ResearchImplementation Brief

SSPs are service programs. Thus, their effectiveness relies on the quality of their service provision.

1. Program participants should alwaysbe treated with dignity and respect.
2. Large numbers of syringes and other injection materials should be provided to participants. UNAIDS recommends 200 syringes per year per PWID in the community to reach “high coverage” [1].
3. To the greatest extent feasible, multiple services should be provided on-site and through active linkage.
4. Nonetheless, variety is good, most importantly having relatively medically-connected and more“street-oriented” programs.
5. “Peer delivered services” and “secondary exchange” in which persons coming to the program get syringes to distribute to their peers should be encouraged [2].
6. Police should not target areas surrounding SSPs. Research shows that policing activities around SSPs can decrease their utilization and their effectiveness [3].
7. SSPs should be located in spots convenient for PWID. Multiple SSP sites within a community also let PWID use programs where they may remain anonymous.
8. Hours of operation should be based on the needs of the population.
9. Some SSPs have found special hours or programs for women and young injectors to be more effective in attracting them to the program.

“Syringe service programs” (SSPs) provide access to sterile syringes and other injection materials for people who inject psychoactive drugs (PWID). The overarching purpose of SSPs is to reduce the transmission of blood-borne viruses, such as HIV and hepatitis C virus (HCV) among PWID. There are a number of different types of SSPs. Syringe exchange programs are the best known. They collect used needles and syringes from PWID and provide sterile needles and syringes in exchange. Thus, syringe exchanges both provide the needles and syringes needed for safer injection and remove potentially HIV/HCV contaminated needles and syringes.

Syringe distribution programs provide sterile needles and syringes to PWID without necessarily collecting used needles and syringes in return. Syringe distribution programs are typically implemented when it is necessary to get large numbers of sterile needles and syringes to the PWID population and logistical problems prevent collecting used needles and syringes in return. Many programs operate as syringe exchanges but with a distribution component. For example, they may provide “starter” kits to new clients or they may give out the numbers of needles and syringes that a client needs even if the client has not returned an equal number to the program.

Pharmacy sales of sterile needles and syringes to PWID are an additional type of SSP. Pharmacy sales programs require laws that permit the sale of syringes without prescriptions and for the purpose of injecting illicit drugs. Pharmacy sales programs have the advantage that there are many more pharmacies than syringe exchange or syringe distribution programs and that pharmacies have much longer hours of operation than exchange programs. Pharmacy sales programs do not typically collect and dispose of used syringes, however, and cannot provide the range of harm reduction services that are available from syringe distribution or syringe exchange programs.

Effective HIV prevention for PWID does not require choosing one type of SSP. These types should be seen as complementary, and the most effective prevention would include implementation of all types of SSPs.

Multiple reviews of the scientific research have concluded that implementation of SSPs has led to reductions in injecting risk behaviors (needle and syringe sharing) and in the reduction of HIV transmission among PWID [4-6]. To give one example, when New York City expanded its syringe exchange programs from 250,000 syringes per year to 3,000,000 syringes per year, the rate of new HIV infections fell from 4% per year to 1% per year in the city PWID population [7]. When combined with medication-assisted treatment of substance misuse and substance use disorders, SSPs have also been shown to reduce HCV virus transmission [8].

SSPs, particularly syringe exchange programs, often provide many additional services beyond the basic provision of sterile needles, syringes and other injection materials. In the US, syringe exchange programs typically provide HIV and HCV testing, referrals to HIV and HCV care, referrals to substance use treatment programs, and condoms for practicing safer sex [7]. Many programs also provide naloxone and training in naloxone administration for reversing drug overdoses[7].  PWID are a severely underserved population in the US, and SSPs often serve as frontline service providers for a wide variety of health and social services for PWID. However, active referral and effective linkages to health care providers and other services are needed to provide a high standard of care and support to PWID.

