.
• Hep C is the leading cause of liver transplants.
• The epidemic of prescription drug use and IDU.
• There are more deaths due to drug overdose than auto accidents.
• Health care is a right.

5. Looking at new
infections:
African-
Americans are
11X, Latinos
are 5x, and
Native
Americans are
2X more likely
to acquire HIV
via IDU than
their Caucasian
counterparts.
CDC, MMWR, HIV Infection Among Injection-Drug
Users --- 34 States, 2004—2007, Nov 22, 2009.

6. It’s not about the needle, it’s about the people…
SSPs make neighborhoods safer for everyone. They also
protect the sexual partners and children of IDUs.
Reggie once injected drugs, contracting HIV
and hepatitis C, which were both transmitted
to his wife. His youngest son contracted
hepatitis C perinatally.
Zee has never injected drugs. The father of her
children did use needles. She found out she was
positive when she gave birth to their daughter.

7. Because they have
been able to access
care, both Reggie and
Zee have been living
with HIV for more
than twenty years.
Reggie is working and
raising his kids.
Zee is working and has
realized a moment she
never thought she
would live long enough
to experience: the birth
of her first grandchild.
Update: Zee passed
away in January, 2015.
It’s not about the needle, it’s about the people…

8. But do syringe service
programs prevent HCV?
 Yes…
 In NYC, from 1990-2001, HCV prevalence was reduced from
91% to 62%.
 A case-controlled study in Tacoma demonstrated a 65%
reduction.
 A 2016 meta-analysis did not show a sig stat difference. But,
OST alone reduced HCV by 39% and OST and SSP by 71%.
 but you have a very limited window of opportunity:
 After initiation of IDU
 One-third became infected within one year
 One-half within five

9. But how
available is
OST?

10. What is harm reduction?
Harm reduction is a set of
practical strategies that
reduce negative
consequences of drug use,
incorporating a spectrum of
strategies from safer use, to
managed use to abstinence.
Harm reduction strategies
meet drug users "where
they're at," addressing
conditions of use along with
the use itself.
-Harm Reduction Coalition, NY,
USA

11.  Is a practical strategy that attempts to
reduce negative consequences of drug
use and other activities.
 Accepts that some will engage in
dangerous activities, but does not
attempt to minimize the harm or
dangers involved.
 Focuses on the individual and their
health and wellness needs.
 Places individuals in the greater social
context.
 Places a value on drug users having a
voice in the creation of programs and
policies designed to serve them.
From www.preventionworksdc.org, Jan. 24, 2011

12. Harm reduction is NOT
 Harm reduction is NOT “whatever happens,
happens.”
 Harm reduction is NOT “anything goes”.
 Harm reduction is NOT simply “meeting the
client where the client is at” (it’s helping them
to change behavior).
 Harm reduction is NOT “Helping a person who
has gotten off drugs to start using again.”
 Harm reduction is NOT condoning, endorsing,
or encouraging drug use.
 Harm reduction is NOT legalization.

13. Harm reduction is not unique to drug use

14. There is more to harm
reduction than preventing HIV
and viral hep.
 Prevention of injection-related
wounds
 Prevention of secondary infections
(endocarditis, cotton fever)
 Safer injection technique
 Alternatives to injecting
 Overdose prevention and response
 Immunization
 STI testing
 Safer sex supplies
 Case management
 Treatment for substance use
disorder
 Employment assistance

15. Access to
buprenorphine/Suboxone

16. Do SSPs work?
YES
• REDUCES HIV
• REDUCES VIRAL HEPATITIS
• REDUCES DRUG USE
• REDUCES IMPROPERLY DISPOSED SYRINGES
• SAVES MONEY AND LIVES
• MOST PEOPLE LIKE SSPS

