SATELLITE SYRINGE EXCHANGE: AN APPROACH INCORPORATING HARM REDUCTION WITHIN HARM REDUCTION
by
Katharine DeBurgh
A Master's Paper submitted to the faculty of the University of North Carolina at Chapel Hill
In partial fulfillment of the requirements for the degree of Master of Public Health in
the Public Health Leadership Program.
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ABSTRACT
Syringe exchange programs are an effective way to prevent the spread of HIV among
injection drug users (World Health Organization [WHO], 2004). Satellite syringe exchange
occurs when injection drug users visit a syringe exchange program to exchange syringes for
themselves as well as for others who do not visit the program directly (Valente, Foreman, Junge,
& Vlahov, 1998). Some studies have concluded that satellite syringe exchange is less likely than
direct contact with a syringe exchange program to eliminate high-risk behaviors such as syringe
sharing, and may result in higher rates of HIV (Green et al., 2010; Bryant & Hopwood, 2009;
De, Cox, Boivin, Platt, & Jolly, 2008; Huo, Bailey, Hershow, & Ouellet, 2005; Tyndall et al.,
2002). This has led some syringe exchange projects to forbid satellite exchange (Des Jarlais,
McKnight, Goldblatt, & Purchase, 2009); although this does not guarantee satellite exchange
will not take place (Lorvick et al., 2006). On the other hand, one study has found that those who
receive new syringes through satellite exchange tend to engage in less syringe sharing than those
who do not receive new syringes at all (Murphy, Kelley, & Lune, 2004). Rather than banning
satellite exchange, public health practitioners must recognize it as a way to reach some
underserved populations. Syringe exchange programs could train those who exchange syringes
on behalf of others to ensure they safely handle used syringes. These programs can also train
these individuals to effectively spread harm reduction education and equipment to other injection
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TABLE OF CONTENTS
Abstract ……… 2
List of Abbreviations ………... 4
Introduction ………. 5
Satellite Syringe Exchange ………. 6
Potential for Controversy ………... 8
Discussion ………. 10
Harm Reduction Within Harm Reduction ……….. 14
Recommendations ………... 16
Conclusions ……….. 18
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LIST OF ABBREVIATIONS
Centers for Disease Control and Prevention (CDC)
Human Immunodeficiency Virus (HIV)
Injection Drug User (IDU)
Institutes of Medicine (IOM)
Satellite Syringe Exchange (SSE)
Syringe Exchange Project (SEP)
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INTRODUCTION
Harm reduction related to drug use is a set of theories and strategies first formalized
during the First International Conference on the Reduction of Drug Related Harm (O‟Hare,
2007). This model seeks to reduce the individual and community harms associated with drug use
(Aston & Seymour, 2010). A key component of harm reduction is delivering services to
individuals without moral judgment. Harm reduction seeks to benefit all individuals who use
drugs, not just those who are ready or willing to quit. For injection drug users (IDUs), one such
harm is the risk of contracting HIV from shared use of infected needles and syringes (UNAIDS,
2010). Syringe exchange programs (SEPs) are a key way to reduce the transmission risk of HIV
in IDUs (World Health Organization [WHO], 2004).
Sharing infected syringes is a major mode of transmission of bloodborne pathogens such
as HIV in injection drug users (Centers for Disease Control and Prevention [CDC], 2009).
According to the CDC, 27% of AIDS cases in the U.S. can be linked to injection drug use (CDC,
2005). For prevention of abscesses and bloodborne pathogens, the CDC recommends using a
new needle for each injection (CDC, 2009). SEPs receive and safely dispose of used syringes
from injection drug users and provide them with new, uncontaminated injection equipment and
disease prevention education. SEPs have been shown to be effective in reducing the transmission
of bloodborne pathogens in injection drug users, including HIV and AIDS (WHO, 2004). There
are many other benefits provided by SEPs, including referrals to drug treatment (Strathdee et al.,
2006), referrals to health care (Des Jarlais, McKnight, Goldblatt, & Purchase, 2009), medical
care for abscesses and wounds (Des Jarlais et al., 2009), and access to preventative health
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shown to decrease the number of inappropriately discarded needles in communities where they
operate (Oliver, Friedman, Maynard, Magnuson, Des Jarlais, 1992; Doherty et al., 2000).
