Center forMississippi Health Policy SYRINGE SERVICES Mee bs Impact on the Spread of Communicable Diseases WM Table of Contents Syringe Services Laws in the US Syringe Services Policy Effectiveness Funding for Syringe Services Programs Policy Considerations a BR NM NY = Endnotes Syringe Services Programs (SSPs) are community-based programs that provide access to sterile needles and syringes free of cost and facilitate safe disposal of used needles and syringes.' Research has shown that SSPs are effective at reducing the transmission of diseases through injection drug use (IDU).? ° Given their clinical effectiveness and the negative associations surrounding SSPs,* they have produced a variety of policy responses from states.° This analysis will examine the available research on the impact of policies surrounding SSPs. MH Syringe Services Laws in the US MISS. CODE ANN. SEC. 41-29-105, SEC. 41-29-139 Prohibits the sale or distribution of drug paraphemalia, specifically defining syringes and needles as paraphernalia. The Centers for Disease Control and Prevention (CDC) estimated that in 2016, nine percent of human immunodeficiency virus (HIV) infections in the United States were attributable to injection drug use (IDU).° IDU has been shown to be the most common means of transmitting hepatitis, and an estimated 30 percent of persons who inject illegal drugs aged 18-30 years are infected with hepatitis.' Studies have shown that the availability of SSPs is associated with a greater than 60 percent reduction in the risk of contracting communicable diseases, such as hepatitis B and C, among injection drug users.® Similar studies have shown that those who did not use a SSP when one was available were three times more likely to contract HIV than those who used the available SSP.° In order to ensure the legal operation of SSPs several states have passed laws allowing for varying degrees of syringe services" (Figure 1). FIGURE 1, SYRINGE SERVICES LAWS BY STATE HB Authorizes SSPs BB Does Not Authorize SSPs Authorizes the Retail Sale of Syringes [=] Exempts Syringes from the Definition of Drug Paraphernalia Sources: CDC. September 27, 2017. Retail Sale Of Syringes. hitps:/Awww.cdc. gov/hepatitis/policy/RetailSaleOfSyringes. htm; CDC. September 27, 2017. Syringe Exchange. https:/www.cdc.gow/hepatitis/policy/SyringeExchange.him; *NOTE: Indiana's law only allows for syringe exchange and the sale of syringes during a state declared disease outbreak emergency. State law prohibits the use of state funding for syringes. Laws relating to syringe exchange come in three primary categories: laws that allow syringe exchange statewide, laws related to the retail sale of syringes, and laws that include or exempt syringes from the classification of drug paraphernalia. Currently, 19 states have laws authorizing syringe exchange statewide, 27 states authorize the sale of syringes without a prescription, and seven states exempt syringes from their paraphernalia laws. 10f 5 Center for Mississippi Health Policy = Report: SYRINGE SERVICES PROGRAMS-Jmpact on the Spread of Communicable Diseases © MAY 2019 Currently, Mississippi law does not explicitly authorize the exchange of syringes and categorizes syringes as paraphernalia but does not have a law prohibiting the retail sale of syringes without a prescription nor a law prohibiting sales specifically to people who inject drugs (PWID)." I Syringe Services Policy Effectiveness A growing body of research indicates that SSPs can be effective in reducing the spread of infectious diseases and getting injection drug users into treatment.' 13 14 15 A limited number of studies have documented negative impacts of these programs, including studies showing that users of SSPs are more likely to have HIV, the utilization of SSPs increases the risk of becoming HIV positive,"* "" and regular use of SSPs is associated with passing of contaminated syringes." A few studies show no difference in the risk of becoming HIV positive between users of SSPs and non-users. In 2010, an international literature review was conducted of 45 studies evaluating the effectiveness of SSPs. Researchers found that most of the available studies suggest SSPs do attract a high volume of HIV positive individuals, but SSPs are not associated with a higher risk of becoming HIV positive. The 2010 review also found that SSPs do attract a high volume of persons who inject drugs, but SSP attendance does not increase syringe sharing, borrowing, lending, or reuse.'