17. State, local, and faith-based organizations around the
country already support SSPs
The following organizations support
SSPs:
oAmerican Medical Student Association
oAmerican Academy of Family Physicians
oAmerican Academy of Pediatrics
oAmerican Bar Association
oAmerican Medical Association
oAmerican Public Health Association
oAmerican Society of Addiction Medicine
oInternational Red Cross-Red Crescent
Society
oLatino Commission on AIDS
oNAACP
oNational Academy of Sciences
oNational Black Leadership Commission on
AIDS
oNational Black Police Association
oNational Institute on Drug Abuse
oOffice of National Drug Control Policy
oPresidential Advisory Committee on AIDS
oUS Conference of Mayors
oWorld Bank
oWorld Health Organization
SSPs also enjoy support from faith
communities, including:
• Central Conference of American
Rabbis
• Episcopal Church
• National Council on Jewish Women
• Presbyterian Church of the United
States
• Society of Christian Ethics
• Union for Reform Judaism
• Unitarian Universalist Association
• United Church of Christ
• United Methodist Church, General
Board of Church and Society
• Regional AIDS Interfaith Network

18. State, local, and faith-based organizations around the country
already support SSPs
 "Syringe decriminalization and
exchange is ...an issue of compassion
and justice... As people of faith, we
are called to be the embodiment of
that compassion and instruments of
that justice in this world to offer an
eternal hope. The hope that someone
may live another day. The hope that
they may be reconciled with their
family. The hope that they can live a
life free of disease. The hope that
they might choose to find treatment.
The hope that with that
one more day, they might find their
own hope for a future outside of their
addiction."
- Pastor James Sizemore, Lead Pastor,
Catalyst Community Church, Fayetteville,
North Carolina

19. Note: since this map was developed, there are now SSPs in Kentucky and West Virginia and more sites in states with programs already listed.
There are already a number of programs:

20. Most funding (82%) for SSPs is public –
Year of Operation
2012 2013
Total $$$ $19,431,912 $21,920,648
City Gov $ $5,789,118 $6,504,086
County Gov $ $1,538,358 $1,431,851
State Gov $ $8,391,180 $10,059,565
Foundation $ $1,966,688 $2,129,610
Individual Donations $696,947 $611,269
Out-of-pocket $ $50,525 $90,250
NASEN $ $4,150 $2,100
CBO Donation $ $28,740 $47,200
Corporate Donation $ $68,300 $157,500
Other $ $856,406 $887,218

21. It’s not just the needle, it’s about the people!
SSPs provide a variety of services in addition to syringe
exchange1
o Onsite medical care 1
o Screening and counseling for HIV, hepatitis C, and
STIs (injection drug users are twice as likely as the
general public not to know their HIV status) 1,2
o Distribution of safer sex supplies, food, and
clothing 1
o Referrals to substance use treatment and support
groups 1
o Medications and resources to prevent death from
drug overdose 3
o Case management
Selected Services Offered by
SSPs Nationwide

22. SSPs Make Communities Safer for Everyone
o SSPs distribute free sterile syringes
to injection drug users (IDUs), which
reduces the likelihood that users will
share injecting equipment.1
o SSPs safely dispose of used
needles, a service not typically
provided by distributors such as
pharmacies.
o SSPs make neighborhoods safer by
reducing needle-stick injuries.1

23. SSPs Protect Those who Protect Us
o Needle stick injuries to law enforcement are a common
occurrence. In San Diego, nearly 30% of officers have
been stuck by a needle.1
o Decriminalization of syringes (and SSPs) has been tied to
reduced needle stick injuries. In South Carolina, where
syringes are legal, officers have experienced needle stick
injuries at half the rate of their counterparts in North
Carolina, where syringes are illegal.2
o In Connecticut, police officer needle stick injuries were
reduced by two-thirds after the establishment of SSPs.3
o “In the cities that have adopted needle services
programs, there is a dramatic reduction in needle sticks
to firefighters who crawl on their hands and knees
through smoke-filled rooms in search of victims.” - Charles
Aughenbaugh, Jr., President, New Jersey Deputy Fire Chiefs Association, Retired
Deputy Fire Chief, March 2011

24. LOCAL EXAMPLES
o In Baltimore, SSPs helped
reduce the number of
improperly discarded syringes
by almost 50%. 1
o In Portland, Oregon, the
implementation of SSPs
reduced the number of
improperly discarded syringes
by two-thirds.2
o In 2008 and 2009, Miami
(which had no SSPs) saw eight
times more improperly
disposed syringes than San
Francisco (where SSPs are
available) despite the fact that
San Francisco is thought to
have twice as many IDUs.3

