Exclude

Training Guide

Guide to Developing and Managing Syringe Access Programs

This module covers:

• Needs Assessment
• Service Delivery Models
• Legal Issues
• Choosing a Site or Sites
• Hours of Operation
• Funding Issues

NEEDS ASSESSMENT

In the earliest days of syringe access, many projects were initiated with minimal planning and with very little infrastructure. Activists and drug users were simply responding to an urgent crisis in their communities, where staggering numbers of people were getting infected with HIV and viral hepatitis. These programs saved countless lives and paved the way for syringe access as it exists today. Over the years, as the practice of providing sterile injection equipment to drug users has gained acceptance and credibility, lessons learned from early programs have informed later practices and recommendations.

Among the activities that have evolved since the early days of syringe access is a more developed process of needs assessment. Time and resources permitting, a comprehensive needs assessment can inform when, where and how the SAP is conducted. Needs assessments can survey the overall social and political landscape under which services will operate – identifying IDU needs and potential allies, while also preparing for opposition and other challenges. A thorough needs assessment – one that is done with the community as opposed to on or about it – can provide a solid foundation on which to build the program, engage stakeholders and best meet the needs of the IDU community. The needs assessment process can be pared down or enhanced depending on the individual circumstances and available resources.

Needs assessments can also be the initial point of contact with many stakeholders, and present a unique opportunity to begin building trust with IDUs and other members of the community. Be as organized in your assessment as you hope to be in running the SAP, and you will gain credibility from the beginning. Take time to listen to people and hear their concerns. Failure to understand the broader community context in which SAPs operate can be detrimental to the viability and long-term sustainability of a project if not handled responsibly and with proper attention and follow-through.

The core elements of a needs assessment process include:

1)  Identifying all relevant stakeholders

2)  Review of existing data, policy, resources and services

3)  Original data collection and analysis

Methods and Strategies

Appendix A [CH1] [CH2] provides a list of additional resources with extensive information on effective needs assessment strategies. The World Health Organization’s Rapid Assessment and Response Guide on Injection Drug Use is an important and extremely comprehensive resource with valuable suggestions for collecting information about IDU community needs.

Data collection using both quantitative and qualitative methods will be valuable. Quantitative data collection includes information that can be measured numerically (for example, the number of IDUs in the community or HIV incidence rates) and is considered more objective than qualitative data collection. Quantitative data collection will rely on more precise and formal measuring instruments. Conversely, qualitative data collection is generally more descriptive and is concerned with data that can be observed as opposed to measured (for example: How does stigma affect IDU access to services? What are the barriers to practicing safer injection?)

Qualitative data often involves interviews or surveys with open-ended questions (i.e., questions that require more than a single-word answer). While quantitative data is often used for technical justification of SAPs that is also more difficult to counter with moral arguments (i.e. the value of SAPs for reducing HIV and HCV transmission), qualitative data is also essential for contributing anecdotal evidence of SAP effectiveness and ascertaining the human need and impact that the SAP can have.

Techniques used for needs assessment include, but may not be limited to:

•  Face-to-face interviews
•  Focus Groups
•  Field observations
•  Analysis of existing research
•  Informal surveys

Be creative. When conducting needs assessment, it is important to reach out to as many constituents as possible, using any or all of the above methods as well as others. For example, focus groups can be conducted with IDUs and service providers (i.e. case managers from local AIDS service organizations), whereas face-to-face interviews may be more appropriate with potential opponents (i.e. politicians, residents, business owners) and law enforcement (i.e. police officers, sheriffs, district attorneys).

Authentic IDU Involvement

IDUs should be involved in the planning and development of an SAP as early as possible, and should have continued roles in decision-making and involvement in daily operations once the program is up and running. Needs assessments are most successful when IDUs are enlisted as partners in making contact with other IDUs, developing research questions, identifying barriers, and providing insight into appropriate times and locations.

IDUs are the experts on injection drug use in their community, and successful Saps work both for and with them. In addition, early and meaningful IDU involvement in planning and needs assessment will help to gain trust and access to IDU communities.

Most new SAP initiatives will already have some contact with IDUs in the community, whether through personal connections or relationships with program clients. If you work for an agency, do IDUs already access services? do you have a rapport with IDUs at your agency? Teach-ins about SAPs for IDU participants can be a tool for soliciting involvement in the planning and implementation process. if your budget allows, it is important to offer compensation to IDUs for their time and expert knowledge.

As the SAP develops, consider forming a participant/ user advisory Board of IDUs who will be available to provide guidance and feedback on all aspects of program development and implementation. IDUs should have representation on any Sap Board of directors, and also be recruited and supported as staff, interns and volunteers.

In cases where IDUs need additional staff and/or volunteer training, it should be provided to promote successful involvement and strong information sharing. Considerations should be made when choosing meeting locations, meeting styles and meeting times. non-IDU team members should also receive training on working with IDUs, and IDUs should be involved in this process of education. In addition, while former users can bring important experience and will sometimes involve fewer organizational challenges, it is also essential to involve active IDUs; they will have the most relevant perspective on the current drug scene.