There are many different models for syringe exchange, including one-for-one exchange,
one-for-one plus a small number of additional syringes (called one-for-one plus), or a need-based
distribution model with or without a turn-in of used syringes as a requirement (Des Jarlais et al.,
2009). Some SEPs have caps on the number of syringes that can be distributed per visit, others
do not. Participants in programs with no limit on distribution of syringes tend to engage in less
reuse of their own syringes than those with caps or a strict one-for-one trade (Kral, Anderson,
Flynn, & Bluthenthal, 2004). However, some argue that maintaining a one-for-one policy allows
SEP personnel to maintain frequent face-to-face interaction with each IDU, allowing them to
refer IDUs to drug treatment or medical care as needed (Tyndall et al., 2002).
Harm reduction follows the same principles as public health. Harm reduction involves
“creating the conditions in which injecting drug users face minimal barriers to safe injection”
(Beletsky, 2005, p. 272). Public health endeavors to “assure conditions in which people can be
healthy” (Institutes of Medicine [IOM], 1988, p. 7). Public health works to make sure all people
have access to healthy choices. Part of public health‟s duty, therefore, is to remove barriers
between people – such as injection drug users – and the tools they need to avoid disease – such
as new syringes.
SATELLITE SYRINGE EXCHANGE
For many reasons, there are some IDUs who are unwilling or unable to go to an SEP
directly. In these cases, satellite syringe exchange (SSE) can provide them the tools they need.
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individual that were originally obtained from formal or „safe‟ sources” (Bryant & Hopwood,
2009, p. 324). There are a variety of sources for new syringes, including pharmacies, mobile
syringe programs, fixed-site SEPs, and SSE. This paper will focus on the relationship between
SSE and fixed-site SEPs.
It is interesting to note that syringe exchange originally began in the form of SSE. In
1980, a “Junkie League” (Junkiebond) was formed in Rotterdam, the Netherlands to protect the
health of IDUs (Marlatt, 1996). Their theory was that “drug users themselves know best what
their problems are” (Marlatt, 1996, p. 784). This led to the first recorded syringe exchange
program in 1984, in which “the Municipal Health Service delivered disposable needles and
syringes in large quantities to the Junkiebond once a week for distribution and collection of used
needles” (Marlatt, 1996, p. 784). It was drug users, not public health officials, who first
developed and implemented the idea of syringe exchange; taking charge of distribution and
collection themselves. Since then, public health has played an important role in obtaining
political support for syringe exchange and establishing and administering SEPs.
Satellite exchangers are individuals who receive services such as supplies and education
from an organized SEP and provide those same services to others who do not access the SEP
directly. SSE can range from casual to highly organized, and can entail the distribution of a few
syringes to large quantities (Lenton, Bevan, & Lamond, 2006). One study found that satellite
exchangers distributed anywhere from three to 700 syringes at a time, with a median of thirty
syringes (Murphy, Kelley, and Lune, 2004). In one study, most satellite exchangers reported
concern for the health of others as their primary motivation for engaging in SSE, and provided
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that 89% of SEPs in the United States permit SSE and 76% encourage the practice (Des Jarlais et
al., 2009).
SSE “extends the reach” of traditional SEPs by making syringes available to injection
drug users (IDUs) at different times and locations, and especially at the time of drug purchase or
injection (Lorvick et al., 2006, p. 866), a time when traditional public health workers typically
would not be present. Further, SSE provides sterile syringes to individuals who might not
otherwise have a source for them (De, Cox, Boivin, Platt, & Jolly, 2008).
From a program administration perspective, SSE can be quite effective for distribution
and collection of syringes and prevention of disease, since the use of satellite exchangers can
allow a single program to cover a large geographic area at low cost (Anderson, Clancy, Flynn,
Kral, & Bluthenthal, 2003). One program, which operates solely through SSE and maintains no
fixed site, is able to use this approach as a way to keep overhead costs low and to assure that
their paid staff members spend almost all of their time engaged in the delivery of services. In
2002, this program was able to spend 75% of its budget on harm reduction supplies rather than
overhead (Anderson et al., 2003).
