Exclude

Training Guide

Guide to Developing and Managing Syringe Access Programs

This modules covers:

• Staying Focused
• Policies and Procedures
• Supplies
• Disposal
• Overdose Prevention
• Data Collection, Monitoring and Evaluation

Whether the SAP operates on its own or is coupled with additional program services, it is essential to keep the syringe access component “low threshold” to ensure that participation is maximized. Low threshold means that to the greatest extent possible, any barriers to receiving services are kept to a minimum. Barriers can refer to:

• Eligibility criteria for participation
• Registration and syringe transaction procedures and requirements (such as ID)
• Required participation in other programs or services
• The level of personal information collected during any interaction (that could make people uncomfortable or reluctant to engage)
• Hours of operation
• Location
• Literacy requirements
• Waiting time to get/dispose of syringes
• Language barriers
• Any other program elements that may make accessing services more cumbersome for the participant.

Ultimately, syringe transactions that are quick, easy and discreet are likely to meet the needs and lifestyle of many participants. However, longer interactions can and should occur – at the discretion of the participant – as a means to invite people to take advantage of other services, for education (ex. safer injection or HIV/HCV prevention) and to allow for stronger relationship-building. Protecting the anonymity and confidentiality of participants is vital.  The fewer rules and regulations, while still prioritizing SAP and participant safety, the more accessible the program will be. Consider the necessity and reasoning behind every requirement imposed on a participant and take nothing for granted.

STAYING FOCUSED

Syringe access programs are fundamentally about serving the needs of drug users – stay focused. When developing the basics of the program, be cautious not to lose sight of the reason the SAP exists and the people you are targeting with your program. While meeting funder and community needs is important, policies and procedures ultimately need to be about getting syringes into the hands of drug users. Consistently question if and how what is being done can better meet the drug user where she/he is at. What may make it easier for a person to use the program?

If certain aspects of programming don’t seem to be working and/or participants are challenging or breaking rules, remember to ask what the program might be able to do differently or better; consider how the program could change to better meet needs and potentially avoid problems. Seek suggestions from participants about how things might be able to be done differently and take the feedback seriously. If a program always asks for suggestions, but never implements changes, participants will be less likely to offer feedback in the future.

POLICIES AND PROCEDURES

Syringe Transaction Models and Policies

The syringe transaction is the primary point of contact between drug users and the program. The quality of this interaction can be critical for setting the tone of the program. When users are able to define the terms of their injection needs, it goes a long way to underline program commitment to the provision of non-judgmental, non-coercive and unconditional support that respects individual rights to health and safety. Basically, people are more likely to trust programs that trust them.

Syringe access programs operate with the primary goal of providing injection drug users with new, sterile injection equipment as a means of reducing the spread of blood-borne viruses and other injection-related infections. In addition, there has traditionally been an emphasis placed on simultaneously removing used injection equipment from circulation through a process of exchanging old syringes for new ones. Both are valid and important goals. Unfortunately, however, time and experience has proven that some efforts to strictly enforce a relationship of exchanging old syringes for new ones has actually proved to undermine the overall effectiveness of syringe access programs. For this reason, programs delivering syringes have modified and adapted early syringe exchange models as a means of increasing access and meeting injectors’ true needs.

This manual takes a firm position that meeting the needs of injection drug users must be first and foremost, placing an emphasis on a needs-based or distribution approach as opposed to the traditional exchange model. Drug users should have unrestricted access to sterile injection equipment. Our position is that any model of syringe access should prioritize the assurance that injectors will have as many syringes, with as much clean injection equipment, as they need to inject safely. Counting syringes, return rates and reporting requirements should not be a factor in determining whether a program will provide access to a tool that could prevent the transmission of HIV and/or HCV and other blood-borne infections. proper disposal should be highlighted and encouraged among SAP participants and tools for educating and promoting safe disposal of used syringes should be incorporated into any SAP model; however, disposal should not be required in order to receive clean injection equipment. Drug users should have access to the injection equipment that they require, in the quantity that they desire.

The following will outline several transaction models for making syringes available, including both distribution and exchange-based models.

Distribution and Exchange

Needs-based syringe distribution is a policy that places no limits on the number of syringes a participant may receive regardless of the number of used syringes returned; participants do not need to return any used syringes in order to receive new, sterile syringes.

Exchange models of syringe access operate under the condition that participants bring used syringes to the program for disposal in order to receive new syringes. This model can operate on a strict “one-for-one” basis or as a modified “one-for-one plus” plan.

A mandate of exchanging used syringes can increase risk to drug users because it is not based on meeting the needs of the user, but is instead about program justification, exchange ratios and data or reporting requirements. It only takes one contaminated syringe to infect a person with HIV or HCV. Therefore, to the person who gets infected, there is little difference between not having enough clean syringes and not having any clean syringes – s/he still did not have what was needed. Further, strict exchange policies can place injectors at increased risk because they may collect, handle and carry potentially contaminated injection equipment (whether it is their own or others’ discarded syringes from shooting galleries and streets) in an effort to meet their own safer injection needs.

Conversely, some have made the argument that if participants must return syringes to get sterile equipment, perhaps they will visit the program more often, thus increasing the opportunity for program intervention. It is true that increased contact with participants could have an impact on relationship building, which is valuable. However, an SAP should not be about coercion or manipulation. Relationships are stronger when they are built on trust and mutual investment. Ultimately, the more trust between the program and the participant, the more likely the user is to access the program on a regular basis because they want to, not because they are forced to in order to meet program requirements.

Needs-Based Distribution

Needs-based distribution emphasizes actual and current injection needs asking participants, “How many syringes do you need?” as a means to identify the number of syringes that will be distributed during a transaction. Disposal is still a priority to programs that engage in needs-based distribution – however it is not a requirement. Ideally, sharps containers are available onsite and education is provided to enable people who are unable or unwilling to travel with used injection equipment to use alternative, safe disposal methods.

Some regulations may place limits or caps on syringe distribution per transaction. For this reason, and because some participants may struggle with proper planning, there should be no limit placed on the frequency of visits participants can make to the SAP.

Some programs will opt for a system of negotiation or “contingency contracting” as a means of engaging in needs- based distribution. In these cases, syringe distribution is based on a system of justification. This means that as long as participants give a reason, they can receive as many syringes as they need. Often in cases of contingency contracting, SAPs will maintain a list of common reasons for not having used syringe returns to access during syringe transactions. Links to sample contingency contracting forms can be found online in Appendix J.

Needs-based distribution is the syringe access policy most likely to meet the true needs of injection drug users. It is also the model most likely to receive community opposition, which can have a serious impact on the long-term sustainability of the project. Anticipating community concerns and responding to them accordingly will be important. Taking a harm reduction approach to opponents and meeting them “where they are at” can be a valuable strategy. That is to say, while people may be opposed to certain SAP policies initially, it is possible for them to change their position, particularly if their concerns are acknowledged in an open and nonjudgmental way. It may be difficult for the community to embrace the SAP right away. Take community relations and concerns seriously, and provide education about the program. Explain the rationale behind policy decisions and take steps to proactively address concerns to help alleviate opposition. For more information on key criticisms of a needs-based distribution policy, as well as possible responses, please see Appendix C.

One-for-One

One-for-one exchange means that for every used syringe a participant brings to the SAP, s/he will receive one new, sterile syringe. The most likely reason to conduct one-for-one exchange is either because of requirements imposed by funders and/or to allay community fears about syringe access programs. These are reasonable concerns. Nonetheless, acting on behalf of these concerns may have negative implications for drug users as well as overall program effectiveness. These factors should be weighed when considering which syringe transaction model will be adopted.