Policies to protect confidentiality and privacy are essential for working with IDUs. Keep in mind that IDUs are often (understandably) distrustful of people asking questions about their drug use, HIV risks, and lifestyle. Most IDUs have an extensive history of being stigmatized for their drug use and related issues by people claiming to care about them or acting with the best of intentions. drug use is illegal, and IDUs have adapted by developing any number of survival strategies. The process of building trust may be incremental, and patience is essential. Active listening, consistency, and respect for privacy and confidentiality are all important in building strong relationships.

Assessing the Public Health Landscape

Information on the current public health impact of injection drug use in your community can be a vital tool in advocating for, developing and running an SAP. Important understandings will also come by investigating the drug paraphernalia laws in your county, city and state, as well as other legal issues affecting syringe access. For more information, see the Legal Issues Section and Appendix B in this manual. Key information to have on hand includes estimates of drug use, HIV and hepatitis C in your community, and evidence for the effectiveness of syringe access.

Common online data sources for reference include:

• The Substance Abuse and Mental Health Services Administration (SAMHSA): Presents comprehensive statistics on alcohol, drug use andmental health topics including demographic trends, prevalence data, economic cost analyses, health consequences and much more
  • Drug Abuse Warning Network (DAWN): Collects and disseminates surveillance data about drug-related deaths and emergency room visits.
• The Centers for Disease Control and Prevention (CDC): Provides surveillance data and trend information on  a wide range of topics including HIV/AIDS, hepatitis C, hepatitis B, needlestick injuries, needle and syringe exchange/access programs and other important topics. Also manages the National Vital Statistics System.
• National Institutes of Health – National Institutes on Drug Abuse (NIH/NIDA): Presents statistical data and trends, resources and fundamental information on topics such as drug use, drug treatment, consequences of drug use, drug use in the workplace, interventions, clinical trials, ongoing research funding sources and other valuable information.

Other relevant information to have on hand may include:

• Local and state HIV and HCV prevalence and/or incidence
  • Check with your local or state health department or the CDC.
• Cost of chronic HCV and HIV treatment vs. the cost of sterile syringes
  • By researching the economic cost on communities of treating people with blood-borne infections, you can build a case for thecost-effectiveness of providing sterile syringes. Search for research that has been published in medical journals and/or at SAMHSA; links to more resources can be found in Appendix A.
• Existing services available for IDUs in your community
  • Mapping services for IDUs in your community will both highlight gaps in care and also build a referral and resource list. SAMHSA hasan online list of national substance abuse treatment providers. Follow up with services locally and research existing SAPs, local AIDS service organizations, homeless shelters, food pantries, community-based organizations and other possible resources. Once you have made initial connections, the organizations you contact can most likely link you to additional providers.
•  Statistics on drug-related emergency room visits
  • While this information may be more difficult to track down, check with Health Departments, DAWN and/or local emergency rooms to see if they compile statistics for quarterly or annual reports.
• Overdose rates
  • Overdose (OD) is a critical public health issue. Statistics about annual deaths and emergency room visits, as well as overall cost on the community, can be used to build support for the SAP. Local information may be available from health departments, while national data may be available at DAWN and the CDC.
•  Pharmacy syringe sales, if applicable
  • If over-the-counter sale of syringes at pharmacies is permitted in your area, contact Health Departments to see if they collect data on the success and use of this program.
• Syringe Disposal Options
  • Contact hospitals, pharmacies, local waste management and other resources to assess existing disposal options. Also, it can be useful to explore the possibility for expanding disposal options (for example, installation of public “sharps deposit boxes” or “kiosks” – secure mailboxes that can be strategically placed in the area to encourage proper syringe disposal.

HRC’s website offers fact sheets on a range of syringe access topics, many of which are listed in Appendix F. Other sources for data, trends and information include, but are not limited to:

• City and State Health Departments
• Community Needs Indexes (where applicable)
• State or City Offices of Vital Records
• Medical Examiners Offices
• Local emergency rooms
• Police reports of drug arrests
• Methadone programs
• Hospital-based and private detoxification programs
• Local drug treatment centers
• Pharmacies and local health-care clinics
• AIDS service organizations and other community-based organizations
• SAPs in other cities and states

In cases where these sources do not have information amassed, interviews with key personnel may be helpful. Compiling information into fact sheets and/or information packages can be helpful and having organized information with documented sources to respond to concerns will support in advocacy for the SAP.

Getting to Know the IDU Community

SAPs exist to meet the needs of injection drug users. An SAP needs assessment can help to determine exactly what the specific needs of the IDU community are and how they may vary between different groups of injectors. The best source by far for understanding these needs is to talk directly to IDUs themselves.

Consider the following:

• Who is injecting drugs?
  • Investigate number of people injecting drugs, age, race, ethnicity, housing status, cultural implications of drug use.
• Which drugs are being injected?
  • Consider form (i.e. powdered cocaine vs. crack, tar heroin vs. powdered heroin, etc.) and common additives or cuts. Findings may influence frequency of injection and/or preferred syringe sizes/gauges (see Module 2: Supplies for more information), other injection equipment necessary, etc.
• When and how frequently is injection occurring?
  • May influence syringe type, syringe distribution policies, hours of operation.
• Where do injectors hang out?
• Where does drug purchase and injection take place?
• Where are people getting syringes currently?
• How frequently do IDUs reuse and/or share syringes?
• Where are people getting other injecting equipment? How frequently do people share other injecting equipment?
• How and where are people disposing of syringes?
• What is the level of existing knowledge about HIV, HCV, and safer injection?
• To what extent are people practicing safer injection/infection prevention techniques?
• What existing services do people who inject drugs access?
• How frequently is overdose occurring? How are individuals and communities responding to overdose?