25. SSPs Do NOT lead to an increase
in crime or drug use.
o Neighborhoods in Baltimore with SSPs experienced an 11% decrease in break-
ins and burglaries, while areas without SSPs saw an 8% increase in such crimes
during the same period.1
o In Seattle, IDUs who had used SSPs were more likely to report a significant
decrease (>75%) in injection drug use, to stop using injection drugs, and to
remain in treatment than IDUs who had never used SSPs.2
o The same study in Seattle found that new users of the SSP were five times
more likely to enter drug treatment than individuals who never utilized the
program.2
Local Examples

26. o In New York City, the growth of SSPs from 1990
to 2001 was associated with a 78% decrease in
HIV prevalence among IDUs.1
o During this time period, the same population
saw a decrease in the prevalence of hepatitis C
from 90% to 63% 2
o One study showed that within 6 months of using
federally-funded SSPs, clients saw a 45%
increase in employment.
o In addition, SSP clients were 25% more likely to
have been successfully referred to mental health
treatment and prescribed medication than other
SAMHSA grantees.3
o In New Jersey, 22% of the state’s SSP clients have
entered drug treatment.4
SSPs Bring Results

27. The most important myth to dismantle:
we can’t afford it.
Every dollar invested in SSPs
results in
$7 in savings
just by preventing new HIV
infections.1
Through Medicaid, Medicare, and Ryan White, the federal government is the
biggest payer of HIV care. So not only are we saving federal dollars, we are
saving entitlement (Medicaid and Medicare) and discretionary (RW) funds.

28. Local Data Helps
o Between 2001 and 2011, Illinois saw a drop of nearly two-thirds in new
HIV cases among IDUs, averting an estimated $200 million in medical
expenses.1
o In Massachusetts, there was a 54% decrease in new HIV diagnosis
between 1999 and 2012, preventing 5,699 infections and saving more
than $2 billion in health care costs.2
o King County (Washington State) spent $1.1 million on SSPs in 2008. If HIV
was prevented among only 1% of IDUs in King County, the resulting
savings in HIV treatment costs will be $70 million.3
o Washington, DC was allowed to spend its own money on SSPs in 2007.
Within two years, 120 HIV infections were averted, resulting in $45.6M in
savings.4 So far, incidence has been reduced by 87%.
o Miami, a city without legal SSPs, published study of the costs of bacterial
infections relating to IDU at Jackson Memorial Hospital. The cost was
$11.4M over 12 month period.5

29. Final Talking Points
This policy costs nothing: Lifting the ban does not involve additional dollars. It simply allows localities to
spend their federal prevention dollars as they see fit. It may be a source of additional federal dollars in the future
if additional dollars are allocated to HIV prevention.
It's cost effective: For every additional dollar invested, an average of $7 dollars in HIV treatment costs are saved.
This does not include other associated costs such as viral hepatitis, secondary infections (e.g. endocarditis),
injection related wounds, or drug overdose.
Federal dollars open doors: Federal funding is often perceived by other donors as a "seal of approval", leading to
new funding streams. Federal grantees can also receive extensive technical assistance at no cost.
It's about local control: States and localities know how best to respond to the epidemics of HIV, viral hepatitis,
and drug overdose.
It's about health disparities: African-Americans are 11x, Latinos are 5x, and Native Americans are 2X more likely
to contract HIV from an infected needle than their Caucasian counterparts.
SSPs are a bridge to related services: HIV testing, viral hepatitis services, treatment for substance use disorder,
and drug overdose prevention and response services.
The changing demographics of injection drug users: Due to the crackdown on prescription drug use, many are
transitioning to heroin use. This new generation of users is more likely to be young, female, and non-urban.
SSPs make neighborhoods safer for everyone: Because they provide a safe place to dispose of used needles,
there are fewer injuries to civilians (kids playing in the park) and first responders alike.

30. “I understand
that there will
be questions,
but this is
common
sense.”
- Sister Maureen
Joyce, CEO of Catholic
Charities, Albany, NY
Messages and Messengers:
law enforcement, faith communities, and families.