POTENTIAL FOR CONTROVERSY
However, there is controversy over the efficacy of SSE at discouraging syringe sharing
and decreasing risk of HIV. A study of Australian injection drug users found that those who
obtain new syringes primarily through satellite exchange were more likely to share syringes than
their peers who visited the SEP directly (Bryant & Hopwood, 2009). Canadian and American
studies have found that SSE recipients engaged in more syringe-sharing (Huo, Bailey, Hershow,
9
level of HIV than their counterparts who visit the SEP (De, et al., 2008). Additionally, one study
found that recipients of SSE may be less likely than direct SEP participants to enroll in drug
treatment (Huo et al., 2005). These findings imply that there is a benefit to IDUs to attend an
SEP, and that SSE alone is not as effective at reducing risk of HIV transmission.
On the other hand, a study of British IDUs found similar levels of syringe-sharing among
those who obtained needles through pharmacies, SEPs, or satellite exchange (Craine et al.,
2010). In addition, a comprehensive California study found that clients of SEPs with less
restrictive syringe distribution policies engaged in similar amounts of syringe-sharing, and
reused their own needles less often than clients of SEPs with one-for-one or one-for-one-plus
policies (Kral et al., 2004). When comparing the HIV risk behaviors of individuals who visited
an SEP directly, those who received syringes through SSE, and those who did not participate in
exchange at all, one study found that individuals who received syringes through satellite
exchange more closely resembled those who visited an SEP directly than those who did not
exchange at all (Murphy et al., 2004). Murphy et al. also documented that SSE recipients
“demonstrated an awareness of harm reduction practices” (Murphy et al., 2004, p. 258).
Individuals receiving syringes from other IDUs through SSE may not necessarily come
into contact with trained public health professionals. Some satellite exchangers may be trained
public health workers, but this may not always be the case. Visits to an SEP can expose IDUs to
many valuable services. SEPs, in addition to providing sterile injection equipment, can act as a
bridge to treatment and medical care (Des Jarlais et al., 2009). Individuals who do not visit an
SEP directly may not receive these vital services. One study found that IDUs who did not utilize
an SEP directly had lower rates of testing for HIV and other bloodborne pathogens (Cao &
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In addition to the concern for SSE recipients, there is cause to be concerned about those
who exchange syringes for others. For example, one study found that IDUs exchanging syringes
for others experienced accidental needle-stick injuries at a greater rate than those who did not
(Lorvick et al., 2006).
Syringe law also is another source controversy around SSE. In the United States, laws
regulating the possession and distribution of syringes are determined at the state level. In
California, syringe possession is treated as drug paraphernalia and is punishable by law;
however, counties or cities may allow SEPs and/or pharmacy sales of syringes (Backes & Rose,
2010). Such cities and counties may exempt individuals from prosecution for violating drug
paraphernalia laws if they possess ten or fewer syringes (Backes & Rose, 2010). A bill currently
before the California legislature would expand this limit to thirty syringes (Legislative Counsel
of California, 2011). Since SSE can involve dozens or, in some cases, hundreds of syringes
(Murphy et al, 2004), this leaves satellite exchangers vulnerable to arrest and prosecution for
possession of syringes.
DISCUSSION
The relationship between syringe source and HIV risk behaviors is complex. There are a
variety of reasons that individuals may receive syringes through SSE. It may be these
characteristics that are the risk factors, rather than SSE itself. Environmental factors and legal
conditions also play a role in HIV rates and the availability of syringes, as do SEP operational
conditions and structures. To view SSE as promoting a higher level of syringe-sharing or HIV is
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A review of the literature shows that those who receive syringes through SSE can have
different characteristics than those who receive syringes from an SEP directly. Specifically, those
who utilize SSE are more likely to be HIV positive (De, et al., 2008), African American (Green
et al., 2010), and male (Green et al., 2010). They are more likely to identify as gay, lesbian, or
transgendered (Bryant & Treloar, 2006). They are more likely to have less than a high school
education (Green et al., 2010) and have unstable housing (Bryant & Treloar, 2006). They are
more likely to inject stimulants (Bryant & Treloar, 2006), to inject daily (De, et al., 2008), and
tend to have an increased number of injections per syringe (Green et al., 2010). In addition, IDUs
who are young (45 years old or less) or who are homeless are less likely to take an adequate
number of syringes if they do visit a syringe exchange project (Heller, Paone, Siegler, & Karpati,
2009). All of these characteristics affect the risk profile of the IDUs who receive syringes
through SSE.
