Introduction

Syringe Service Programs (SSPs), sometimes referred to as Syringe Exchange Programs, aim to provide people who inject drugs (PWID) with sterile supplies to reduce the transmission of diseases like Human Immunodeficiency Virus (HIV) and Hepatitis. Syringe services are deeply rooted in harm reduction principles; they follow a ‘person-centered’ approach where clients are at the center of the services offered. The harm reduction approach recognizes that complete abstinence from substance use is not always possible or desired and focuses on mitigating the risks associated with ongoing substance use. SSPs prioritize the basic needs of PWID by offering stigma-free spaces to discuss their substance use. They are associated with a reduction in substance use, prevention of infectious diseases, linkage to treatment for substance use disorder (SUD), overdose prevention, crime reduction, and improved community safety (Carroll, 2023). These services are an invaluable resource for community health and safety. It is important to understand the history of SSPs in order to improve and expand these services across the United States.

Background

The history of SSPs is closely associated with the study and discovery of bloodborne pathogens like HIV. Throughout the 1800s, scientists around the world began exploring microbiology and bloodborne pathogens. One of the earliest recorded cases of infection after an injection was reported in the peer-reviewed medical journal, The Lancet, in 1876. A publication in 1891 identified that needle sharing could lead to the spread of bloodborne viruses (Exchange Supplies, n.d.). However, it would be decades until this information was spread globally.

The discovery of HIV and Acquired Immunodeficiency Syndrome (AIDS) marks an important moment in history for SSPs. HIV was officially identified as the cause of AIDS in the early 1980s and, initially, it was thought that these conditions primarily impacted men who have sex with men (MSM) (Jarlais, 2017). Scientists developed an HIV antibody test in the mid-1980s, and it was quickly recognized that in addition to MSM, injection drug users were equally at risk for the disease. A study conducted in Edinburgh, Scotland in 1986 found the prevalence of HIV in PWID to be as high as 85% (Robertson et al., 1986).  As of December 1988, there were over 80,000 cases of AIDS in the United States (CDC, 1989). It wasn’t until the 1990s that Hepatitis was also identified as a significant health risk for PWID (Exchange Supplies, n.d.).

These scientific developments were important, as they raised awareness on the rising morbidity and mortality rates associated with HIV and Hepatitis. This prompted agencies from national to hyper-local levels to implement public health initiatives, like SSPs, across the U.K. and U.S. However, factors like social stigma and health governance would create barriers to implementing programs to reduce HIV transmission from injection drug use for decades to come.

The First Wave of Syringe Service Programs

The first wave of SSPs was directly associated with the need to respond to the rising HIV crisis globally. The United Kingdom first began providing sterile injection equipment as early as the 1960s (Bennett, Jacques & Wright, 2011; Exchange Supplies, n.d.). Later, the U.K. Department of Health and Social Services (DHSS) launched its first official SSP as a pilot program in 1987. From this pilot program, the DHSS also established set criteria for SSPs. The criteria were to provide equipment on an exchange basis for individuals who already inject drugs and are unable or unwilling to stop; to provide assessment of and counseling for substance use disorders; to provide advice on safe sex practices and HIV counseling; and to collect information on clients and encourage collaboration for monitoring and evaluation. Soon after these guidelines were released, the number of SSPs across the United Kingdom and the United States grew (Exchange Supplies, n.d.).

A general set of principles was developed to accompany the U.K.’s DHSS criteria to lay the foundation for the future of SSPs. These programs were distinct in that they focus on harm reduction rather than abstinence, putting clients at the center of their work. This ‘person-centered’ approach meant meeting people where they are at, whenever they need help. The guidelines of a person-centered SSP were to have no waiting lists; collect the least amount of information from the client as possible; focus on easy access to supplies; not require abstinence to participate; and to remove any entry criteria to receive services (apart from being an injection drug user) (Exchange Supplies, n.d.).