The answers to these kinds of questions should inform program model, hours of operation, the kinds and quantity of syringes and other supplies that will be furnished, special services that may be required, and almost every aspect of SAP programming. Responses gathered will also help to justify the need for an SAP and key elements of the program design. The more comprehensive the needs assessment of local drug users, the more meaningful the services provided will be. Further, the information collected during initial assessment can be revisited and used for comparison as an evaluation tool once the SAP has been established.

Getting to Know Additional Stakeholders

Understanding who is already in support of SAPs and who may have concerns early on is critical. Consider the following list of potential stakeholders:

• Local Community-Based Organizations (CBOs) and AIDS Service Organizations (ASOs)
• Law enforcement, including police and district attorneys
• Faith-based organizations
• Health departments, other government agencies, and elected officials
• Local community boards, neighborhood groups, tenant and block associations
• Relevant city workers and departments, such as Sanitation Departments, Fire Departments and/or Parks Departments
• Local residents and business owners/managers
• Methadone and other drug treatment programs
• Neighborhood schools and daycare programs

By contacting and engaging these stakeholders early in the needs assessment process, you will be able to gauge their level of support or resistance to the program, can gain insight into their experiences with IDUs in the community, and address any concerns that they may have proactively. Also, early inclusion of as many stakeholders as possible may avert unanticipated roadblocks can strengthen proposals for funding if there is multi-agency collaboration, and will generally result in a more thorough understanding of community needs.

SERVICE DELIVERY MODELS

There are a number of service delivery models that can be used to make syringes available. SAPs may operate using a single model exclusively, or opt to incorporate a mix of models to broaden their coverage and meet IDU needs in varying contexts. Needs assessment findings can be useful when choosing a service delivery model, many factors may inform which approach or approaches are adopted such as:

• Local drug scene
• Resources and budget
• Staff/volunteer availability
• Organizational structure
• Geographic context (e.g. urban vs. rural)
• Political climate

The following will briefly outline inherent strengths and potential limitations of several syringe delivery models. For additional information and technical assistance, please contact HRC at hrc@harmreduction.org or find us online at www.harmreduction.org.

Fixed Site

The SAP is housed in a building or single location such as a storefront, office, or other similar space. Fixed sites are often more appropriate when IDUs are somewhat centrally located in a particular area.

Fixed sites offer greater opportunity to integrate other services, including drop-in centers, counseling and referral, case management, medical services, HIV and HCV testing, support groups, food provision, abscess and wound   care, etc.

Strengths

• Offers shelter from street-based activities
• Opportunity to create a comfortable “safe space” for building trust
• Protection from the weather
• Room for growth and potential expansion into other service areas such as medical care, counseling, acupuncture, etc.
• Increased privacy and out of the direct line-of-sight of local residents, businesses
• On-site storage space
• Easily supports computer-based record-keeping systems
• Privacy for SAP participants

Limitations

• Participants must come to you
• Potential limitations on hours of operation (including staffing issues)
• Higher overhead and upkeep (including security system and maintenance)
• Can become the focus of community opposition
• Difficult to stay attuned and adjust to changes in the drug scene, neighborhood development (for example, if your location becomes irrelevant)
• Greater visibility of individual drug users

Mobile/Street-Based

Syringe access is conducted by foot or bicycle (especially in urban areas) or by using a vehicle – oftentimes a van, bus, or even motor coach. Stops are made at designated locations at specified times. This method may also be referred to as outreach.

Mobile delivery is useful in situations where drug markets/concentrations of drug users are geographically dispersed or there are limited public transportation options are available to participants. Mobile delivery may also be preferred in areas where there is a high likelihood that there will be police surveillance of fixed sites.

Mobile delivery is often used in conjunction with a fixed site program, but may just as easily operate as a stand- alone program. Nonetheless, the legal issues for a mobile delivery model are consistent with fixed sites or other models. It is most often the case that mobile routes are pre-approved and authorization must be sought to adjust or change locations. Working with and educating law enforcement (and other stakeholders) about mobile syringe access is critical to ensure the safety of outreach workers.

Some mobile units/fixtures will also provide ancillary services such as on-site counseling, HIV and/or HCV testing, abscess and wound care, other medical services such as directly-administered antiretroviral therapy and tuberculosis screening and treatment, referrals to drug treatment and access to low-threshold buprenorphine, etc.