While SSPs have been shown to lead to large reductions in injecting risk behavior and to prevent HIV and HCV transmission, they should be considered to be a component of “combined prevention and care” for HIV and HCV among PWID. Implementing multiple different components of combined prevention has led to the greatest reductions in HIV and HCV transmission among PWID [8,9]. SSPs, treatment for substance misuse and substance use disorders (including medication-assisted treatment), and treatment for HIV and HCV infection are generally considered to be the major components of evidence-based combined prevention and care.

Resistance to SSPs has usually been based on the supposition that the programs will somehow “encourage” illicit drug use and increase crime. However, there is extensive evidence to the contrary, showing that SSPs do not increase drug use or crime, and that the programs also reduce the number of discarded used syringes in the community [10-12]. In fact, a study in Connecticut reported that needlestick injuries among police officers were reduced by one-third after SSPs were implemented [13]. Moreover, the areas of the US that have been experiencing increased illicit drug injection are often the very areas that currently lack SSPs [14].

For further information on this brief contact CDUHR at CDUHR@nyu.edu.

1. WHO, UNODC, UNAIDS (2013).
   Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. Geneva, Switzerland: World Health Organization. Available at: http://www.who.int/hiv/pub/idu/targets_universal_access/en/.
2. De P, Cox J, Boivin JF, Platt RW, Jolly AM (2008).
   Social network-related risk factors for bloodborne virus infections among injection drug users receiving syringes through secondary exchange. Journal of Urban Health, 85 (1), 77-89. doi: 10.1007/s11524-007-9225-z.
3. Bluthenthal RN, Kral AH, Lorvick J, Watters JK (1997).
   Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco. Medical Anthropology, 18 (1), 61-83. doi: 10.1080/01459740.1997.9966150
4. Blower SM, Hartel D, Dowlatabadi H, Anderson RM, May RM (1991). Drugs, sex and HIV: A mathematical model for New York City. Philosophical Transactions of the Royal Society of London, Series B, Biological Sciences, 331 (126), 171-187. doi: 10.1098/rstb.1991.0006
5. Blower S (1991). Behaviour change and stabilization of seroprevalence levels in communities of injecting drug users: correlation or causation? Journal of Acquired Immune Deficiency Syndromes,  4 (9), 920-923.
6. Gibson DR, Flynn NM, Perales D (2001). Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users. AIDS, 15 (11), 1329-1341.
7. Des Jarlais DC, Arasteh K, McKnight C, et al. (2017).What happened to the HIV epidemic among non-injecting drug users in New York City? Addiction, 112 (2), 290-298. doi: 10.1111/add.13601
8. Hagan H, Pouget ER, Des Jarlais DC. (2011). A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. Journal of Infectious Diseases, 204 (1), 74-83. doi: 10.1093/infdis/jir196
9. Des Jarlais DC, Arasteh K, McKnight C, et al. (2010). HIV infection during limited versus combined HIV prevention programs for IDUs in New York City: The importance of transmission behaviors. Drug and Alcohol Dependence, 109 (1-3), 154-160. doi: 10.1016/j.drugalcdep.2009.12.028
10. Goodreau SM (2006). Assessing the effects of human mixing patterns on human immunodeficiency virus-1 interhost phylogenetics through social network simulation. Genetics, 172 (4), 2033-2045. doi: 10.1534/genetics.103.024612.
11. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER (2000). Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment, 19 (3), 247-252.
12. Marx MA, Crape B, Brookmeyer RS, Junge B, Latkin C, Vlahov D, Strathdee SA (2000). Trends in crime and the introduction of a needle exchange program. American Journal of Public Health, 90 (12), 1933-1936.
13. Groseclose SL, Weinstein B, Jones TS, Valleroy LA, Fehrs LJ, Kassler WJ (1995). Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers–Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 10 (1), 82-89.
14. Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D (2015). Syringe service programs for persons who inject drugs in urban, suburban, and rural Areas – United States, 2013. MMWR Morbidity and Mortality Weekly Report, 64 (48), 1337-1341. doi: 10.15585/mmwr.mm6448a3