There are a variety of factors that may keep some IDUs from going to an SEP site. Many
of these reasons are related to the nature of illicit drug use and the associated laws. Fear of police
surveillance can keep individuals from visiting a syringe exchange site. A California study
showed that even in counties where SEPs operated legally, 17% of participants reported being
arrested or cited for drug paraphernalia (Martinez et al., 2007). As one interviewee stated, “I‟d
rather get AIDS then go to jail” (Feldman & Biernacki 1988, p. 35).
Research has shown that IDUs are more likely to obtain needles through SSE when there
are limitations on the operations of SEPs (Stopka, Singer Santelices, & Eiserman, 2003). Limited
hours of operation of an SEP can be a barrier for some populations (Voytek, Sherman, & Junge,
2003; Murphy et al., 2004). Programs that have extended their hours of operation have been
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Place is an important factor in syringe exchange, as it is in other areas of public health.
One mapping study showed that female sex workers tend to avoid areas known for violence or
policing, which can push them from areas with health care services and syringe exchange
programs (Shannon et al., 2008). The convenience of a location is also a factor (Rich, Strong,
Towe, & McKenzie, 1999). IDUs may avoid an area that is too “out in the open” (Murphy et al.,
2004, p. 255) or a neighborhood perceived as unsafe. Geographical proximity affects IDU
utilization of SEP (Gindi, Rucker, Serio-Chapman, & Sherman, 2009). IDUs who live in an area
with no SEP may rely on someone with reliable transportation to visit an SEP in a nearby city to
exchange syringes for the group (Murphy et al., 2004).
Two studies have shown that the primary reason individuals do not go to a fixed site SEP
is a desire to avoid being identified as a drug user to police, employers, social contacts, or family
(Murphy et al., 2004; Stopka et al., 2003). Further, drug users with a history of arrest are more
likely to avoid visiting an SEP (Murphy et al., 2004).
A California study showed that some recipients of SSE do not go directly to the SEP
because “If I have that [injection supplies] around all the time, I‟ll end up using more, and I‟m
trying to keep it down low” (Snead et al., 2003, p. 340). Similarly, injection drug users who do
not inject frequently, as well as those with a shorter injection history, seem less likely to use
SEPs (Cao & Treloar, 2006).
For some, disability or mental illness prevents travel to an SEP (Murphy et al., 2004).
These barriers include issues such as agoraphobia and physical health challenges such as
wheelchairs. Other reasons given by IDUs who prefer to use SSE were convenience (De et al.,
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mental state and/or problems with transportation” (De et al., 2008, p. 81), lack of awareness
about the program (Rich et al., 1999), or fear of harassment or stigma (De et al., 2008).
These reasons, each elucidated by research, do not imply blame. Whether an IDU cannot
or chooses not to go to an SEP is not necessarily a fault of the IDU. Nor is it necessarily the fault
of the SEP. These barriers – be they geographic, legal, operational, or personal –simply reflect
the conditions and culture in which syringe exchange currently must operate.
Each method of syringe access has advantages and disadvantages. Research has shown
that each modality of syringe access attracts IDUs with a different risk profile – for example,
IDUs that access mobile van-based SEPs tend to be at greater risk of HIV than those who access
fixed-site SEPs (Miller, Tyndall, Spittal, Li, Palepu, & Schechter, 2002). Therefore, it is best to
employ every possible method of access in order to obtain maximum disease prevention results
(Henman, Paone, Des Jarlais, Kochems, & Friedman, 1998). As one researcher stated, “legal
access through all means is the most likely way to promote the use of sterile syringes” (Stancliff,
Agins, Rich, & Burris, 2003).