 Strengths

• Flexibility if the drug scene or neighborhood changes
• Often more acceptable to community residents and businesses
• Informal and low threshold, depending on location (ex. sidewalk or park)
• May reach IDUs less likely or unable to come to a fixed site
• Van potentially allows for expanded service provision

Limitations

• Harder to deliver ancillary services than with a fixed site
• Inclement weather can dissuade participants from coming to SAP
• Strenuous work conditions (due to the elements and/or issues of personal safety)
• Challenges related to supervising outreach staff
• Van involves high overhead because of insurance, fuel, upkeep, parking, driver, etc.
• Need off-site storage
• Participants will be seen out in the open, which may create privacy concerns

Home Delivery/Urban

Injection supplies are delivered to where a person lives (or another agreed upon site) in the city, such as SRO hotel rooms, scattered site housing and/or shooting galleries. Service delivery can happen on a regular schedule, or by appointment via cell phone or pager. Urban delivery may be combined with mobile or fixed sites and is often useful when groups of IDUs reside or congregate in a single location.
Strengths

• Safer for participants
• Potential for large transactions
• Participants do not need to transport used injection equipment
• Provides opportunity for intimate contact and information-sharing about injection practices, health and other issues
• May reach IDUs less likely or unable to come to  program site
• Potential interaction with family and support networks
• May provide more privacy for participants
• Often easier to start up

Limitations

• Participant needs to be at home
• Requires substantial trust to overcome potential privacy concerns
• Potentially time consuming
• Need mode of transportation for supplies
• May be difficult to sustain
• Need agreement with SRO owner to provide services
• Participant can be put at risk if drug-related activities take place or are exposed in monitored facilities (ex. eviction from City housing)

Home Delivery/Rural

Delivery of injection equipment to where a person lives (or other pre-specified meeting locations) in rural or suburban areas. Appointments can be scheduled on a regular basis, or made as needed via cell phone or pager.

Similar to urban delivery, rural delivery may be combined with other program models to reach participants that would otherwise be unable to access program services. Sustainability of rural delivery can sometimes be an issue due to time and resource demands.

Strengths

• Safer for participants
• Potential for large transactions
• Participants do not need to transport used injection equipment
• Provides opportunity for intimate contact and information-sharing about injection practices, health and other issues
• May reach IDUs less likely or unable to come to program site
• Potential interaction with family and support networks
• May provide more privacy for participants
• Often easier to start up

Limitations

• Participant needs to be at home
• May be perceived as an invasion of privacy
• Potentially time-consuming and difficult to sustain
• Can involve a lot of driving, resulting in high overhead
• Requires a vehicle

Secondary or Peer Delivery Modules

Secondary or peer delivery modules occur when participating drug users distribute syringes within their drug-using networks after being supplied with equipment by the SAP. Secondary access can be combined with other models and is appropriate in most drug scenes.

It is important to have established policies and procedures in place for secondary and peer-based models, with protections in place for peers. Legal restrictions may limit peer delivery due to issues regarding distribution of paraphernalia; however some areas (such as New York State) have worked with Health Departments to authorize peer delivery. Check local restrictions to ensure peer safety.

In some cases, SAPs have been able to use a peer-based model to increase the likelihood that participants will have access to sterile injection equipment closer to the point of drug purchase or injection.

Strengths

• Taps into peer knowledge of drugs, drug use, and the local drug scene
• Increases access to sterile syringes for groups less likely to access other SAP services (e.g. women, younger
• IDUs)
• Encourages people to talk about the SAP and may attract new participants
• Empowers peers to provide services to their own community and take ownership in the work
• Extends reach to IDUs less likely or unable to come to program site
• Increased volume of delivery

Limitations

• Cost of training and supervision of peers
• Possible conflicting identities as peer workers and IDU community members
• Managing boundary issues can be challenging
• Peers may need to collect and transport other participants’ used injection equipment

Hospital/Clinic Based

Syringe access is provided out of a hospital or clinic-based setting. Hospital-based delivery may be one avenue for delivery in cities/areas with heightened restrictions on other SAP models, or may be used in conjunction with other models. Doctors also have the capacity to furnish prescriptions for syringes; this may be able to further support expanded syringe access, even in areas where other models are also in place.

Strengths

• Opportunities to get immediate medical care for abscesses and other wounds or health issues
• Access to regular HIV and or HCV testing
• May provide more privacy
• Biohazard disposal likely on-site or otherwise pre-established

Limitations

• Possible negative associations with medical system (i.e. poor medical treatment, stigmatization)
• Potentially clinical and/or cold environment
• Internal referral mechanisms to other health care services may be poor or difficult to access

Integrated Syringe Access Services

An organization serving IDU or related populations adds syringe access into their existing array of services, rather than creating a separate syringe access program. In some cases, syringe access services may be restricted to the programs’ clients, rather than available and advertised to all IDUs. Examples of potential settings for integrated services include case management programs, methadone programs, research or clinical studies, homeless shelters, and housing providers.

Strengths:

• Pre-existing organizational infrastructure and client base
• Multiple ways of getting syringes to participants, depending on the type of services provided by the agency (mobile, fixed site, delivery, etc)
• May have additional staff or resources available

Limitations

• Staff may be resistant to new programs & new ideas, especially if the agency follows a traditional abstinence approach
• SAP may not be prioritized by the agency which could hinder program success
• Agency policy may impose difficulties on low threshold service delivery
• Interactions with non-IDU participants may pose challenges
• Multiple funding streams may limit program autonomy and/or use of culturally appropriate materials

Collaboration or Satellite Structure

Partner agencies that provide related, but different services within the community (e.g. social, shelter, youth, etc.) will incorporate SAP services at their site on behalf of the parent SAP.