Some opponents to syringe access may believe that without a strict disposal requirement built into the program – theoretically implying that used  syringes  would  hold   premium   value  to SAP participants – improperly discarded syringes will increase in neighborhood streets and parks. Research has never been able to validate this fear. Research has found, however, that people are still getting infected with HCV and HIV, and are still sharing syringes. It can  be implied that this is a result of people not having enough of their own, sterile injection equipment. It is extremely unlikely that, when given the choice between someone else’s used syringe and a new, sterile syringe, a person will choose to put himself or herself at risk. In addition, research has also shown that despite syringe access programs that require used syringes for exchange, existing criminal penalties associated with carrying used injection equipment and fear of arrest are likely to have a far greater impact on the disposal behaviors of injection drug users.

Moreover, caution must be used when arguments for or against syringe policies become about ratios of used-to-new syringes. When this happens, the focus is shifted away from the prevention of infectious disease and the promotion of health and well being of drug users and communities, and instead places attention on an inventory of syringes and equipment. This is not a numbers game, but a life and death situation that has very real consequences for drug injectors at risk for HIV, HCV and other blood-borne infections.

Another potential danger of strict one-for-one policy is the impact on staff and volunteer exchangers. Despite the perceived legitimacy of program policies on paper, when faced with a drug injector who does not have sufficient returns to guarantee that they will not inject with used equipment, few staff will be able to ethically justify denying sterile syringes. In practice, strict one-for-one policies thus set program staff up to lie and bend the rules in the name of encouraging safer injection. This dishonesty, while certainly understood, impacts relationships between staff that are willing to defy the rules and staff that are not. In addition,  it can encourage favoritism among participants toward staff willing to provide more syringes. Ultimately, any break in trust and consistency can also challenge program legitimacy.

It is also possible that if a person does not have any syringes to exchange – for any number of reasons they may not visit the SAP at all because they assume that they will not be able to access services.

Vouchers can serve as a tool for exchanges with one-for-one policies in cases when a participant returns more syringes than they want in return at a given transaction. For example, a person returns 200 syringes, but only wants 100 syringes in return. The SAP will then issue the participant a voucher (similar to an IOU) for the additional 100 syringes that can be redeemed at a later date.

SAPs will also use vouchers when they do not have enough supplies to complete the transactions or in cases where there are limits on the numbers of syringes a participant can receive during any single transaction (perhaps due to restrictions imposed by funders or regulations), despite the number of syringes returned by the participant.

Reasons an SAP Participant May Not Have Enough Syringes for Exchange:

• Have already safely disposed of syringes
• Homelessness
• Fear of traveling with used injection equipment
• Fear of arrest, police sweeps in the area, etc.
• Police confiscated syringes
• Started with insufficient number, and have been unable to exchange up to their current needs
• Recently initiated injection
• Have begun injecting more frequently
• Traveled from an area that has minimal syringe availability
• Do not prepare drugs themselves/someone else/ partner holds injection equipment
• Were not planning on injecting
• Housing program/shelter restrictions
• Hiding syringes out of shame/secretive use
• Fearful/drug-induced paranoia
• May not be an injector (getting syringes for friends/family)
• Safety reason (i.e. they have lost the cap on a syringe)
• Previously disposed of syringes to keep away from children

One-for-One Plus

A syringe exchange policy of one-for-one plus means that for every one used syringe returned by an injector, it is possible for the participant to receive more than one sterile syringe, as pre-defined by program policy. This model was developed in response to concerns about straight one-for-one exchange and in an effort to better meet the actual needs of participants. Most often, in the case of one-for-one plus, there is still some requirement that participants turn in used syringes in order to receive new ones, however there is more flexibility when participants do not have enough, or possible any, used syringes to exchange.

For example, some programs employ the use of “starter kits.” Starter kits are designed for people who do not have any syringes to return and usually consist of one or two syringes, however this number is variable depending on program policy and could be larger. Some programs will also use what have been called “incentive syringes.” This refers to additional syringes that are distributed to a participant who needs more syringes than they have to return. For example, someone returns 5 syringes, but asks for more syringes so perhaps the program will distribute 10 syringes – 5 syringes in exchange for the returns, in addition to 5 syringes as an incentive that the participant will return more the next time. Incentive syringe policies are usually pre-determined, but may also involve a process of negotiation between the SAP worker/manager and the participant in an effort to better meet needs.

In another example, although there may be a cap on the number of syringes a participant can receive at each encounter, programs may not have to place any limits on the number of encounters that can occur within a certain time period. So, if a participant can receive 10 syringes for every one syringe returned, 5 encounters logged with one return each time will result in the participant receiving 50 syringes total. Further, some programs will take a very liberal approach to one-for-one plus. In some cases, if a participant returns even one syringe, the program will employ “contingency contracting” to justify distributing the necessary quantity of syringes.

One-for-one plus is more effective in enabling participants to meet their actual injection needs than a strict one-for- one policy. In addition, it begins to take pressure off the participant to carry used and potentially contaminated injection equipment back to the program. As well, it takes some of the pressure off staff who may be inclined to break SAP rules in that there is a built-in alternative to denying syringes without returns. Further, it gives staff another opportunity to engage with participants about planning and disposal.

As with any policy that may involve a process of negotiation, the possibility exists that without proper training and support, staff could manipulate the policy and apply it in a discriminatory manner by showing favoritism to certain participants. Another potential challenge associated with one-for-one plus is that it may be more susceptible to community backlash. As noted above, however, there is research to support the need for alternatives to one-for-one exchange. Making sharps containers widely available and providing education about proper disposal to participants, as well as setting up a system for your program to respond to any complaints of improper syringe disposal will help to counter opposition. In cases where there are open-air drug markets, or centralized places where people inject and/or leave syringes, consider conducting public “clean-ups” when SAP staff will go into the community and pick up discarded syringes.

Disposal Options

An important element to any SAP, regardless of transaction policies, is to incorporate a strong disposal component. this will not only respond to community concerns but is a pragmatic and responsible service to injection drug users. While disposal may be encouraged as a requirement for acquiring new syringes, as is the case with certain exchange models, education and resources for proper offsite disposal of syringes should also be a priority. Education on proper disposal with the use of sharps containers and/or other containers (detergent bottles or beverage containers, for example) as well as the dangers of improper disposal techniques is essential. Sharps containers can be made available in a wide variety of shapes and sizes – from small, portable containers to 2 -or 8-gallon containers – to best meet all participant needs. proper syringe disposal is discussed in greater detail later in this section.

Enrollment/Intake Procedures

Enrollment or intake marks the formal establishment of a relationship between the participant and the SAP. This means that, regardless of intake procedure, the participant is no longer completely anonymous. Enrollment offers an important opportunity to begin building trust with the participant and will aid in setting the tone for future interactions.

Intake for syringe access services should be minimal to accommodate participant needs and encourage enrollment. It may be necessary however, to employ an extended intake for more intensive SAP services such as case management, housing, mental health and/or benefits assistance where additional information is required for thorough and responsible service delivery. Nonetheless, any intake process must be mindful of whose needs are being met by the collection of information – the participant, or the program, government or regulating body.

Enrollment can serve several purposes:

1. Participants may receive legal protection for needle possession as a result of being enrolled in the SAP. This is the most important and valid reason to institute enrollment procedures.
2. During enrollment, the program is able to inform the participant about SAP policies and services, hours of operation and any rules or regulations.
3. During enrollment, the program can collect valuable demographic and statistical information. This information can be used to track ;and monitor program activity, inform evaluation and future programming, justify program existence, and may be of interest to funders and regulators. Data collection, however, must never take priority over meeting the needs of participants.

Most SAP funders and/or regulators will require the establishment of enrollment policies and procedures. In cases where there is no mandate, an SAP should evaluate the necessity of formal enrollment for syringe access. Removing the enrollment process can be an appropriate strategy to reduce barriers to participants accessing syringes. When deciding upon any enrollment procedure, programs must weigh the costs and benefits of each step or requirement as it applies to the SAP, its funders and regulators and the participant. Generally speaking, the easier, faster and less invasive the enrollment process, the better. Drug users have many reasons for being guarded with their personal information. The greater anonymity participants are able to maintain, the more likely they are to engage with the program.

