The National Harm Reduction Coalition estimates that approximately a quarter of people living with HIV/AIDS also require treatment for a substance use disorder. With the growing opioid crisis impacting many rural communities in the U.S., the risk for new HIV infections due to injection drug use has become an even larger threat. The Centers for Disease Control and Prevention warned that hundreds of U.S. counties are increasingly “vulnerable to the rapid spread of HIV among injection-drug users.” In particular, Central Appalachia has the most counties considered “highly vulnerable.”
Harm reduction is a strategy that aims to reduce the harms associated with the use of drugs, including the risk of acquiring HIV or other blood-born infections. Harm reduction strategies may include implementing syringe exchange programs (also known as syringe services programs) or providing education and treatment for drug dependency.
Instead of focusing on preventing drug use, harm reduction offers services for drug users to reduce the additional harms associated with using drugs. The World Health Organization strongly recommends harm reduction as an evidence-based model for the prevention, treatment, and care of HIV. In addition, the National HIV/AIDS Strategy for the U.S. states that interventions that increase access to sterile needles and syringes among people who inject drugs can reduce the risk of acquiring HIV.
Several states have implemented laws that mandate syringe exchange programs. For example, in 1997 New Mexico passed the Harm Reduction Act, which required the New Mexico Department of Health to administer a harm reduction program with a syringe exchange component. As of 2015, Kentucky became the first state in the southern portion of the U.S. to legalize syringe exchange programs. According to the North American Syringe Exchange Network, as of May 2015, there were 228 active syringe services programs offering an exchange program for individuals in 35 states, as well as in Washington, D.C., Puerto Rico, and the Indian Nations.
For more information about harm reduction models that have been implemented in rural communities for substance use disorders, please see the Harm Reduction Models section of RHIhub's Rural Prevention and Treatment of Substance Abuse Toolkit.
Examples of Syringe Exchange Programs and Treatment for Drug Use and Dependence:
- Open Aid Alliance is an organization based in western Montana that works to reach and engage underserved populations to prevent the spread of HIV, hepatitis C virus, and other sexually transmitted infections through harm reduction. The main areas of focus include education, testing, and screening. An important element of this organization is its syringe exchange program, which has provided thousands of new syringes and supplies to people. This exchange program was one of the first open syringe exchange programs operating in the state.
- Southern Tier AIDS Program (STAP) is an organization providing comprehensive HIV/AIDS prevention and treatment services to people who are living in the southern portion of the state of New York, regardless of ability to pay. Some of the prevention services offered to clients include a focus on substance use disorder prevention and treatment, as well as a STAP syringe exchange program where people can anonymously receive sterile syringes. In addition, the organization provides educational classes about how to prevent opioid overdose, as well as other information and referrals for people with substance use disorders.
- Health Services Center (HSC) administers substance use disorder treatment services for people who are both HIV-positive and -negative. HSC integrates substance use disorder treatment into HIV treatment to decrease barriers to care. Strong case management services, transportation support, medication reminders, and free medication all help clients address multiple needs so that they can focus on staying healthy. Two featured programs include the Corrections and Offender Re-Entry (CORE) Program and Behavioral Day Treatment (BDT). CORE is an outpatient treatment program for adults recently released from a jail or prison. The program consists of comprehensive treatment and HIV prevention and education services and requires twice-weekly group meetings. BDT is an in-depth treatment program that requires meetings four times a week for 20 weeks.
- HIV Alliance is a nonprofit organization in Oregon that offers many prevention and treatment services. The organization promotes a philosophy of harm reduction and offers both secure locations for syringe drop-off in the community as well as pickup services for used syringes when needed. In several Oregon counties, HIV Alliance is one of the only organizations that offers syringe exchange services in several Oregon counties.
- The Deschutes County Syringe Exchange is a program administered through Deschutes County Health Services in Oregon that provides syringe drop boxes and new sterile syringes to members of the community in both Bend and rural Redmond. The program also educates the community about overdose prevention as well as how to prevent the spread of infections through needle use.