31. What about pharmacies?
• OTC access varies by state
• Full range of SSP services are not available
• Not equitably distributed (like food deserts)
• Not required to stock syringes
• Pharmacy has discretion about whom to
serve; more likely to refuse service to people
of color
• False choice: we need both

32. A Brief History of the Ban
o In 2009, Congress removed a 21-year prohibition on the use of
federal funds to support SSPs.1 Two years later, Congress re-
imposed the ban on federal funding for SSPs.2
o While the ban was lifted, federal dollars were used to support
SSPs in California, Connecticut, Delaware, Illinois, Massachusetts,
Minnesota, New Jersey, New Mexico, New York, Puerto Rico,
Vermont, and Washington.3
o Funding came from CDC, HRSA, and SAMHSA. IHS was a potential
source which wasn’t tapped.
o Seen as a “seal of approval”, lifting the ban opened doors from
other donors.
o These dollars were used to: expand service hours, provide services
in new locations, and provide additional services such as case
management and overdose prevention services.

33. What exactly happened in
December of 2015?
 Report language
"Needle Exchange Programs.—The Committee maintains its support for federal, state and local efforts to address the abuse
of prescription painkillers and other opioids. The Committee is alarmed by trends in urban and rural communities which
indicate a transition to injection drug use, and supports state and local efforts to mitigate the spread of related
infections, such as Hepatitis and HIV/AIDS, and associated healthcare costs. The Committee believes the
determination about whether to implement needle exchange programs remains a quintessentially local function, and
therefore maintains its prohibition on the use of federal funds for the purchase of syringes or sterile needles as a title V
general provision. The provision is modified, however, to allow existing programs in hard-hit communities to access
federal funds for other program elements, including substance use counseling and referral to treatment, that support
communities in their drive to end the cycle of dependency. Eligible programs must demonstrate a need or federal
support based on actual cases of Hepatitis or HIV/AIDS or on conditions posing a significant risk for an outbreak."
 Budget language
SEC. 520. Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to purchase sterile
needles or syringes for the hypodermic injection of any illegal drug: Provided, That such limitation does not apply to
the use of funds for elements of a program other than making such purchases if the relevant State or local health
department, in consultation with the Centers for Disease Control and Prevention, determines that the State or local
jurisdiction, as applicable, is experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV
outbreak due to injection drug use, and such program is operating in accordance with State and local law.
 So what?
So basically with this partial lift, federal dollars could go to all aspects of an SSP, except for the needles themselves. It's
counter-intuitive, but not a big deal since syringes are often the least expensive part of operating an SSP. It is an
improvement over how things once were. Previously, federal dollars could not be used for syringes, personnel, and
housing the exchange (either a vehicle or a building). The other issue (which is just FYI) is working with the CDC to
define "conditions posing a significant risk" and "hard-hit communities".

34. Where do we go from here?
 HHS guidance https://www.aids.gov/pdf/hhs-ssp-guidance.pdf
 SAMHSA-specific guidance for Minority HIV/AIDS Initiative
(MAI):https://www.aids.gov/pdf/sasmhsa_ssp_guidance_for_hiv_gran
ts.pdf
 SAMHSA-specific guidance for block grants:
https://www.aids.gov/pdf/sasmhsa_ssp_guidance_state_block_grants.
pdf
 CDC guidance: http://www.cdc.gov/hiv/pdf/risk/cdc-hiv-syringe-
exchange-services.pdf
 CDC Determination of Need Request info (results in 30 days):
http://www.cdc.gov/hiv/risk/ssps.html
 Those that have already achieved approval: California, Colorado,
Maryland, Massachusetts, Michigan, New Jersey, Pennsylvania, Utah,
Vermont, Washington, West Virginia (select counties) – Kanawha
County and Berkeley County

36.  What to do now?
 Contact your GPO (HRSA,
SAMHSA, CDC, IHS) to express
interest.
 Investigate the legal environment.
 Apply for determination of need.
 Possible funding angles:
HIV/STI/Viral Hep. prevention and
diagnosis, vertical transmission,
bridge to SUD treatment, linkage
to care.

37. Is there more money now?
 Not yet.
 But you can use existing funds.
 You will be more competitive for future funds.
 There may be additional funding in the future.
 There may be funding opportunities of which
you are not yet aware right now.