Having a clear understanding of program and intake goals is important when determining which information is essential to collect, which information – though valuable – is not vital and how information should be collected.

• What information can be used to protect the injector from law enforcement?
• What information can be valuable in evaluation, to provide to funders and/or to demonstrate program need effectiveness?
• Would the collection of certain information put participants at risk in any way and/or could it be perceived  in such a way?

The following list offers suggestions for information that may be collected at intake/enrollment; this list is meant to offer a range of sample ideas, and is not meant as a template for intake. Keep in mind that when it comes to enrollment, the rule of thumb is generally that less is more.

• First Name only – This may prove valuable in identifying the participant as a member of the SAP and/or as protection from law enforcement.
• Initials – Initials can be used as an alternative to collecting names. Some programs will use first and last initials, or some combination of the participant and their mother’s names. For example, the first two letters of the participant’s last name and the first initial of the participant’s mother’s first name. Mother’s names may be more universally acceptable than the names of any other family members.
• Race/Ethnicity– General demographic data to better understand who the SAP is servicing.
• Gender – General demographic data to better understand who the SAP is servicing.
• Date of Birth or Year of Birth – This is often asked in cases where it is necessary to establish that the participant is over 18 (perhaps for legal issues), but can also be prove valuable in identifying the participant as a member of the SAP as protection from law enforcement (see special considerations with youth below).
• Zip Code or area of Current Residence – General demographic data to better understand who the exchange is servicing and who the program may be missing.
• Drug of Choice – This can be used to assess and tailor program services based on the needs of participants and to understand the participant base and report to funders.
• Injection Frequency – This can be helpful when estimating supply quantities.
• Years Injecting – This is a sensitive question that may be unnecessary, but is sometimes included in an effort to show that the program is not encouraging drug users to begin injecting. In cases where a participant is fairly new to injection, it may prompt heightened intervention and engagement, but is never grounds to deny enrollment.
• Housing Status – This can be used to tailor program services based on the needs of participants and to understand the participant base, report to funders and secure additional funding.

Whenever information is requested from a participant, it is a good rule to explain why it is being collected and any potential implications for the participant. If there is not a good reason for collecting the information and/or this reason cannot be openly shared with the participant, it could be necessary to reconsider why the information is being collected at all.

Special considerations

There are some considerations when establishing enrollment/intake procedures that deserve special mention:

Checking ID: Asking participants to provide ID upon enrollment is not recommended, may deter people from accessing program services, and serves as a threat to participant anonymity; it is unrealistic to assume that everyone will have ID. When providing information, participants should be taken at their word. It is common for homeless and transient individuals to have their ID stolen or lost and it can be very difficult and time consuming to replace it. Further, there are many additional reasons why participants are unlikely to have ID and/or may be unwilling to share their identity with the program. The request can come across as isolating and threatening and should be employed only in situations where need is absolutely essential and can be clearly justified.

Verifying injection status: It is not recommended to include current injection verification as part of enrollment or intake. One fear raised by opponents to SAPs is that the service will increase transition by non-injection drug users to injection. Despite the fact that there has never been any evidence to support this claim, some programs have been known to require proof of current injection, usually by the display of track marks, upon enrollment. Programs must consider the purpose of such practices. Will a novice injector be denied sterile equipment? If so, would that be consistent with the mission of the program to protect the health of IDUs and their communities? Is it possible that an injector is rotating their shot in a way that minimizes tracks (which is considered a safer injection practice)? What if a participant injects in their groin or in other private areas to conceal track marks, or out of necessity (and isn’t that their right)? In some cases, non-injectors may also be coming to the exchange in order to retrieve sterile injection equipment for friends or loved ones who inject. Requiring people to show track marks can be a degrading and unnecessary practice. Ideally, people seeking syringe access services should be taken at their word.

Young Injectors (under 18): Age should not be criteria for program exclusion; however heightened engagement with injectors under 18 may be necessary, and further, may be expected by funders or regulators. Enrollments with younger participants should be handled with care. In cases where regulating bodies require a specific protocol for enrolling younger participants, it is likely that the specifics of such a protocol will be clearly defined by the regulator. In cases where there is no required intervention, having specific policies and procedures for working with younger users on hand may still be helpful in fielding community response. There may be a need to identify potential treatment, health care and/or other referral networks that will be made available to younger injectors. Please see Module 5 for more information on working with youth.

ID cards

ID cards can be used to verify that participants are enrolled in the SAP. The primary purpose of the card has been  to serve as a tool for participants who need to prove SAP enrollment, most often to law enforcement, and thereby to prove that they are legally entitled to carry syringes. Using ID cards can also speed up individual transactions at the SAP once intake procedures have taken place (when applicable).

Similar to any enrollment procedure, the use of ID cards should only be instituted if there is a clear benefit to the participant – such as legal protection. ID cards and other enrollment procedures should not exist as a function of data collection for the SAP. The use of ID cards may compromise participants’ sense of anonymity and/or may be perceived as a barrier to accessing the program. For this reason, only in cases where possession laws may place the participant at risk of prosecution will ID cards likely be necessary.

If ID cards are used, an anonymous and unique identifying code will be constructed upon enrollment using information that the participant can easily reproduce. This can include any combination of the following, or other similar, information:

• First and/or last Initial/s (ex: Jane Doe = JD)
• Year of Birth (ex: March 25, 1975 = 1975 or 75)
• Day of Birth (ex: March 25, 1975 = 25)
• Zip Code (ex: 11226) – Although this information may change over time and be difficult to reconstruct.
• Mother’s First Initial (ex: Mother’s name is Susan = S)
• Gender (ex: Male = M)

While it is possible that this information can (knowingly) be completely false or made up, programs should investigate any possible repercussions from law enforcement or local courts if valid identification cannot be verified when the card is used by participants to avoid prosecution. The value of using verifiable information and carrying the ID card should be explained to the participant, as well as exactly how the unique identifier is constructed. Sometimes program details (address, phone, etc) will be printed on the card along with information describing relevant legal statutes and/or public health codes. Any limitations of the card should also be explained, specifically that police may choose to ignore the card and that it does not offer protection from drug possession or criminal charges other than syringe possession.

A participant is never required to take an ID card and syringe transaction policies should not require that a card be presented. It is reasonable to assume that participants may not always carry their cards with them, and/or may lose them with some frequency. In cases where a participant has their ID on hand, no additional information is usually necessary. If a participant does not have their ID with them, codes should be able to be reconstructed quickly, participants can be offered a duplicate card, and if necessary and/or enrollment is suspect, intake information can always be collected again. Quick and easy intake procedures will expedite this process.

Education

Enrollment is a good opportunity to provide specific core information to new participants. Information should be organized to minimize time. Topics that may take top priority include:

• SAP policies and procedures
• Legal rights of SAP participants
• Information about preventing blood-borne infections, specifically HIV and HCV
• Availability of other injection-related equipment (such as cookers, cottons, ties, alcohol swabs, etc) to encourage single-use of all injecting equipment
• Syringe disposal options available on- and off-site

Any educational session that is incorporated into enrollment must be flexible, and while people should be encouraged to participate, it should not be mandatory for program enrollment.

Other points of discussion that can be made available on enrollment include:

• Safer injection – vein care and the prevention of bacterial infections and other injection-related health concerns (staph, abscesses, endocarditis, etc.)
• Overdose prevention and any on-site OD prevention services
• Safer sex
• Any other program services available

 Syringe Tracking

An alternative to participant intake, though it is less common, is to track the movement of syringes. This can be done by placing a barcode or other marking on the syringes themselves, which is then used to track distribution, movement, and return rates of syringes. This method does not provide specific information about participants, though some information may be approximated, such as gender, race/ethnicity, age, etc. Of course, the unreliability of any approximated data will severely limit its value and legitimacy. Aside from the limited usefulness of solely tracking syringe movement, the procedure of marking syringes can threaten the sterility of the syringe and can also be very time-consuming.