? A systematic review conducted in 2013 of 15 studies*° and subsequent research including a 2014 meta-analysis of 12 studies*' and a 2017 Cochrane review"? found evidence that syringe exchange programs are associated with reductions in HIV transmission, and a combination of SSPs and opioid-substitution therapy could reduce the risk of hepatitis C transmission among PWID. Much of the opposition to SSPs derives from moral, social, or cultural concerns. One of the primary concerns with SSPs is that federally funding SSPs would contradict law enforcement efforts to stop illegal drug use and amount to a tacit Pw) . approval of drug use." In 2010, the federal ban on funding SSPs nn the ° p sition to SSPs derives" was lifted for a short time until 2012, when the ban was reinstated."* ? ? . 25 26 Research conducted in 2015 specifically evaluated the impact of the federal policy change to allow for local funding for SSPs in the District of Columbia. Researchers found that the policy change had a significant and immediate impact on the decline in incidence of new HIV infections attributable to injection drug use (IDU), and the policy would have had a sustained impact had it remained in place.?" I Funding for Syringe Services Programs Funding SSPs has been shown to be cost effective"® and to have a significant impact on the performance of SSPs."° A recent national level economic evaluation of return on investment showed SSPs deliver a financial rate of return between $6.38 and $7.58 for every dollar spent. °° Research shows that approximately 50 percent of SSPs receive state and local government funds. Funding from state and local government is associated with larger numbers of syringe services per year, 20f5 Center for Mississippi Health Policy = Report: SYRINGE SERVICES PROGRAMS-Jmpact on the Spread of Communicable Diseases © MAY 2019 more total services offered, and a greater likelihood of offering counseling and testing. Among programs that receive state A recent national level economic evaluation of return on and local government funding, this funding investment for SSPs showed SSPs deliver a financial rate accounted for approximately 87 percent of of return between $6.38 and $7.58 for every dollar spent. their budget for syringe services. Foundation grants and private donations are the two other major sources of funding for SSPs.*" The most recent federal guidance on using federal funds for syringe services SSP SUPPORT SERVICES OTHER THAN comes from the Consolidated Appropriations Act of 2016, which maintains the SYRINGES AND NEEDLES prohibition on the use of federal funds to purchase syringes for the purpose of = Counseling illegal drug use.*? °° Federal law was modified in 2016 to relax limitations on the = Screening use of federal funds by state health departments in consultation with the Centers © Prevention for Diseases Control and Prevention (CDC) for SSP support services other than = Vaccinations . : : = Provision of Naloxone the purchase of needles and syringes (see sidebar), based on evidence of a * Mental Health Services demonstrated need. A state can demonstrate need by experiencing, or being : eee Care at risk for, significant increases in hepatitis infections or an HIV outbreak due to = Recovery Support Services injection drug use. Under CDC and Department of Health and Human Services = Referral to Coordinated Substance guidance on the use of federal funds for SSPs, state laws would still control Use Disorder Services whether a SSP or the sale of syringes could be authorized. *4 In order to be approved to use federal funds for these purposes, a state must request a determination of need for SSPs. As of 2019, 37 states and the District of Columbia have been declared jurisdictions experiencing Only ten states, including Mississippi, have not or at-risk of significant increases in hepatitis infection requested an at-risk design ation from the CDC. or an HIV outbreak due to injection drug use. Only ten states, including Mississippi, have not requested an at-risk designation from the CDC.