Strengths

• May attract different groups of IDUs than parent program
• Increase accessibility in terms of location, time, culture and age group
• May offset operational and human resource costs from the parent SAP to the satellite site

Limitations

• Difficult to maintain consistent policies between parent SAP facility and satellite site
• Staff turnover at satellite may require frequent training of staff by parent SAP
• Inventory may be difficult to track without specific systems in place

Pharmacy Voucher Program

Organizations work with pharmacies by providing participants with vouchers redeemable for free syringes at participating pharmacies. Pharmacy voucher programs are especially useful in areas that have been unsuccessful in implementing SAPs but where over-the-counter sale of syringes without a prescription is permitted by law. Pharmacy voucher programs are also useful areas where drug use may be geographically distant and IDUs are unable to travel to the SAP.

In cases where pharmacy vouchers are used, SAPs may provide pharmacies with equipment and disposal services.

Strengths

• Mainstream location
• May have longer, more convenient hours
• May be located closer to where injectors live or hang out

Limitations

• Pharmacists and pharmacy staff may hold pre-existing biases toward IDUs and selectively serve participants
• IDUs may receive less individualized education, referrals and safer injection information
• Pharmacies may be unwilling to dispose of used equipment
• Pharmacies may have caps on the number of syringes per transaction
• May be more difficult to provide injecting equipment other than syringes (cookers, cottons, water, ties, alcohol, etc)

Using Multiple Program Models

Whenever resources allow, a multiple program model is often the most effective way to reach the greatest number of IDUs. Combining models, for example – one fixed site with a mobile van, or a mobile unit with peer-based walking delivery – literally works to “meet IDUs where they’re at” and increases the likelihood that syringes will reach even the “harder to reach” IDUs. In addition, multiple program models offer increased flexibility to direct resources to the most effective means on an as-needed basis, allowing programs to respond to shifts in behavior patterns among local IDUs.

When using multiple program models, it is important to be sure that all aspects of the program will be sustainable. Multi-approach models can require significant resources and demand more from staff. Nonetheless, for participants, the same standards of consistency will apply. If one aspect of the program loses credibility, it is possible that all aspects of the SAP will suffer. However, when well-executed and fully resourced, multi-approach services can be a valuable, comprehensive approach.

LEGAL ISSUES

Although advocacy in many states has paved the way for successful syringe access, the legal landscape can be complicated and challenging to navigate. This section will outline some of the key considerations around legal issues when trying to implement syringe access. In particular, it is necessary to evaluate the legality of operating the SAP from a program perspective, as well as any legal implications for participants.

Fear of drug use and drug users along with the impulse to regulate socially undesirable activities has led to sweeping restrictions on the possession, sale and distribution of needles and syringes which may be used for the injection of drugs. Public health imperatives and again, the work of activists, drug users and their allies, have successfully pushed for changes and an easing up of some legal restrictions on syringe access and possession over the years. In addition, the lifting of the federal ban on funding for SAPs in late 2009 offers a huge push for public health ideology and authority to overrule criminal statutes limiting SAP initiation and operation. It is important to understand, however, that there are differences between Federal and state law. Nevertheless, all states do have statutes that will allow public health authorities to dictate what is needed in order to respond to public health emergencies and prevent the transmission of infectious disease.

There is no federal law that precludes SAP implementation. There are, however, several types of laws and/or regulations that vary by state that are of particular importance to consider with regards to the operation of SAPs:

1. Drug paraphernalia laws

• Laws that regulate the distribution AND possession of drug paraphernalia including syringes and crack pipes/stems. Paraphernalia laws may also extend to cookers and other injection supplies.
• Without proper legal justification, participants can be arrested and charged for possession of clean or used injection equipment.
• Without proper legal justification, SAP workers can be at risk for possession or distribution of syringes and other supplies.
• Most often, paraphernalia law infractions qualify as misdemeanors, however, in some states they are felonies.
• Some states categorically exclude syringes from paraphernalia laws, while others have special exclusions outlined for pharmacists or SAPs

1. Syringe prescription laws

• Laws requiring a physician’s prescription for sale or distribution of syringes.
• Can provide some safety around the possession of syringes obtained without a prescription.
• In some states, regulations may apply restrictions by age, quantity of syringes, etc.
• SAPs may have legal authorization to operate despite restrictions being in place around syringe prescription.

1. Over-the-counter pharmacy sale regulation

• Regulations that restrict over-the-counter pharmacy sale and distribution of syringes.
• Regulations may impose limits by prescription, age, syringe quantities or other factors.
• SAPs may have legal authorization to operate despite restrictions being in place around over-the-counter sale.

1. Explicit syringe exchange/access laws or regulations

• Laws or regulations that pertain exclusively to the operation of SAPs.
• May make SAP operation legal contingent on compliance with operation requirements, such as when, where, how and how many syringes are exchanged/distributed.

