Needle Exchange Task Force Report to the Board of Supervisors May 14, 2002 | |
This is a report to the Board of Supervisors by the Needle Exchange Task Force, established by the Board to develop a plan for needle exchange in response to the dual epidemics of HIV/AIDS and Hepatitis C in the county | |
Needle Exchange Task Force Membership | |
The Task Force included | |
▪ Steve Wagstaffe, Deputy District Attorney | |
▪ Jim Fox, District Attorney | |
▪ Horace Hurst, Deputy Sheriff, a representative from the Sheriff's office | |
▪ Bruce Tognetti, Police Chief from Brisbane, representing the Police Chiefs Association | |
▪ Ken Pesso, a representative from Probation | |
▪ Pat Morrisey representative from the Human Services Agency's Alcohol and Drug Program | |
▪ Desi Tafoya, representative from the Human Services Agency's Alcohol and Drug Program | |
▪ Amy Portmore MD, representing the San Mateo County Medical Society | |
▪ Sarah Cottrell, an epidemiologist in the Disease Control and Prevention Unit, representing the Health Department | |
▪ Lisa Netherland, representing AIDS prevention services in the Health Department | |
▪ Joey Tranchina, who coordinates San Mateo County's needle exchange program | |
▪ Kim Fredericks, who coordinates Santa Clara county's needle exchange program; and | |
▪ Nina Grossman, who coordinates San Francisco's needle exchange program. | |
Jonathan Mesinger, from Hospital and Clinics, John Conley, Deputy Director of Public Health, and Scott Morrow MD, County Health Officer, provided staff support to the Task Force. | |
Background | |
Our community is caught on the horns of a social dilemma: enforcing laws or improving and promoting health. In the circumstances and situations the Task Force dealt with, these two very important concepts in our society were often at odds. Given this dilemma, the task force decided that it would primarily focus on the health issue of reducing the spread of HIV, Hepatitis C (HCV), and other blood-borne pathogens in our community. Task Force members realize that optimally, no one would inject illicit drugs, but some people will continue to engage in this highly risky behavior due to the powerful nature of addiction. Viewing needle exchange as a health issue helped the task force complete its work | |
In June, 1999, the board was presented with a request to support a program addressing the issue of Hepatitis C in San Mateo County. At that time, the board requested that a plan be developed and presented. In July, 1999 the County Health Services Agency convened a Hepatitis C Task Force, comprised of community members, County health experts and expert community health providers to determine the extent of the epidemic in the county and to develop a plan of action. The Task Force completed its assignment and presented a plan to the Board in December, 1999. Based on the report of the Hepatitis C Task Force, funds were allocated by the Board to: study Hepatitis C virus (HCV) prevalence and distribution, increase awareness of HCV in high-risk populations, and make recommendations regarding further HCV efforts in San Mateo County | |
To determine the extent of the Hepatitis C endemic in San Mateo County, a point prevalence study, which concluded in September 2000, was conducted. The aim of the study was to estimate HCV seroprevalence in local high-risk individuals, to identify factors locally associated with HCV infection, and to gather initial information on drug use in identified populations. The study provided HCV testing to 1,026 persons in population groups considered at high risk for HCV infection. Participants were recruited through several sites/programs serving high-risk individuals, including alternative test sites (ATS) for HIV testing, the needle exchange program, the county's AIDS clinic, and the county jail. The results of the study showed alarmingly high rates of HCV infection in these populations. HCV seropositivity was highest among participants recruited through needle exchange sites (N=272, 52.9% positive), followed by the jails (N=176, 30.1% positive), HIV clinics (N=77, 28.6% positive), and the ATS sites (N=501, 22.8% positive). The prevalence study was presented to the Board in March 2001. At that time, a number of actions were taken by the Board. Stable funding for HCV testing and prevention education was implemented. The Board also recommended that "Harm reduction", as an operating principle, should be more strongly emphasized in dealing with substance use and the HCV endemic in San Mateo County. The Board also formed a Task Force to review and make recommendations on the current status of and the long-term plan for needle exchange in the county. The Task Force began meeting in the Fall of 2001 and concluded it's mission in 2002. This report is the result of the work of the Board-commissioned Needle Exchange Task Force | |
A. Activities of the Needle Exchange Task Force | |
The Task Force accomplished a number of activities. They are listed below: | |
1) Review of Needle Exchange Programs | |