The discovery of HIV prompted a response from communities across the U.K. and U.S. to act; however, the development of SSPs in the United States would prove to be difficult due to the social and political barriers to harm reduction implementation. In the 1980s, the Reagan Administration’s response to the rise in HIV associated with injection drug use was the “Just Say No” campaign. This initiative focused on abstinence and did not highlight the services to support people in addressing substance use disorder (Onion et al., 2017). This not only ostracized PWID who were not able to stop their use, but it also impacted the development of SSPs across the United States (Jarlais, 2017).  For example, the New York City Department of Health attempted to launch an SSP as early as 1985; however, this initiative was struck down by the Mayor of the City. The first SSP was established in New Haven, Connecticut in 1986 by a former injection drug user (IDU), Jon Stuen-Parker (PBS, 2006). However, Stuen-Parker had been informally distributing free, sterile supplies to injection drug users in his community for years (McLean, 2011). The supplies offered by Stuen-Parker’s SSP were technically illegal, as they were considered drug paraphernalia at the time. He was, along with many others responsible for launching SSPs across the U.S., arrested several times for this work (McLean, 2011). In 1988, the United States passed a bill which prohibited the use of federal funds on SSP (Jarlais, 2017). Although many SSPs were run by non-governmental agencies, they worked under the guidance and support of local and state governments. The implications of this legislation included increased stigma and discrimination against PWID (Jarlais, 2017).

Research and Development of Syringe Services

The 1988 ban on using federal funds for SSPs included federal research funds, which then limited the opportunity for national research on the implementation and efficacy of SSPs. In fact, in the first 10 years after HIV was discovered, only 32 research articles were published on SSPs (Jarlais, 2017). This lack of scientific literature could have prevented the wide-scale implementation of SSPs in response to the HIV/AIDS crisis in the 1980s. However, the U.S. National Institute on Drug Abuse (NIDA) recognized this issue and began funding research on SSPs in the 1990s. By 1998, the Secretary of the U.S. Department of Health and Human Services found that SSPs were safe and effective based on the published literature (Jarlais, 2017; McLean, 2011). By the early 2000s, the data on the efficacy of SSP were clear: needle and syringe programs were reducing the rate of new HIV infections in PWID (CDC, 2024; Jarlais, 2017; McLean, 2011).

Needle and syringe services reduce the transmission of many infectious diseases and are not associated with increased substance use nor increased crime rates (CDC, 2017; NIH, 2021). SSPs are associated with an estimated 30-50% reduction in HIV and Hepatitis infections (CDC, 2024; McLean, 2011). Preventing new cases of these infectious diseases saves the U.S. health care systems millions of dollars each year; according to the CDC “Hospitalization in the US due to substance-use related infections [of HIV] alone costs over $700 million annually” (2024). Health care services for chronic Hepatitis-C in the U.S. are estimated to cost around $15 billion each year (CDC, 2024). Investing in the prevention of these conditions is a cost-effective approach that prioritizes the needs of people who use drugs; however, changes needed to be made to the legislation around SSP funding.

In 2015, Scott County, Indiana experienced an alarming spike in new HIV infections; in a population of 4,200 people, over 130 new HIV cases were recorded (Conrad et al., 2015). At this time in Indiana, as well as in other states, SSPs were illegal. It was found that this spike was associated with injection drug use, and it prompted a nationwide response. Although the 1988 ban on federal funds for SSPs was never formally repealed, amendments were made to allow state governments to allocate some funds for costs associated with running an SSP (Jarlais, 2017). However, the law still restricts federal funding to be used for syringes (CDC, 2024). Instead, these funds can be used for indirect costs such as staff salary, technology, and other resources to help bolster needle and syringe services. This legislation demonstrates the cultural shift toward harm reduction that has been occurring in the United States.

Modern Syringe Services Programs

The principles of harm reduction and SSPs continued to take form in the U.S. and U.K. throughout the 1990s through today. Needle and syringe programs have expanded into multi-service agencies that serve the community at large, not only PWID (Jarlais, 2017). These additional services include linkage to treatment for substance use disorders, HIV/Hepatitis testing and counseling, vaccinations, testing for sexually transmitted infections, and referrals to care for infectious diseases (CDC, 2024). In addition to these direct services, SSPs also serve as community hubs for people who use drugs (Carroll, 2023). They create spaces for people to share their lived experiences with substance use with health professionals and certified peers, which can help improve health outcomes (Carroll, 2023). For example, individuals who participate in SSPs are more likely to engage in treatment for substance use disorder than those without syringe services (Carroll, 2023; CDC, 2024). Participants in SSPs are also more likely to receive overdose prevention education, preparing them to respond to an overdose in their community.