Many states still have anti-drug paraphernalia laws in place, despite having additional statutes that open the door for syringe access via SAPs and pharmacies. While state law may not prohibit the distribution of syringes via SAPs, there can be local laws in place that do. It is important to know the law in any jurisdiction the SAP may operate and/or participants may live. Further, be cautious in cases where the criminal code may contradict the public health code. Investigate the likelihood that SAP participants will be charged with drug possession should they get caught with residue in a syringe that they are bringing back to the SAP for disposal. Understand local, city, and state laws around syringe access as completely as possible, and remember to seek support from existing programs in or around your locality. In some cases, advocacy may be necessary to change existing laws.

Most states have successfully deregulated over-the-counter sale of syringes without a prescription at pharmacies. This has positive implications for overall syringe access as well as for protecting participants who are carrying syringes.   However,  even in states where deregulation has been passed, there may still be limitations imposed on who can purchase syringes, the number of syringes that can be obtained at a time and/or there may be ID requirements to purchase syringes. In addition, oftentimes it is up to individual pharmacies to decide if they will participate in over-the-counter sales, and some still may operate using bias and discrimination if they suspect syringes will be used for injection of illicit drugs. Many pharmacists still need education about the benefits of providing sterile injection equipment to drug users and/or cultural competency when working with drug users.

SAPs should be aware of policies around syringe access from pharmacies, and any related laws that may impact the SAP and its participants.

The following resources are available to find out more about specific regulations in your area:

1.  Your local health department
2.  Harm Reduction Coalition (HRC)
3. Temple University’s Project on Harm Reduction in the Health Care System
4. American Civil Liberties Union (ACLU)

Appendix A provides links to additional resources that point to background on the legal basis for syringe access in the United States, while Appendix C details specific strategies for legal justification of SAPs that have been successful. Also, if at all possible, it can be helpful to build relationships with some good, local criminal lawyers who support syringe access and with whom you can consult as needed.

All staff at the SAP must be trained and well-versed in legal issues related to the  SAP.  It is important for all staff to understand the legal rights of SAP participants as well as the overarching authorization or legal justification for the SAP to operate. In addition, any legal documents – such as waivers or authorizations should be easily accessible to all staff in case of incidents with law enforcement. Staff and peers should receive proper SAP identification, indicating their affiliation with the program.

Regardless of the kind of protection offered under the law for SAP operation, it is crucial to engage with local law enforcement early in order to minimize any potential problems or confusion. Particularly in cases when there are recent changes to penal codes, law enforcement may not understand the protections for SAPs and their participants. In addition, given the vulnerability of drug users when it comes to law enforcement, it is the responsibility of the SAP to ensure that participants understand how they are protected, and any ways in which they may not be protected from prosecution. Module 4 will discuss negotiations with law enforcement in greater detail, however, the more education and outreach that can be done to local law enforcement early on – including an outline of the legal authorization for your program as well as benefits of the SAP to officer and public safety – the better.

Drug users can still be arrested for possessing hypodermic needles and syringes (clean or used), even if they can be legally purchased over-the-counter without a prescription or obtained legally from SAPs. Despite laws, regulations and legal precedents that protect SAP participants from prosecution for syringes obtained or being returned to SAPs, arrests or additional charges (paraphernalia or drug possession for residue in syringes or cookers) are not uncommon. It is always important to distinguish between the law of the land and the law as it plays in the street. that is to say – sometimes law enforcement officers make arrests, despite protections under the criminal or public health code – creating very real consequences for drug users.

CHOOSING A SITE OR SITES

Site location

Choosing site location for conducting syringe access services – be it fixed, mobile or outreach sites – can be among the most important factors in the success of the program. Site location can inform whether IDUs will visit the site, how comfortable they feel once they get there, and, in some cases, the level of community resistance the SAP may face.

An SAP can have wonderful services and excellent staff; however, without IDUs it will not function. An inconvenient location, or one that is perceived as threatening in any way (ex. near a police station), could easily deter IDUs from visiting the program – even when they are interested in taking care of their health and using sterile injection equipment.

Beyond making it difficult for IDUs to access sterile injection equipment, improper site location can have other ramifications. In extreme cases, controversy around location choices can undermine overall support for syringe access, attract heightened scrutiny directed at program operations and participants, and jeopardize relationships with allies and other stakeholders.

When choosing a site, it is important to know as much as possible about the location. Certain locations can almost guarantee community opposition. For example, an SAP is likely to invite public opposition if it is too close to any place where children congregate, including:

• Schools
• Playgrounds
• Children’s nurseries and day-care centers
• Youth and after-school programs

In urban areas, restaurants with outside seating or shops with window displays may be concerned about drug users congregating in front of the program. Residential areas can also pose challenges – commonly known as NIMBYism (Not In My Back Yard). In general, it is important to keep in mind that IDUs are likely to gather and hang out in front of the program or across the street; it is the responsibility of the SAP to protect both participant safety and program viability from the program’s outset, which includes anticipating problems before they occur.

Of course, it is equally important to choose a site that will be convenient and accommodating to the IDU community. The good site is going to be one that makes transactions quick and easy so that, if need be, IDUs can continue with any other activities with as little disruption as possible. A good location will also be close to where IDUs live, work and/or obtain drugs. Ideally, it will be easy to find, but still somewhat discreet.