SSE is necessary in order to provide services to those most at risk for drug-related illness.
Some IDUs cannot or will not go to a needle exchange location. Just as there are many factors
that contribute to a person‟s willingness and ability to access medical care (Andersen, 1995),
there are many factors that contribute to a person‟s willingness and ability to access an SEP
(Gindi et al., 2009). In both cases, these factors include race, age, gender, beliefs about health,
and perception of their need for care as outline by Anderson‟s Behavioral Model of Health
Services Use (Figure 1). These factors can predispose individuals to seek care, enable individuals
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Figure 1 Adaptation of the Anderson Behavioral Model of Health Services Use
In accessing SEPs, age is an important factor, with younger IDUs less likely to access
SEPs (Gindi et al., 2009). Language and cultural barriers can keep IDUs from knowing about
vital services or the laws that protect them (Groseclose et al., 1995). It has been found that
satellite exchange can be particularly effective for homeless youth (Sears, Guydish, Weltzein, &
Lum, 2001).
HARM REDUCTION WITHIN HARM REDUCTION
Direct SEP participation has been associated with less syringe sharing (Bryant &
Hopwood 2009; Huo et al., 2005; Tyndall et al., 2002) and, in at least one study, lower incidence
of HIV (De, et al., 2008) than SSE. However, SSE is associated with lower rates of syringe
sharing than those found in individuals who do not exchange syringes at all (Murphy et al., 2004;
Huo et al., 2005).
PREDISPOSING CHARACTERISTICS
Demographic Social Structure
Health Beliefs
ENABLING RESOURCES
Personal/Family Community
NEED
Perceived (Evaluated)
15
A survey of California needle exchange participants revealed that 70% of clients engaged
in SSE even when SEP policy specifically prohibited it (Lorvick et al., 2006). Among SEPs with
no such policy, 78% of participants engaged in SSE – a statistically insignificant difference
(Lorvick et al., 2006). Satellite exchange happens whether it is encouraged or not. Some IDUs
are unwilling or unable to go to a fixed site SEP because of the various factors discussed. For
those IDUs, SSE may be the only viable way to get a new syringe. Fortunately, there are drug
users who are willing and able to bring new syringes to their peers and reduce the ongoing risk of
disease transmission among IDUs.
SSE is associated with risk, both for the exchanger and the exchangee (De et al., 2008
Lorvick et al., 2006; Tyndall et al., 2002). However, banning the practice does not seem to work.
It would be more consistent with harm reduction principles to acknowledge that a large
percentage of IDUs will be distributing the new syringes they collect to other IDUs. Once the
fact of SSE is acknowledged, programs can actively provide resources, training, and support for
the satellite exchangers. Specifically, those who exchange syringes for others can be taught how
to handle and store used needles safely in order to avoid needle stick injuries. Further, they can
be taught to pass on harm reduction principles to their peers. These benefits are impossible if
SSE is forbidden.
A Baltimore SEP study showed that, while only 10% of their participants were satellite
exchangers, these individuals accounted for 64% of the syringes exchanged (Valente et al.,
1998). This means satellite exchangers are introducing sterile needles into the community and
returning potentially-contaminated needles to be disposed of properly. Satellite exchangers
16
over time, IDUs tend to become direct SEP users, even if they start as indirect users through
receiving SSE (Green et al., 2010).
HIV risk factors appear to be correlated with harm reduction services contact – the more
contact IDUs have with harm reduction services, the more likely they are to change their
high-risk behaviors (Miller et al., 2002; Bryant et al., 2010). It is important to acknowledge that IDUs
themselves can provide harm reduction services through SSE. In fact, because of their
membership in the community, satellite exchangers can be more effective than fixed site SEPs at
reaching IDUs with harm reduction messages (Valente et al., 1998; Broadhead, Heckathorn,
Grung, Stern, & Anthony, 1995).