Overall, SSPs are continuing to evolve to meet the needs of PWID and their surrounding communities. Leaders in the United States must continue to review the efficacy of harm reduction services and pass legislation to improve how we address substance use disorders. MATTERS is working to launch its own mail-based SSP across New York State, which is planned to be operational by the end of 2024. These services will further strengthen the MATTERS program in its efforts to link people with substance use disorders to the resources and treatment they need. Stay up-to-date on all MATTERS service offerings by registering for our quarterly newsletter at https://mattersnetwork.org/email-newsletter-signup/.

References

Bennett T., Jacques S., Wright R. (2011, October 19). The emergence and evolution of drug user groups in the UK. Scott Jacques. https://doi.org/10.21428/7b6d533a.d5c77044

Carroll, J.J. (2023, Jan 23). Syringe services programs: A NACo opioid solutions strategy brief CORE STRATEGY. National Association of Counties. Retrieved from: https://www.naco.org/resource/syringe-services-programs-naco-opioid-solutions-strategy-brief

Centers for Disease Control and Prevention (1989, May 12). AIDS and Human Immunodeficiency Virus Infection in the United States: 1988 update. Morbidity and Mortality Weekly Report 38(S-4); 1-14. Retrieved from: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001477.htm

Centers for Disease Control and Prevention (2024, February 8). Funding for syringe services programs. Retrieved from: https://www.cdc.gov/syringe-services-programs/php/funding/index.html

Centers for Disease Control and Prevention (2017 August). Reducing harms from injection drug use & opioid use disorder with syringe services programs. National Center for HIS/AIDS, Viral Hepatitis, STD, and TB Prevention. Retrieved from: https://www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf

Centers for Disease Control and Prevention (2024, February 8). Syringe services programs. Retrieved from: https://www.cdc.gov/syringe-services-programs/php/index.html

Centers for Disease Control and Prevention (2024, February 8). Safety and effectiveness of syringe services programs. Retrieved from: https://www.cdc.gov/syringe-services-programs/php/safety-effectiveness.html

Conrad C., Bradley H.M., Broz D., Buddha S., Chapman E.L., Galand R.R., Hillman D., Hon J., Hoover K.W., Patel M.R., Perez A., Peters P.J., Pontones P., Roseberry J.C., Sandoval M., Shields J., Wathall J., Waterhouse D., Weidle P.J., Wu H., & Duwve J.M. (2015, May 1). Community outbreak of HIV infection linked to injection drug use of oxymorphone – Indiana, 2015. Centers for Disease Control and Prevention Mortbidity and Mortality Weekly Report (MMWR) 64(16); 443-444. Retrieved from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6416a4.htm

Exchange Supplies (n.d.). The history of needle sharing and the development of needle and syringe programmes. Exchange Supplies. Retrieved from: https://www.exchangesupplies.org/articles/article/history_of_needle_and_syringe_sharing_and_the_development_of_needle_exchange

Jarlais, D.C.D. (2017, July 26). Harm reduction in the USA: The research perspective and an archive to David Purchase. Harm Reduction Journal. doi: 10.1186/s12954-017-0178-6

McLean K. (2011, March 1). The biopolitics of needle exchange in the United States. Critical Public Health 21(1): 71-79. doi: 10.1080/09581591003653124

National Institutes of Health (2021 June). Syringe services programs. National Institute on Drug Abuse. Retrieved from: https://nida.nih.gov/research-topics/syringe-services-programs

Onion A., Sullivan M., Mullen M. & Zapata C. (2017, May 31). Just Say No. History. Retrieved from: https://www.history.com/topics/1980s/just-say-no

PBS (2006). Needle exchange: A primer. FRONTLINE: The Age of AIDS. Retrieved from: https://www.pbs.org/wgbh/pages/frontline/aids/past/needle.html#top

Robertson, J.R., Bucknall, A.B.V, Welsby P.D., Roberts J.J., Inglis, J.M., Peutherer J.F., & Brettle R.P. (1986, Feb 22). Epidemic of HIV/AIDS related virus (HTLV-III/LAV) infection among intravenous drug abusers. British Medical Journal; 292(6519): 527-529. doi: 10.1136/bmj.292.6519.527

Thangsing, C. (2012). Standard operating procedure: Needle syringe exchange program for injecting drug users.United Nations Office on Drugs and Crime. Retrieved from: https://www.unodc.org/documents/southasia/publications/sops/needle-syringe-exchange-program-for-injecting-drug-users.pdf