Proximity to public transportation, particularly in urban areas where it may be the primary mode of transport, is also an important factor. Using information gathered during needs assessment, look for a location that will be convenient to copping spots (places where people buy or “cop” drugs), but not so close that the program, its participants or anyone else may be compromised. A good question to ask in a needs assessment would be, “How  far do you think you would be willing to walk for clean injection equipment?” Consider traffic patterns around a potential location – will drivers have a hard time parking? Will people on foot have an easy walk? Will the program be accessible to people with disabilities?

SAPs may also benefit from being near methadone programs, hospitals, welfare or public assistance offices, shelters, soup kitchens and/or other ASOs or CBOs.

Fixed-Site Considerations

Choosing a fixed site comes with unique considerations. When choosing a site, consider issues such as program growth, storage space and general feel. Programs that feel too “clinical” may be less appealing. In addition, consider the design and layout of your program – will it be able to fit desks, couches, chairs, etc?

The layout should also allow SAP staff to easily see what’s going on at all times – including where people are and that all participants are safe. Given the nature of working with people who use drugs, it is important to be able to monitor for overdose as well as other safety issues at all times. On a related note, when choosing a fixed SAP site, the bathroom can be an important consideration. It is not uncommon for IDUs to be transient and/or homeless and a restroom can be an especially valuable resource. In many cities, public showers and restrooms for IDUs can be hard to come by. Keeping a biohazard disposal container in the bathroom can reduce the incidence of sharps or other biohazard material from being disposed of improperly. Finding a site with a shower can be of particular value, although it will also pose organizational challenges. Even bathrooms without showers will often be used for “bird baths” (i.e. showering in the sink), private time, changing clothes and other needs; because the bathroom can be such a valuable resource, it can be useful to monitor how long individual participants spend in the bathroom.

Once a site is identified, proactive and strategic community relations will be crucial. Be honest with the landlord and your community, however also be attentive to the privacy of your clients and be discreet. You will be running a public health initiative that targets drug users in the neighborhood. Emphasize that you and/or your agency cares for the welfare of the community. Be up front that there is likely to be heavy traffic with people coming and going frequently, and that there will be policies and procedures in place to monitor the safety of the building, as well as the safety and security of any other tenants. If applicable, explain that an alarm system will be installed. In addition, if state or city Health Department funding is being used, this can add credibility and financial stability to the application. Emphasize that an SAP is a comprehensive program offering a range of services, among which are syringes, as well as referrals to treatment and supportive services.

HOURS OF OPERATION

SAP hours of operation can have significant implications on program success and accessibility. Ideally, program hours meet drug users on their schedules. It is unlikely that syringe access is going to fit neatly into a nine-to-five schedule. Ask drug users when the program should be open. Often, longer hours and/or hours ranging throughout different time periods in the day are likely to increase the number of people who will be able to visit the program. However, the best hours are going to be the ones that are convenient to the users in the community – being open 6 hours as opposed to 3 means little if users are not able to visit the SAP during open hours. If possible, on-call hours, facilitated with the use of a cell phone or pager system can be great resources as well.

Consider who will be coming to the SAP. If the target population includes a high proportion of sex workers, it will be important to include evening and nighttime hours. If the SAP will target people attending methadone programs and/or otherwise acquiring methadone, morning hours and evening hours are likely to meet participant needs. The needs assessment process can serve as an opportunity to talk to users, identifying when/if people may be working, public transit schedules and other factors that may influence when someone could come to the SAP.

Hours of operation may vary depending on the SAP model. Fixed sites may remain open for longer stretches of time, while mobile programs may operate as shifts, spread throughout the day and night. Fixed sites that are coupled with a drop-in center may try to be open during hours when participants are more likely to need refuge, such as early mornings or late nights. Special safety considerations should be made when choosing hours of operation for street-based teams. Seasonal variation in clientele may also impact program hours. Summer hours may need to be extended to accommodate for an increase in transient users. In addition, people may or may not have different needs depending on the day of the week and/or time of month.

Once hours of operation are established, it is essential to be consistent and reliable – all of which are part of building trust with participants. Be sure the program has proper resources to ensure sustainable and adequate staffing during open hours. Hours should be clearly posted and staff must know the importance of operating on time. Many SAPs will stay open on holidays, even if they have limited hours and/or services. Holidays can be especially stressful times for many drug users, and the resource may be of heightened importance. Either way, be sure to communicate any program closures or changes in regular hours with as much advance notice as possible.

FUNDING ISSUES

Securing funding for syringe access can be an intimidating process. However, even before the signing of the Fiscal Year 2010 Consolidated Appropriations Act in late 2009 – which made it possible to use federal dollars to fund SAPs – individuals, organizations, health departments and coalitions have been able to acquire the funds necessary to provide sterile injection equipment, and oftentimes supplementary services. It is true that funding is limited, and while many syringe access programs in the world operate with a small budget of $100,000 or less, there is funding. Even in more conservative political climates the public health imperative has been able to triumph over dogmatic opposition.