RECOMMENDATIONS
If it seems SSE is not as effective at preventing HIV as a fixed site SEP, a perspective
shift may be in order. IDUs who exchange syringes for their peers engage in valuable harm
reduction work. In fact, it was IDUs who first implemented syringe exchange–and it was in the
form of SSE (Marlatt, 1996). It can seem to public health workers the IDUs who are exchanging
for their peers are not doing enough to prevent syringe sharing and HIV. However, it is important
to consider the perspective of the IDU. In many cases, public health now administers programs
originally developed by and for IDUs. SEP personnel must ask themselves what they can do to
enable satellite exchangers to pass along sufficient supplies and harm reduction messages and
materials to their peers. The California HIV Planning Group‟s Substance Use/IDU Task Force
recommended that IDUs themselves be included in “designing, delivering, and evaluating
17
Because SSE extends the reach of vital syringe exchange programs, it should be
encouraged. Ignoring the possibility of SSE – or worse yet, forbidding it – does not guarantee it
will not take place. Therefore, it would be wise to incorporate training and support for satellite
exchangers into the design of SEPs (Voytek et al., 2003). These practices would allow SEPs to
train satellite exchangers in how to handle used needles safely, how to provide harm reduction
messages to their peers, and even how to prevent and reverse drug overdose. One
California-based study showed that IDUs engaged in SSE were interested in becoming peer educators and
receiving formal training (Snead et al., 2003). SEPs can provide resources and training to the
IDUs willing to provide this service to others, in order to make sure they can effectively pass on
harm reduction supplies and education.
To facilitate SSE, SEPs should employ less restrictive policies for distributing syringes
when legally possible. Evidence shows that SSE is more common at SEPs that have less
restrictive policies, i.e., without a strict one-for-one syringe exchange requirement (Bluthenthal
et al., 2007). Less restrictive policies also result in greater syringe coverage, meaning individuals
are more likely to be able to use a new syringe for each injection (Bluthenthal et al., 2007).
Evidence suggests that IDUs who do not visit an SEP directly receive fewer HIV tests
than those who do (Cao & Treloar, 2006). To address this issue, public health professionals
might consider developing programs to take HIV testing services to IDUs, rather than requiring
the IDUs to come to a fixed site for testing. Such a program could include pre- and post-test
counseling and referral specifically tailored to meet the needs of IDUs in the field.
Widespread implementation of SSE may prove to be a controversial decision. Therefore,
syringe providers must work with local medical and public health entities when designing and
18
community. The California experience teaches that opposition to SSE can be overcome through
the use of evidence and authority (Backes & Rose, 2010). Many policymakers have fears about
syringe exchange that can be assuaged by use of the existing data on practices and outcomes.
Policymakers in California tended to be influenced by the local health officer – a physician –
when it came time to implement syringe exchange at the local level (Backes & Rose, 2010). As
with any public health program, it is important for SEPs to work with local opinion-leaders and
the community at large. This will afford stakeholders an opportunity to share their knowledge,
values, and experiences as public policy regarding SSE is developed.
In some areas, satellite exchangers are vulnerable to arrest and prosecution as they deliver
needed syringes to other IDUs. Advocates of public health must work to change this. In
California, personnel who work or volunteer for an SEP may be exempted from prosecution for
distribution of drug paraphernalia (California Health and Safety Code 11364.7). It is important to
extend this exemption to include individuals participating in SSE, in California and anywhere
drug paraphernalia laws are enforced.
CONCLUSION
Clean needles save lives. Syringe exchange projects bring life-saving equipment and
harm reduction education to an at-risk population, reducing the spread of HIV. SSE extends the
reach of SEPs. While in some instances, the data suggests that SSE is less effective than SEP
attendance at preventing HIV, SSE can and does prevent infection. SSE is to be encouraged and
facilitated rather than prohibited.
It is important for IDUs to utilize SEPs directly when possible. These public health
19
HIV-testing, and many other services. However, not all injection drug users are willing or able to
attend a syringe exchange project. Satellite syringe exchange provides this underserved
population of drug users with valuable disease-prevention services. Satellite syringe exchange
20
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