SUPPLIES

In addition to syringes, there are a wide variety of other supplies that are important for SAPs to stock and distribute in order to offer a true comprehensive approach for preventing infectious disease and promoting safer injection. Blood-borne infections such as HCV can be transmitted through sharing any piece of injection equipment that may have blood on it.

In addition, not all syringes are the same. Needles and syringe barrels are available in a wide variety of sizes, and injection drug users may have very particular habits when it comes to preparing and injecting drugs. Injection equipment may also vary depending on the drug being injected. Ideally, SAPs will offer needle and syringe sets in a variety of sizes. If an SAP does not offer the preferred size and brand of syringe a user prefers, s/he may be less likely to access the program.

It is important to consult drug users to learn about their injection preferences. Open dialogues about current injection equipment and practices may also provide an opening for guidance around equipment that may promote better vein care and safer injection.

Needles and Syringes

Consider the following when making needle and syringe selection:

Needle Gauge: Refers to the size of the bore or hole in the needle. With needles, the higher the gauge (G), the  thinner the needle. Standard insulin sets, often popular with injection drug users, typically have a 27 gauge (27G) or 28G needle. Standard tuberculin sets come with a 25G needle.

• Safer Injection Tip: The smaller the needle gauge (= higher number), the smaller the puncture wound and therefore, less bleeding, less damage to the vein and less opportunity for infection; it will also be easier to find smaller veins.

Intramuscular injections – required for steroids and other hormones – require a larger gauge needle (typically 21G or 23G). People injecting methadone and/or certain drugs that are cut with a lot of impurities that may clog the syringe may also prefer needles with a higher gauge (smaller number).

Needle Length: Insulin needles are typically 1/2 inch in length and tuberculin needles are typically 5/8 inch in length. These are usually preferable for intravenous drug injectors. Longer needles are typically needed for intramuscular injections.

• Safer Injection Tip: A needle that is too short may miss the vein, and one that is too long may go through the vein or be difficult to position.

Syringe Barrel Size: Standard insulin and tuberculin syringes are typically 1 cc or 1/2 cc in size and calibrated by .10  ccs along the barrel of the syringe. Most intravenous drug users will prefer either 1 cc or 1/2 cc syringes. People injecting cocaine and other drugs that may require more dilute may prefer 1 cc syringes. Methadone and/or steroid or hormone injectors may request 3 cc syringes.

Brand: Different manufacturers create needles and syringes with varying quality. Some brands are more comfortable to inject with than others, and the plungers on some brands of syringes are easier to manipulate than others. Many drug injectors will have a preference over the brand of syringe they use, though size of the needle and syringe may be a bigger factor.

Fixed/Detachable Needles: Syringe and needle sets will either come with the needle fixed to the syringe or with a detachable needle. Some IDUs may prefer to use syringes with a detachable point. This may be, for example, because they prefer to use a larger syringe barrel with a smaller gauge needle. This is not uncommon for injectors of methadone where a 3 cc syringe may be used with the needle from a 1cc detachable set, for example which may be easier to manipulate or less intimidating.

Detachable sets may also be a useful tool for reducing risk of HCV transmission through splitting drugs. Using a dedicated syringe only – without the needle – for splitting drugs/measuring doses can reduce the likelihood that the drug mixture will be contaminated with blood from a syringe and needle set that can puncture skin and/or has been used for injection.

It is noteworthy, however, that some research suggests that HIV and HCV may remain viable longer in syringes  with detachable needles – thus placing people who use syringes with detachable needles at higher risk for HCV and HIV transmission. This is largely because the construction of the syringe leaves increased amounts of blood inside the syringe. This information should be made available upon distribution of detachable sets to participants who may still prefer to use this type of needle and syringe.

Single-Use Retractable Syringes: “Single-use” syringes are needle and syringe sets that come equipped with a mechanism that retracts the needle after an injection, to ensure that the syringe will only be used once; these are most often used in medical settings to reduce incidence of needlestick. While these syringes could theoretically be valuable for preventing disease transmission and syringe reuse, research has shown that drug injectors typically do not like them and do not want to use them. They are also more expensive than traditional syringes. Therefore, they are not recommended for use in SAP programs.

Some reasons injectors have given for disliking single-use syringes include:

• The plunger cannot be removed – which is useful for mixing drugs and or loading drugs from one syringe to another.
• If the needle retracts prematurely, it can interfere with registering the shot, retrieving the drugs, and/or re-booting.
• If the set clogs, there is no way to retrieve the drug mix from inside the syringe barrel
• In cases of emergency or inadequate supply, they cannot clean and reuse their own syringes.

Other Injecting Equipment

The following list outlines various injecting equipment and supplies that are required for distribution as part of a comprehensive strategy to reduce the spread of HCV, HIV and other blood-borne infections and to promote injector health. Each item provides a description of the equipment as well as an explanation of why it is important. Links to additional resources related to injection equipment can be found in Appendix A.

Cookers (Caps)

Cookers are used to mix up (cook) the drug solution. The most common type of cookers distributed at SAPs (in the US) are aluminum “caps” – like those used for bottle tops. Caps may come with or without “threads” – the indentations in a cap when it is used for screwing it on and off of a bottle. Some users prefer “shell caps” – caps without threads – because the drug mix may otherwise get stuck in the threads. Some users will prefer the threaded caps, or a combination of the two, because they are often a slightly different size and can be used to stack with smaller caps; this is for saving cookers and drug rinses (rinsing is a technique of adding water to a used cooker or cotton to access any residual drug).

Why?

Blood inside used cookers can transmit HCV and other blood-borne infections if a contaminated cooker is used to fix drugs for injection. Cookers can get blood in them in several ways – some examples include:

• If a contaminated syringe is used to put drugs into or pull drugs out of a cooker.

• A contaminated cotton or contaminated water (more details below) is put into the cooker.

• If someone has had trouble finding a vein or has a problem with a syringe during injection, they may put drug mix that is mixed with blood back into a cooker to start again.

Also, it is not uncommon for IDUs to share or sell rinses. IDUs should be encouraged to use a new or clean cooker, or their own cooker, for every injection and should be advised of the dangers associated with sharing cookers/rinses.

Cottons/Filters

“Cottons”, also called filters, are used to filter impurities in the drug mix when pulling it into the syringe. Filters should be 100% cotton (or a medically appropriate alternative) and usually come in the form of smaller and/ or larger pellets. Cottons will often be reused in an effort to get as much residual drug out of the cotton; this is referred to as a rinse. Smaller pellets are harder to use multiple times; less reuse will decrease the likelihood of cotton fever, a condition related to injection drug use that is caused by injecting bacteria that can develop in used cottons or filters.

Why?

Blood in used cottons can transmit HCV and other blood-borne infections if a contaminated cotton is used to fixed drugs for injection. Blood can get into cottons in the same ways as with cookers (see above). In addition, cottons can easily grow/collect harmful bacteria when left over time and reused. IDUs should be encouraged to use a new, clean cotton and/or their own cotton for every injection.

In the absence of safe and sterile cottons, drug users will commonly use other products to filter their drugs, including cotton swabs, tampons, pieces of clothing, and cigarette filters among other things. Participants should be advised that cigarette filters contain tiny particles of plastic or glass and are dangerous for use as a filter. Participants should also be advised that if they are using other items as filters, cotton works best, the cleaner the item the better, and it is important to wash hands when pulling pieces off for use, to reduce the likelihood of bacteria being transferred to the filter.

Tourniquets/Ties

Tourniquets, also called “ties” are used by injectors to help identify veins and make them easier to hit. Latex tourniquets are most common and usually stronger than non-latex tourniquets however people with latex allergies will need alternatives.

Why?