A successful strategy for funding syringe access programs will:

• Be well organized and well informed
• Take full advantage of public and private resources at the community, city, state and federal levels
• Tailor funding proposals to highlight the benefits of the SAP in relation to the needs and goals of the potential funding source
• Use needs assessment to inform on local drug user issues including unique needs and gaps in services
• Take advantage of support from community allies and advocates
• Apply a creative approach
• Maintain focus and persistence

When applying for funding, be mindful of requirements that will be tied to monies received. In some cases, the reporting and evaluation requirements attached to project awards can be strenuous. There may be political ramifications associated with accepting money from certain sources – namely corporations or drug companies. In addition, certain funders can strangle program autonomy with regulations that may oppose the ideological foundation upon which the SAP was built. These considerations, with others, will be weighed against the benefit of receiving funds essential for basic operations. Although it is possible to start and run programs on an entirely volunteer basis and with donations of syringes and other supplies (maintaining more program control) this strategy faces significant challenges to the long-term sustainability because of shifts in supply availability, staffing and potential conflicts in ideas about program direction.

Budget Considerations

Here are a couple of items that could get overlooked when putting together a budget. not all are essential – but may be worth consideration:

• Stipends: For interns and/ or peer workers
• Travel Reimbursement: For volunteers, interns and/or peers. particularly in areas with extensive public transit, travel reimbursement
• can be an option for implementing participant compensation programs if necessary.
• Insurance: Several kinds of insurance may be necessary including renters insurance, loss or theft insurance, vehicle insurance for mobile programs, product insurance (computers, photocopiers, etc.)
• Office Supplies: although it seems obvious, costs for toner for printers and/or copiers and other basic office supplies can add up.
• Cleaning: Depending on the model (fixed site, etc), the number of staff and/or the level of foot traffic anticipated at the program, it may be necessary to hire someone to clean the program on a regular basis. this can also be a job designated in part to volunteers or as a job training initiative, in which case funding should still be allocated for the position.
• Staff Development Costs: on-going training and support for staff is essential for preventing burn-out and high staff turnover. Consider costs of training for staff, as well as staff clinical supervision and/or retreats.
• Basic Comfort Supplies: Making the Sap a comfortable place to hang out is important. Consider costs of creating a warm and hospitable environment for participants with coffee, food, games, television/entertainment, artwork, etc.

Potential funders

A long-standing and extensive resource for SAPs, especially for new or low-budget programs, has been the North American Syringe Exchange Network. NASEN is a nonprofit organization that provides services in promotion of expanding access to tools and services that promote the health and well-being of drug users. To that end, they provide both technical and financial assistance . The NASEN Buyers Program offers a way for SAPs to acquire low-cost syringes and supplies. NASEN grants  are  available  to  small  or  new  SAPs  with  budgets  of $75,000 or less, and awards do not exceed $15,000 (at the time  of  this   printing).   In   addition,   NASEN   offers   Start-Up Kits to new projects made up of credits to their Buyers Club for more than 12,000 syringes and/or supplies. Start-Up Kits are geared towards programs with little to no operational history or funding, and require a minimum staffing commitment to ensure that the program will be sustainable. For programs that find themselves with a temporary lack of funding, NASEN also offers a short-term loan program for financial assistance and/or Buyers Club credit.

With the federal ban on funding for syringe access having been lifted in the final days of 2009 , organizations and health departments already receiving federal dollars will be able to use this money to pay for syringe access. This includes programs receiving funding from the Centers for Disease Control (CDC), the Health Resources and  Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institutes of Health. It is expected that the CDC will issue guidelines for the use of federal funds.

At the city and state levels, many health departments and/or government offices are already invested in, or have expressed support for, syringe access programs as part of comprehensive plans to address HIV and viral hepatitis transmission and prevention. Engage with the city and state Health Department to learn:

1. If there is a departmental policy regarding syringe access and whether collaboration will be an option.
2. Specifically what types of support (financial or otherwise) may be available.
3. The application process, waiver requirements and/or regulations attached to partnership with the Health Department.

If the Health Department does not currently have a position on syringe access, it could be a worthy investment to develop an advocacy strategy to educate potential allies at health departments about the public health value of investing in syringe access programs. For more information on working with Health Departments, please see Module 5.

Investigating other potential sources of funding at the local level is also important. For example, some localities will have city councils with funds available for allocation to community groups and coalitions. Some areas may also have community boards with discretionary accounts for distribution to community groups.

Next to health departments, possibly the greatest source of funds available for syringe access come from grants received from private foundations. When researching potential foundations:

• Be sure to carefully investigate the foundation’s specific aims, goals and requests (i.e. restrictions, reporting requirements, budgetary limitations, etc).
• Explore foundations that support HIV and HCV prevention, public health and/drug user health and rights, homelessness and poverty issues, general social welfare and social justice initiatives, among others.
• Some funders that may not be willing to fund syringe access directly, may still be interested in funding ancillary services, such as testing, counseling, other prevention efforts, etc.
• When you find a potential funder, look at previous grant recipients to see what kinds of specific projects the foundation awards money to.
• Be sure to look at typical award amounts to inform your budget and assure that it will be worth the effort it takes to prepare a comprehensive proposal. A list of funding resource links can be found in Appendix A.
• The Foundation Center provides services to help research and locate appropriate sources for funding.

Other private sources of funding worthy of inquiry may include:

• Universities
• Hospitals
• Research Institutes
• Pharmaceutical Companies
• Corporate Sponsors
• Individual Donors
• Professional fundraisers and/or fundraising events