38. Sustainability

39. Diversification of funding streams
 Because of ACA and depending on your
state’s Medicaid program, you may be
able to bill for the following:
 Preventive health screening, behavioral
health screening (EtOH, SBIRT), case
management, medical interpretation,
naloxone, medication-assisted treatment
(suboxone).
 Please provide one-stop shopping!

40. What do SEPs look like?
 Arranged delivery
 Mobile unit
 Stationary site
 Sometimes the community provides for itself. Other
times it invites county health or local service providers
to come in.

41. Don’t Forget:
 Health department
 AIDS service organizations
 Current SEPs
 You may want to provide
your own services, but this
way you can provide
services NOW and gather
data to justify future
funding.

42. Legal environment
 Federal Land.
 Area with law specifically
enabling SEP.
 Area with no legal opinion.
 Area with law specifically
prohibiting SEP.

43. Laws in OK and KS
 Standard drug paraphernalia laws: intent determines
legality of syringe.
 Options: eliminate syringes in the list of paraphernalia, “tell
officer law”, exception for syringe exchange participant (ID
card).
 Physician Prescription of Sterile Injection Equipment
 Reasonable Claim to Legality: OK
 Clearly illegal: KS
 Pharmacy Sale of Prescribed Syringes
 Reasonable Claim to Legality: OK
 Clearly illegal: KS
 Naloxone law in OK is exceptionally progressive.

44. Legal work-arounds
 Utah
 North Carolina
 Long Island

45. Law enforcement support
 Webinar: http://www.preventionjustice.org/18-
webinar-strategies-on-expanding-harm-
reduction-through-law-enforcement/
 Slides: http://www.preventionjustice.org/wp-
content/uploads/2016/01/Law-Enforcement-and-
Harm-Reduction-Webinar-Slides.pdf
 List of resources:
http://www.preventionjustice.org/wp-
content/uploads/2016/01/Resources-on-Law-
Enforcement-Syringe-Service-Programs.pdf

46. If you build it, will they come?

48. What did we
see when
people came?

51. What do wound care kits
look like?
 Document the problem
(also provides baseline
data)
 Wound care kits (as
pictured, but with
antibiotic ointment, gauze,
and one-pager instead of
bleach and bottle).
 Utilization review of the
components of the wound
care kits.
 Bake sale/bottled water
drive.

52. Community health is like that
movie about baseball.

53. Additional considerations
 One-for-one vs. needs-
based exchange.
 Secondary exchanges.
 Counting-out syringes
returned.

54. Plan of action
 Visit NASEN website to
see if there is already
someone doing this
work in your area.
 Sign-up for the harmred
listserv.
 Sign-up for the NNAAPC
working group.
 Inform your GPOs at
HRSA, SAMHSA, CDC,
and IHS of your interest.
 Reach out to local law
enforcement.

55. Learn from those who went
before you

56. An expert:
Is someone who
has made every
possible mistake
in a given
situation

57. Your new best friends
 NASEN (North American Syringe Exchange Network): www.nasen.org
 Directory of SSPs with contact info, Dave Purchase Memorial National
Survey, ordering info.
 Harm Reduction Forum listserv: http://drcnet.org/mailman/listinfo/harmred
 The most efficient way to find out the latest and ask for help.
 Washington Heights Corner Project: http://www.cornerproject.org/resources
 Program policies and procedures, curricula, marketing materials.
 Tribal Syringe Exchange Outreach Project:
 Alex White Tail Feather, Executive Director, NNAAPC,
awhitetailfeather@nnaapc.org

58. Websites worth perusing*
 Harm Reduction Coalition: http://harmreduction.org/
 North Carolina Harm Reduction Coalition:
http://www.nchrc.org
 Chicago Recovery Alliance:
http://www.anypositivechange.org
 Prescribe to prevent (for prescribers and pharmacists):
http://prescribetoprevent.org
 *And I’ll be providing a list of Native American-specific
resources.

59. QUESTIONS????

60. Thank you!
Mary Beth Levin, MPH
Associate Professor
Department of Family Medicine
Georgetown University School of Medicine
levinmb@gmail.com