Blood can get onto tourniquets and transmit HCV and other blood-borne infections. Although sometimes overlooked as a risk factor for HCV, tourniquets will often get blood on them during the injection process. If a tourniquet is left on when the needle is removed, it can cause a person to bleed excessively. Also, someone who may have to tie off multiple times trying to find a suitable injection site may move the tourniquet over recent puncture wounds, resulting in blood getting on the tie. Blood on ties may be difficult or impossible to see or distinguish from dirt. IDUs should be encouraged to use their own ties and/or mark them to be able to identify which is theirs.

Sterile water vials

Water used for injection can be contaminated with blood. It is important to use sterile water to avoid infections when dissolving and mixing up drugs and when rinsing syringes after injection. Sterile water can be purchased in small, single-use vials. Plastic bottles are more practical than glass bottles, and the smaller the bottle, the less likely people will reuse and/or share the water. In cases where budgets are limited, water may be considered lower priority IF all participants have access to alternative clean water sources. This will not be the case if the SAP serves homeless or transient IDUs and/or IDUs who frequently inject in public spaces or other places without consistent running water.

Why?

Water used for injection can easily be contaminated with blood and can therefore transmit HCV and other blood-borne infections. Blood can get into water when an IDU inserts a used syringe into a cup, vial or other vessel either to draw up water for mixing drugs or rinsing syringes or to put water back into the vessel after the syringe was rinsed. Because of the way blood disperses in water, it can be especially high-risk to reuse water. In addition to blood-borne viruses, IDUs are at risk for other bacterial and viral infections as a result of using unsterile water sources such as puddles, toilet water, old water bottles, etc.

Alcohol swabs

Small alcohol prep pads are used to clean an injection site prior to injection to remove bacteria and germs that could be pushed into the skin. After injection, swabs can be used to clean dried blood from near injection sites and fingers; however alcohol will keep blood directly at the injection site from clotting and could cause excess bleeding. Alcohol swabs can also be used to clean one’s hands if there is no facility to wash them prior to injection.

Why?

Alcohol pads are important for preventing infection and promoting better vein health. The better condition an IDU’s veins, the easier it will be to get a good hit and the less likely the person will have to puncture themselves multiple times. This can reduce the amount of blood that is involved in the injection process and ultimately have implications for reducing the spread of HCV and other blood-borne infections.

The following supplies are not injection-specific, but are also considered to be essential:

Condoms (male and female)/Dental Dams and Lube

Though not specific to injectors, condoms and lube are almost always made available at SAPs to encourage safer sex and reduce transmission of HIV and other STIs.

Why?

Using drugs may influence a person’s judgment, reduce inhibitions and/or otherwise increase the likelihood of engaging in unprotected sex. In addition, managing a drug habit may lead to limited economic choices which can in turn lead to increased sale of sex for money. Unprotected sex can lead to increases in HIV and HCV that can then also be transmitted through injection drug use. Lube is also important because drug use can lead to lengthier sessions that, especially when compounded by dehydration, can lead to tearing or sores and subsequent HCV transmission.

Health-related literature

A range of health-related literature can be made available to support supplies that are distributed. Literature can cover topics such as: SAP services, locations and hours, Blood-borne virus information, including HIV and HCV; safer injection and vein care; liver care; local health centers and clinics; sexually transmitted infections (STI) and free or sliding-scale STI testing sites; drug treatment options (methadone, buprenorphine, etc.); overdose prevention and education; holistic medicine and any other number of topics.

Why?

Participants need to be able to access information in different formats, on their own time. When choosing materials, be mindful about issues such as:

• Cultural relevance

• Language

• Reading level

• Accuracy (are they up-to-date?)

Informational literature assists people in understanding how to reduce risk of transmitting HIV, HCV, and other blood-borne infections, how to prevent and respond to overdose and avenues for seeking help, among other things. Literature is a non-confrontational way to help people gain knowledge and protect themselves and those around them.

The following supplies are also strongly recommended if budget permits:

Powdered Citric or Ascorbic Acid

Used for helping to dissolve crack and other solid drugs. This may actually be a required item, if participants are injecting crack and/or certain forms of tar heroin or other solid drugs.

Why?

In order to inject crack and other solid drugs, they must first be broken down and dissolved. IDUs will commonly use vinegar or lemon juice in this process which can cause dangerous bacterial infections and abscesses. Reducing abscesses and other skin infections also has implications for transmission of HCV and other blood-borne infections because of the subsequent presence of open wounds and potential for blood transmission.

Gauze pads

Sterile, dry materials for stopping blood flow after injection.

Why?

Using gauze pads reduces excess bleeding after injection and will reduce the risk that blood will be spread to surfaces and other areas.

Band-Aids

For covering injection sites and/or hiding track marks.

Why?

Band-aids will reduce excess bleeding as well as wound exposure to blood and other germs after injection. Encouraging band-aid use will reduce the risk that blood will be spread to surfaces and other areas.

Antibacterial Ointment

Antibacterial ointment can be helpful in addressing concerns related to minor skin and/or injection-related infections and increase healing time.

Why?

Skin infections and puncture wounds can increase risk of HCV and blood-borne infections because they provide an avenue for blood-blood transmission.

Twist ties

Twist ties are used for holding aluminum cookers if drugs are heated.

Why?

Heating aluminum cookers that do not have a handle can result in burns on fingertips which can subsequently increase risk of transmitting blood-borne infections. In addition, hot cookers can result in spilled drugs.

Bleach Kits

Bleach kits contain small, portable vials of full-strength bleach and water to be used in cleaning surfaces as well as used syringes and cookers.

Why?

There is debate over the distribution of bleach kits. Although bleach has been proven effective in killing HIV in syringes when used properly, research has been inconclusive regarding its effectiveness in killing HCV, and it is more likely that bleach is NOT effective 100% of the time. However, success rates for killing HCV have most recently been put above the 90th percentile. That said, there is a legitimate fear that making bleach kits available to injectors gives a false impression that bleached syringes will be safe and will not transmit infection. Recognizing that adequate injection supplies may not be available at all time, bleach kits can be one tool along a continuum  of tools used for reducing risk (i.e., it is less risky to use a bleached syringe than one that has not been bleached, though a sterile syringe is preferred above all). See Appendix G online for more information on proper bleaching technique.

Split-Safe kits

Safe-split kits are intended to reduce risk when drugs are prepared in one liquid solution and split or shared among multiple people. Split-safe kits usually include a cooker (maybe in a different color, such as gold) and a syringe that is both without a needle and usually has a different color plunger to avoid confusion with syringes being used for injection.

In the absence of split-safe kits, injectors can be advised to use a dedicated and identifiable syringe (marked with a permanent marker or a rubber band, for example) for splitting drugs that will never be used for injecting or with contaminated cookers, cottons or water.

Why?

Splitting drugs is a major factor in transmission of HCV and other blood-borne infections.

Fit Packs

A “Fit Pack” is a container that has the capacity to both store new syringes and safely secure used syringes after injection.

For example, one common fit pack model holds 10 new syringes on one half of the container, and as syringes are used, they are deposited into a tamper resistant compartment on the other side of the same container. As the used compartment fills up, the area for new syringes is compacted. There are other models that use the same concept and are meant to accommodate smaller or larger numbers of syringes.

Why?

Small, manageable disposal containers will enable participants to safely return syringes to the SAP, or dispose  of them on their own. Proper disposal reduces accidental needlestick as well as syringe reuse and sharing.

Safer crack use supplies

It is not uncommon for SAPs to serve IDUs who also smoke crack. The following supplies should be considered for distribution:

• Pyrex pipe/stems – Unlike glass, Pyrex stems do not break when heated. Also, unlike some metal pipes, Pyrex will not release toxic fumes when burned.
• Brass screens – Screens are used to filter the crack through the pipe. Brass screens are better than steel wool because they are less likely to break up or loosen which can cause choking, burns and cuts.
• Mouthpieces – Rubber or certain plastic mouthpieces that fit on stems/pipes can be used to prevent lip burns and to allow individuals to have their own mouthpiece if they are sharing a pipe.
• Lip balm – Balm can help protect and heal burnt or chapped lips.