* In 2015, there were approximately 200 SSPs in 33 states, and as of 2018, there were 320 SSPs in 41 states* *" (Figure 2). FIGURE 2. LOCATIONS OF PUBLIC OR PRIVATELY FUNDED SSP'S Sources: North American Syringe Exchange Network. SEP Locations. hitps:/Awww.nasen.org/map/ 30f5 Center for Mississippi Health Policy = Report: SYRINGE SERVICES PROGRAMS-Jmpact on the Spread of Communicable Diseases © MAY 2019 Mi Policy Considerations Research indicates that state and federal policies have a direct impact on the existence and effectiveness of SSPs.** °° *° In a comprehensive study prepared for the Centers for Disease Control and Prevention it was recommended that the federal government repeal the ban on the use of federal funds for syringe exchange services and commit substantial federal funds to providing syringe exchange services and to expanding research. The study also recommended several policy options for states: repeal their laws requiring prescriptions for access to syringes, repeal paraphernalia laws applying to syringes, and allow for the sale of syringes without a prescription." In the wake of the opioid crisis the National Center on Addiction and Substance Abuse made several policy recommendations including changing state laws to authorize the distribution of sterile syringes and changing state laws to allow for access to state funding for SSPs.*? Recently, Indiana adopted the policy approach of changing state law to provide an exception to prohibitions on SSPs during disease outbreaks.*? Delaware and Kentucky recently passed legislation authorizing statewide SSPs that provide referrals to drug treatment. Legislation passed in 2016 in North Carolina permits government and non-government organizations to operate syringe services programs that may also distribute naloxone." If Mississippi intends to use federal funds for SSP services, the state must request an at-risk designation from the Centers for Disease Control and Prevention as a jurisdiction experiencing significant increases in hepatitis infection or an HIV outbreak due to injection drug use.* As part of a recent federal initiative to eradicate HIV, Mississippi was identified by the Department of Health and Human Services as one of seven states to be targeted due to a substantial rural HIV burden' (Figure 3). FIGURE 3. STATES WITH SUBSTANTIAL RURAL HIV BURDEN Source: U.S. Department of Health and Human Services. (2019). What is 'Ending the HIV Epidemic: A Plan for America'? https://flles.hiv.gov/s3fs-public/ending-the-hiv-epidemic-flyer.pdf 4of5 Center for Mississippi Health Policy = Report: SYRINGE SERVICES PROGRAMS-Jmpact on the Spread of Communicable Diseases © MAY 2019 10 11 12 13 14 15 16 17 19 20 21 22 23 24 25 26 27 Endnotes Centers for Disease Control and Prevention. (2018). Syringe Services Programs. Retrieved from https:/Avww.cdc,gov/hiv/risk/ssps, html, Des Jarlais, D.C., Marmor, M. (1996). HIV incidence among injecting drug users in New York City syringe exchange programs. The Lancet, 348(9033), 987-91. Hagan, H., Des Jarlais, D.C. (1995). Reduced risk of Hepatitis B and Hepatitis C among Injection Drug Users in the Tacoma Syringe Exchange Program. American Journal of Public Health, 85(11), 1531-1537. Weinmeyer, R. (2016). Needle Exchange Programs' Status in US Politics. AMA Journal of Ethics, 18(3), 252-257, doi 10.1001 /journalofethics.2017.18.3.hlaw1-1603. Centers for Disease Control and Prevention. (2017). Laws Related to Syringe Exchange. Retrieved from https: ih iti i ingeExchange,h Centers for Disease Control and Prevention. (2016). HIV/AIDS Among People Who Inject Drugs. Retrieved from https://www.cde,gow/hiv/group/hiv-idu.html, Centers for Disease Control and Prevention. (2016). 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What is 'Ending the HIV Epidemic: A Plan for America'?. Retrieved from https:/Awww.hiv.gov/federal-response/ nding-the-hiv- verview, SAN Te SR SAY OSS) PROGRAMS Impact on the Spread of Communicable Diseases Center jorMississippi Health Policy Plaza Building, Suite 700 120 N. Congress Street Jackson, MS 39201 Phone 601.709.2133 Fax 601.709.2134 www.mshealthpolicy.com Wi @mshealthpolicy