- Santa Fe Mountain Center offers harm reduction programming with funding through the New Mexico Department of Health HIV/AIDS Infectious Disease Bureau. Part of this programming includes a very active syringe exchange program, which provides services throughout the rural county of Rio Arriba, New Mexico. In 2015, Santa Fe Mountain Center exchanged over 1 million syringes. The harm reduction program is predominantly mobile and the staff travels hundreds of miles each week to visit homes and work with people in villages throughout the county. The program also provides counseling and food assistance to people based on need.
Considerations for Implementation
Harm reduction programs may be controversial and stigmatized when implemented in rural communities. Principles of harm reduction include respecting the decisions of people and offering solutions that are supportive of these decisions. The high-risk practices of people who inject drugs can also make this population especially challenging to locate and engage in prevention activities in general.
While recent research has suggested that injection drug use, especially prescription opioid use, is dramatically increasing in rural communities throughout the U.S., these communities have the most limited access to substance use disorder treatment services with the least number of providers able to administer treatment.
Injection drug users often face additional social issues, such as homelessness, a history of trauma, incarceration, poverty, and a lack of health insurance, which can hinder their ability to stay engaged in both prevention and care. In addition, the use of injection drugs can increase other risky behaviors, which can pose challenges for retention in programs. Since drug use is stigmatized and also criminalized in communities, it can prevent individuals from utilizing treatment services for fear of the repercussions.
To offset many of these retention and engagement challenges, some rural communities have decided when possible to co-locate services to provide both substance use disorder treatment, a syringe exchange, and HIV/AIDS treatment in the same location. Collaborations are essential for referrals to programs and to help provide more comprehensive services to communities in need.
Funding continues to be a challenge for many substance use disorder treatment programs. Before 2015, federal funding could not be used to implement syringe exchange programs. In 2015, the bipartisan budget agreement revised this longstanding ban, and the U.S. Department of Health and Human Services has since issued guidance for use of federal funds in order to implement and expand syringe exchange programs. Communities implementing this model may consider seeking foundation and state/local funding to support these programs as well.
Resources to Learn More
Directory of Syringe Exchange Programs
Provides a resource and searchable database of active syringe exchange programs throughout the U.S. Users can search the directory by zip code, state, or landmark and can find additional information about nearby programs, such as contact information and location.
Organization(s): North American Syringe Exchange Network
Harm Reduction Coalition: Syringe Access
Provides key information about the benefits of syringe access programs in reducing transmission of HIV and hepatitis C. Also a central source for updates on promising harm reduction strategies to lower the incidence of HIV.
Organization(s): Harm Reduction Coalition
Reduction for HIV Prevention
Provides information about the meaning of harm reduction in terms of HIV prevention and includes citations from research into programs that use harm reduction strategies. Also provides a worldwide perspective of harm reduction approaches to HIV prevention.
Injection Drug Use and HIV Risk
Provides information and facts about HIV and injection drug use in the U.S. Also describes HIV prevention challenges that arise when targeting individuals that share syringes and use injection drugs.
Organization(s): Centers for Disease Control and Prevention
A resource with information about how syringe services programs can reduce new HIV infections. The website also provides updated guidance from the Centers for Disease Control and Prevention, Health Resources and Service Administration, and Substance Abuse and Mental Health Services Administration on the use of federal funds for implementing these programs in communities.
Organization(s): HIV.gov, U.S. Department of Health & Human Services
Threading the Needle-How to Stop the HIV Outbreak
in Rural Indiana
Describes the lessons learned from the HIV outbreak in rural Indiana in 2015. The authors detail steps that could have been taken to mitigate the harm from the outbreak and strategies that could have prevented the outbreak all together. Many of these approaches can be applied to other rural communities facing similar issues.
Author(s): Strathdee, S.A. & Beyrer, C.
Citation: New England Journal of Medicine, 373, 397-399