Why?

HCV can be transmitted through burns or cuts resulting from smoking crack. This has implications for IDUs who are also smoking crack and may have misconceptions about their HCV risk. A comprehensive strategy to reduce the risk of HCV and other blood-borne infections among injectors will include related behaviors that accentuate risk of infection and transmission.

Baggies for packing supplies

Cottons, cookers and other supplies are generally purchased in bulk and need to be bagged prior to distribution. Small plastic bags with zipper closures work well and come in a variety of sizes.

Why?

By bagging bulk items such as cookers and cottons it will preserve the sterility of the items.

Bags for carrying away supplies

Participants will often need bags to carry away supplies from the exchange. Brown lunch bags are popular because they are sturdy and discreet, but any bags that are large enough and don’t reveal content should   work.

Why?

By providing bags for transport, it will enable participants to better meet their actual injection needs by providing a means to carry away all of the necessary items (as opposed to only taking what will fit in pockets, for example).

Inventory Quantities and Management

It can be difficult to decide how many syringes and other injection equipment to acquire prior to opening the program. There are several factors that will influence variations in supply need, especially early on. Most obviously, it may take some time to get the word out about the program and recruit new participants to the SAP. In addition, demand for syringes may vary depending on seasonal variations in IDU communities. For example, some cities will attract higher numbers of transient drug users during summer months. The needs assessment process will likely assist in determining initial supply quantities, based on the number of participants that are anticipated to enroll in the program over a certain period of time, often the first 12 months. Some primary factors to consider are:

The estimated total number of IDUs in the community.

• The percentage of IDUs the SAP anticipates reaching by the end of the first 12 months (accounting for increases occurring incrementally over time).
• The average number of syringes (and variations of syringe sizes) expected to be delivered to each participant per week; this number may be graduated, growing incrementally over time, to account for behavior change.
• Current drug trends that can influence the number of syringes that participants may need. For example, increases in cocaine injection can result in more frequent injection, and subsequently, a need for increased supply quantities.

See Appendix D for more information on developing syringe and supply estimates.

When deciding upon quantities of additional injection supplies, a good rule of thumb is that at least one cooker, one cotton (or small bag of cottons), one vial of water, one alcohol swab, and one tourniquet should be available for every syringe distributed. If additional injection equipment is not made available in sufficient quantities, it will be impossible to truly curb infection of HCV.

It is also important to establish an organized system for managing SAP inventory. This system should include a way to keep track of on-hand supplies as well as a timeline for ordering new supplies, leaving enough time to receive orders even despite unanticipated shipping glitches. Also, when applicable, remember to monitor any expiration dates on supplies. Keeping the SAP stocked is vital to maintaining trust among participants, as well as encouraging positive behavior change. When supplies at the exchange run out while participants are working on modifying injection behaviors, it makes it easier to fall back to old habits. Along these lines, it is also important for more than one staff person to be involved in, and aware of supply purchasing procedures. While it may be useful to assign a point-person or people to be primarily responsible for managing stock and or placing orders (in order to avoid duplicate orders and/or work), it is essential that this knowledge be shared and that others can respond in the absence of the point-person. The danger is that if only one person knows when and how to order supplies, the SAP could suffer shortages in the event that the staff person leaves, is on vacation or has an emergency.

Where to get supplies

The following is a list of not-for-profit venues for obtaining syringes and other injection supplies:

• The NASEN (North American Syringe Exchange Network) Buyers Club offers a way for SAPs to acquire low- cost syringes and supplies.
• When working in collaboration, Health Departments will often manage syringe supply.
• Other exchange programs can be a resource for new or smaller programs to obtain syringes and other supplies and/or in cases where there is a short-term/emergency need; other programs may also be able to share vendor information for supply purchase.

In addition, there are also several for-profit entities that sell safer injection supplies and equipment. Many of these companies can be found online, or feel free to contact HRC for more information.

DISPOSAL

Assisting participants with the proper disposal of used syringes and injecting equipment is an important role for the SAP. In turn, the SAP must comply with regulations for subsequently disposing of used syringes, which qualify as Regulated Medical Waste (RMW).

Proper disposal is first and foremost about individual and public safety; improperly discarded waste poses a risk for the continued spread of infectious disease and can result in accidental needlestick injuries. In addition, improperly discarded injection equipment can draw unnecessary attention and negative criticism to the SAP despite program efforts to improve disposal practices. Unfortunately, although improper syringe disposal does tend to decrease when an SAP is present, the reality is that drug users may still be afraid to carry used injection equipment for fear of interactions with law enforcement, and stigma around drug use makes disposal options scarce and difficult to access.

SAP Disposal of Returned Injection Equipment

The SAP will be held to standards for the proper disposal of used injection equipment, which is qualified as Regulated Medical Waste  (RMW). It is important for the SAP to carefully document all procedures for handling   and disposing of medical waste. Also, when RMW is disposed of, keep clear and verifiable records. It is also a good idea to become familiar with state disposal laws for your area.

Safe disposal procedures are necessary to avoid accidental needlestick injuries among staff, volunteers and participants, but also to avoid any potential backlash, should an accident occur. Although the likelihood of infectious disease transmission is low in cases of accidental needlestick, it can be a very stressful and anxiety-producing experience for anyone involved. For more information on needlestick injury prevention and response, please see Module 3.

The following are tips for the proper handling and disposal of syringes at the SAP level:

• Research statewide regulations for the proper handling and disposal of RMW.
• Consider reserving funds in the budget to hire a private waste management service that will pick up and dispose of used syringes and sharps. In most cases, these services include any necessary supplies to properly package medical waste for disposal. Hiring a service is also useful to document proper disposal of equipment.
• Contact the local Health Department about possible partnerships to manage drop-off/collection of RMW.
• Staff must be required to attend training on proper disposal and handling of used injection equipment.
• Participants should be instructed to handle and dispose of their own returns, placing them directly into sharps containers themselves. Staff should not physically count or handle returned syringes.
• Do not make hand-counting of returns a requirement; if disposal numbers are required to receive new equipment and/or for monitoring and evaluation purposes, estimates of return numbers should be sufficient. Returns can also be measured and estimated by weight.
• Anyone working at the SAP should be instructed never to handle loose sharps without tongs, puncture-proof gloves and other protective equipment. Closed-toe shoes should always be worn while working at the SAP.
• Cleaning staff should be mindful of potential loose sharps and/or broken needle points.
• If a mobile unit is used, be sure sharps containers can be (at least) partially closed when the vehicle is in motion, in case of short stops or accidents. Similar strategies should be used for street outreach.

Individual Disposal

Tips for increasing proper disposal and handling of sharps among individuals and SAP participants (see Appendix A for links to additional resources):

• Encourage participants to return used syringes and injecting equipment to the SAP for proper disposal. This can and should be done even in cases where disposal is not required in order to receive new equipment.
• Sharps containers are vital to safe syringe disposal. Distribute sharps containers to participants in multiple shapes and sizes for easier and safer transport of used sharps and biohazard.
• When regulation sharps containers are not available , encourage participants to use other rigid containers (such as detergent bottles, beverage bottles, etc), clearly marked as “DANGER: SHARPS” or “BIOHAZARD”, to transport waste.
• Educate participants about proper handling of used syringes.
  • Breaking the needle off of used syringes is dangerous and increases risk for needlestick injuries. If the syringe cap is lost, and no sharps container is available, the tip can be carefully broken off and re-inserted to the barrel of the syringe, reinserting the plunger afterward to trap the tip safely in the barrel.
  • Only recap your own syringes. Recapping others’ syringes can increase risk of needlestick. It is unnecessary to recap if you have a sharps container readily available.
  • To properly re-cap, it is best to leave the cap on a hard surface and without touching the cap, insert the point into the cap to avoid finger pricks.

• Educate participants about the risks of carrying other people’s syringes to the SAP, unless points are properly enclosed in a sharps container.
• Explain that flushing syringes in the toilet, throwing them away in the garbage, leaving them in parks/alleys, throwing them in drains, rivers and streams and any other improper disposal methods puts municipal workers and others at risk of needlestick, and/or can increase pressure on the SAP.
• Emphasize legal rights of syringe exchange participants to return used equipment.
• Educate about other possible disposal sites including hospitals, nursing homes, pharmacies, etc.

Sharps “kiosks” or mailboxes can be a valuable tool to promote proper disposal of used syringes, especially in cases where there is not a necessity to log returns to specific individuals. Kiosks can be set up in specific locations to enable easy access to disposal and help keep neighborhoods and streets clean. Although kiosk implementation is sometimes met with resistance by community members or city agencies, there have been several cases of successful implementation.

Community Retrieval/Syringe Collection

It is important for the SAP to respond to community concerns regarding the improper disposal of used injecting equipment. In addition to educating participants and providing resources to increase proper disposal, SAPs may also consider engaging in pro-active syringe clean-up efforts in the community. This can be done by organizing crews of SAP staff and/or volunteers to go into community areas that may have higher rates of discarded injection equipment and conducting “needle sweeps”. Of course, any member of a clean-up team must be trained on proper handling and disposal of RMW and tools such as tongs, sharps containers and puncture-proof gloves must be made available to workers.

In some cases, when there is a clear and necessary advantage, these “sweeps” can be made public through the use of media outlets as a way to attract positive attention to the SAP and increase support. However, any time the media is contacted and involved in SAP activities it is essential to weigh the potential for negative consequences against any possible gains. Also, it is imperative to make every effort to protect confidentiality of SAP participants.

Another strategy for assisting the community in improper syringe disposal is to develop a resource whereby the SAP can respond directly to specific community concerns. For example, the SAP can institute a hotline for community members to call and report any incidents of improperly disposed syringes. The SAP can then dispatch trained staff to retrieve and dispose of the sharps. Advocating for the use of syringe disposal kiosks in areas where IDUs are likely to access them – parks, public bathrooms, pharmacies, etc – can also be very useful.

OVERDOSE PREVENTION

When working with injection drug users, it is imperative to address overdose (OD) prevention and response. Overdose poses a significant health risk to drug users and is the second-leading cause of accidental death in the US, just behind automobile accidents. SAPs are in a unique position to address OD prevention and response so that should overdose occur, it is not fatal.

Comprehensive training on overdose prevention, recognition and response should be a requirement for all staff and should also be made available to SAP participants. Programs will also benefit from having specific protocols in case of an OD at the program.

OD Prevention and Response

In order to comprehensively address overdose, an SAP should:

1. Train all staff and volunteers on OD prevention, recognition and response.
   1. Training should include the use of naloxone (Narcan), a drug used to reverse the effects of opiate overdose, and if possible, staff should receive prescriptions to be able to legally carry it. Although naloxone is not technically defined as a controlled substance by the federal or state law, it is currently a prescription drug in the United Sates that is subject to the general laws and regulations that oversee all prescriptions in regular medical practice. Therefore, it is possible for someone to face prosecution if they are in possession of, or use, naloxone without a prescription. Further, in some states, naloxone can only be prescribed to people who use drugs. Hiring drug users as staff would ensure that naloxone is still available on site in case of emergency.
   2. Anyone who works or volunteers at an SAP, including front-line staff, administrators, executive directors, cleaning staff, etc, should receive comprehensive OD prevention, recognition and response training.
2. Address overdose with participants through training on prevention, recognition and response, as well as with ongoing education campaigns.
   1. Ideally, the SAP will be able to make naloxone (Narcan) available to participants.
   2. For assistance instituting an overdose prevention program, please contact HRC’s S.K.O.O.P. (Skills and Knowledge on Overdose Prevention Project) at hrc@harmreduction.org or in California, the DOPE Project at dope@harmreduction.org.
3. Develop protocols for responding to onsite overdose, designating staff roles and responsibilities (see Appendix E for sample protocols).

Overdose is always a possibility when working with IDUs. If an overdose occurs on-site at an SAP, being prepared to respond quickly is vital in order to decrease the likelihood that the overdose will be fatal. Also, overdose – regardless of preparedness and positive outcomes – can be a traumatic experience for staff and participants alike. Without proper training, the event can be chaotic and valuable time may be wasted. When a person has overdosed, every moment counts; planning ahead can save time and hopefully, a life.

Once a protocol is developed, all staff must be trained on implementation; it is a good idea for staff to practice OD response. Staff and volunteers can role-play overdose scenarios as they would in the event it should happen in real life. Practice can be very helpful for minimizing anxiety, finding gaps in the protocol, and generally preparing staff in case of a true emergency.

Participant Education on Overdose

An SAP presents an ideal opportunity to engage with the people about overdose prevention. While it is important for the SAP to have a response protocol in place, most overdoses are going to occur outside of the program. Arming participants with the knowledge and tools necessary to properly respond to an overdose is an important responsibility of SAPs and can save lives.

There are many myths among drug using communities about the proper way to respond to an OD, and unfortunately some of these techniques can actually increase risk to the person in need. However, these myths represent a desire to respond to OD. Teaching proper overdose response, coupled with programs that train on naloxone use and provide prescription and distribution of this life-saving drug, can go a long way.

Some considerations when developing an OD education program for participants:

• Keep training sessions brief and to the point.
• Make training and education available at different times.
• Consider a brief overview of OD prevention and response upon participant enrollment.
• Develop a program for training on the use of naloxone, as well as prescription and distribution to participants. Resources on such programs are available at harmreduction.org.
• Use educational posters and brochures to make information available at any time, and make it a regular issue for discussion at the SAP.
• Develop opportunities for participants and/or staff to process and mourn the loss of those close to them in the event that a fatal overdose occurs in the community.

DATA COLLECTION, MONITORING AND EVALUATION

Ongoing data collection, monitoring and evaluation serve many important purposes for the SAP:

• To measure program effectiveness.
• To report back to regulators and funders about program successes and challenges.
• To mitigate community concerns and/or objections to the SAP.
• To identify program strengths and weaknesses.
• To improve program services and participant satisfaction.
• To apply for additional/ongoing funding.
• To inform future goals and outcome measures for the SAP.
• To identify existing gaps in service provision.

It is important to create a clear and simple plan for collecting data and monitoring SAP activities. A good monitoring and evaluation plan is not overly laborious, does not unduly burden participants, and does not interfere with meeting participant needs. Setting clearly defined aims and goals at program onset and on a yearly basis will make it easier to identify information to collect, how best to monitor activities and which outcomes to measure. This will both strengthen funding proposals and help to improve the SAP and its services. Most funders will also have specific guidelines for reporting and evaluation. It may be necessary to collect and enter data for multiple funders or agencies; try to streamline this process to reduce the burden on staff.

Transaction Data

In 2009, a group of researchers and experts in harm reduction gathered to develop a series of best practices for effective SAPs, later compiled in the report, “Recommended Best Practices for Effective Syringe Exchange Programs in the United States: Results from a Consensus Meeting.” Below are their recommendations for SAP data collection and evaluation:

1.  Variables for SEP Data Collection

The data collection burden on both SEPs and IDUs should be minimized to capture only essential information regarding the services provided/received and oriented strictly to SEP program evaluation. Moreover, data collection should never interfere with IDU participation or SEP operation. Below we enumerate and describe the types of data that SEPs should collect for the purpose of program evaluation.

• Transaction-level. SEPs should collect only essential data concerning each interaction with participants. SEPs and/or their respective jurisdictions may elect to ask IDUs for additional, optional individual-level information at each SEP transaction. Such additional, optional individual-level data collection may occur either at periodic intervals or on a continuous basis, and should position the SEP to understand better its participant population and the manner in which they utilize services. The decision for whether and how to collect this information should be made locally and explicitly justified.

• Essential information at each SEP transaction

• Number of syringes distributed

• Number of syringes received

• Optional individual-level information at each SEP transaction

• Gender, age, race/ethnicity, current zip code/geographic area residing

• Last visit to SEP

• Number of people for whom IDU is obtaining syringes (i.e., numeric indicator regarding secondary syringe exchange)

• Site/service location of transaction

• Date, time

• Program-level. SEPs usually provide a range of supplies, services, referrals, and even structured education and training, beyond the distribution of new and sterile syringes. Aggregate data capturing these activities can be compiled at the program level, and reported at regular intervals.

• Number of new and sterile syringes distributed

• Number of used/contaminated syringes received

• Number of other supplies delivered (e.g., alcohol pads/wipes, condoms, etc.) (where relevant)

• Characteristics of other services provided (e.g., vaccination, infectious disease testing, DOT, wound care, overdose prevention training and response, etc.) (where relevant)

1. Evaluating SEPs

SEP evaluation should be reasonable and rigorous in its approach, design, and methodology, and may be  utilized to assess the effectiveness of SEPs at the local/jurisdictional level. Evaluation should focus on assessing the volume, adequacy, and public health impact of services. Program evaluation should be periodic and involve randomly drawn samples of IDUs rather than requiring the continuous involvement of all IDUs who access SEP services. Evaluation should include survey administration and, where appropriate, testing for exposure to blood-borne infection. Surveys should be brief and targeted to capture information on injecting and other health risk behaviors, health problems, social-contextual characteristics, and other relevant information to guide program development and improvement.

It is recommended that any data collected from participants be optional and well justified.

Tracking syringe disposal will depend on the type of program (ex. pharmacy and hospital programs are less likely to track disposal), method of return/disposal (ex. returns are calculated by weight will be tracked differently) and criteria for syringe access (ex. if return is required for syringe distribution).

Information can be tracked using paper forms and/or computer databases. Using paper forms that are then entered into a computer can be a useful backup in case of technical problems or data losses. Sample transaction forms can be found online in Appendix J.

Monitoring Strategies

A number of strategies can be used to collect information and monitor program services on a regular basis:

• Log books: Shift log books kept by staff and outreach workers can be a valuable tool for evaluating the  quality of interactions with staff; participant perceptions of the SAP; anecdotal reports of behavior change among participants; and staff perception of SAP strengths and weaknesses. Log books may also be used to keep track of incidents that occurred during the shift, participant reports about drug quality and/or injecting behavior patterns and/or any participant questions and feedback.
• Incident reporting forms: Standardized incident reporting forms can be used to report any incidents (favorable or negative) that occur at the SAP such as relevant interactions with community members or neighbors, encounters with law enforcement and/or emergency medical services, overdoses and outcomes, needlestick injuries, violence, theft and/or any potentially inflammatory interactions.
• Staff/Team Meetings: Weekly, biweekly and/or monthly staff/team meetings provide an opportunity for SAP workers to process daily events, offer feedback, report on important incidents, clarify policies and monitor that SAP activities are occurring efficiently and effectively. Notes can be kept of meetings, being careful to protect participant confidentiality, for reference and reporting purposes.
• Participant Feedback Forms/Suggestion Boxes: Providing participants with an anonymous and easy way of offering feedback, suggestion, criticism and/or praise can be valuable. Any feedback should be completely voluntary and optional.
• Participant Advisory Board (PAB), Community Advisory Board (CAB) or User Advisory Board (UAB): A PAB, CAB or UAB is an organized group of SAP participants and drug users who can offer feedback, guidance and recommendations regarding SAP policies and services. Although incredibly valuable, setting up a PAB, CAB  or UAB may require a heightened level of organization, resources and commitment. IDU involvement in evaluation, through an advisory board or other vehicle, is recommended.

Reporting and Evaluation

In addition to being a requirement of most funders and regulators, consistent reporting and evaluation will make for a stronger SAP, one that is prepared to share information about its accomplishments, demonstrate its effectiveness and is accountable to any and all stakeholders. Evaluation and reporting, however, should foremost be valuable to the SAP and its participants. More than just a collection of numbers and/or details collected for the sake of maintaining funding, the process of tracking and understanding what is working well, areas for improvement and trends in syringe delivery can be extremely helpful.

Reports

Reports of SAP successes, challenges, transaction data, incidents and other valuable information can be compiled into reports at various intervals: weekly, monthly, quarterly and/or annually. Creating forms and checklists to standardize information to be included in reports can be a useful strategy for simplifying the task. Frequent routine reporting will make end-of-year reporting to funders and regulators easier and less time-consuming, and will decrease the likelihood that reports will reveal any big surprises as to whether the program has been meeting pre- defined goals.

Evaluation

Regular evaluation will be valuable to the continued growth of the program and to ensure the SAP is effective. It can also be instrumental in validating need for the expansion of services. The SAP should be committed to making changes as a result of findings.

There are different types of evaluation that may be appropriate, including:

• Process evaluation: Used to measure how the SAP is conducting services overall and the effectiveness of the SAP in meeting its goals. It will include measures such as coverage of syringe delivery, return rates, participant satisfaction, cost-effectiveness of the program, etc.
• Outcome or impact evaluation: Measures the overall impact of the SAP on the community and will investigate broader measures such as behavioral and biological outcomes, impact on infectious disease rates and incidence, etc. Generally speaking, outcome evaluation will be more expensive and it can face challenges to accuracy and reliability, given limitations inherent in measuring social trends.

Evaluation does not have to be complicated. Consider which aspects of the SAP that you want or need to evaluate. Be realistic about what can and cannot be measured. If budget permits, it can be valuable to hire an outside consultant to conduct program evaluation. This will decrease internal bias and offer fresh perspective. In addition, evaluation can be a lot of work, and contracting out can relieve that burden from staff and volunteers who will be busy with their regular duties. It may also be possible to partner with a university, where academic researchers may be interested in conducting the evaluation. In any case, outside evaluators must be chosen with care to ensure that they will respect the SAP, its mission and its participants.

Conducting evaluation in harm reduction programs brings a unique set of challenges. Harm reduction programs traditionally place higher value on issues such as:

• Smaller, incremental changes
• Individualized change based on goals participants define for themselves
• Staff and participant attitudes and well-being
• The “spirit” in which services are delivered (a combination of moral, ethical, ideological and experiential values)

A successful program will, therefore, be one that runs according to the values and principles of harm reduction, such as:

• Treating people with dignity and respect
• Creating a nonjudgmental and safe environment for participants
• Meeting people where they are and encouraging people to set their own goals
• Involving drug users in program activities, direction and evaluation

In addition, quantitative measures to consider for evaluation include incident rates of HIV, HCV and HBV as well as “coverage” estimates, or how well the SAP is reaching IDUs (this is discussed in more detail in the World Health Organization/UNAIDS publication Guide to Starting and Managing Needle and Syringe Progammes).

Methods

After deciding specifically what needs to be evaluated, there are numerous methods that can be used to conduct an assessment.

Any reports that have been written should be compiled and reviewed. In addition, syringe transaction, referral and enrollment data will of course be needed for analysis. Log books, meeting notes, staff evaluations, incident report and other existing sources of information should also be reviewed for inclusion in evaluation.

The following activities may also be appropriate on a semi-annual or quarterly basis as a means of soliciting specific input from participants and other constituents for evaluation purposes. These activities should be targeted, brief and accessible:

• Focus groups
• Participant surveys or questionnaires
• Staff surveys or questionnaires
• Community surveys or questionnaires
• Interviews