The first task was to review the state of needle exchange in surrounding jurisdictions, around the country, and around the world. The Task Force spent most of its review time looking at the operations of needle exchange programs in San Francisco, San Mateo, and Santa Clara Counties. Government funds support needle exchange programs in San Francisco and Santa Clara. The task force learned that the needle exchange program which has been operating for over 13 years in San Mateo County will end this summer due to loss of funding. All other funding sources for this program have been exhausted. With loss of this program, no needle exchange program will exist in San Mateo County. | |
2) Scientific Studies | |
The Task Force reviewed a summary of scientific studies related to substance abuse, needle exchange, and disease transmission around the world. The Task Force found that numerous studies have demonstrated the effectiveness of needle exchange. There are at least six federally funded reports, conducted independently by the National Commission on AIDS in 1991, the General Accounting Office in 1993, the University of California in 1993, the Centers for Disease Control and Prevention (CDC) in 1993, the National Academy of Sciences in 1995 and the Office of Technology Assessment in 1995. These studies show that needle exchange programs can reduce HIV infections by at least one-third, reduce needle sharing by as much as 80%, improve admission into substance abuse treatment programs, and do not increase either the number of injection drug users or the amount of drug use in injection drug users. | |
In an April 1998 letter to Health and Human Services Secretary, nine of the nation's chief medical and research experts, including the National Institutes of Health (NIH) Director, the National Institute on Allergies and Infectious Diseases Director, the National Institute on Drug Abuse Director, the Surgeon General, the Centers for Disease Control Director, the Office of HIV/AIDS Policy Director and the Substance Abuse and Mental Health Services Administration Administrator stated: "After reviewing all of the research, we have unanimously agreed that there is conclusive scientific evidence that needle exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs." | |
3) Legal status | |
The Task Force reviewed the legal status of needle exchange in the county. In 1999, the State of California enacted legislation allowing local governments to legalize syringe exchange programs within their jurisdictions. Assembly Bill (AB) 136, which became law in January 2000, protects local jurisdictions and their agents from criminal prosecution for distributing hypodermic needles or syringes in syringe exchange programs authorized pursuant to "a declaration of a local emergency due to the existence of a critical local public health crisis." San Mateo County is currently under such a declaration, approved by the Board of Supervisors | |
4) Public Support | |
The Task Force found that there is strong public support for needle and syringe exchange programs. A population-based representative sample of adults over the age of 18 was conducted in February 2002 in conjunction with the community needs assessment. We found that about 75% of San Mateo County adults either agree or strongly agree that needle and syringe exchange is an effective strategy to reduce HIV and HCV transmission in injection-drug-using populations. Nearly 50% of the adult population strongly agree with the above statement, while only about 9% strongly disagree with it | |
5) Cost and Effectiveness | |
The Task Force investigated cost of prevention and cost of treatment. The total lifetime cost of single HIV/AIDS patient is $120,000-$150,000 and the total lifetime cost of a Hepatitis C patient can run $250,000. Our best estimate is that an optimally effective needle exchange program in our county will need to furnish approximately 600,000 needles each year. Such an effective program will prevent dozens of infections with HIV and/or HCV each year in our community. As a result, we will save $12-25 in related treatment costs for every $1 we spend on this program. As the studies reveal, not only is needle exchange effective in preventing disease, it is also a highly cost effective prevention strategy. | |
B. Recommendations | |
Based on review of the scientific literature and the experience of other programs, the task force developed these recommendations. Four operating principles were used to develop these recommendations. The principles focused on the science related to needle exchange. The principles are to: | |
▪ Minimize barriers to accessing clean needles and syringes | |
▪ Maximize access to clean needles and syringes both by geographic location and time of day | |
▪ Maximize the collection of used needles | |
▪ Use needle exchange as a conduit to support services and ultimately to recovery | |
The task force recommends that needle exchange continue in this county and that it be integrated into existing programs to the degree possible. The specific recommendations of the task force follow: | |
1) Operations: The Task Force recommends that needle exchange should be integrated into the activities of county functions that deal with the control of blood-borne diseases and/or substance abuse, particularly those dealing with injection drug use. These programs have access to, deal with, and for the most part have strong working relationships with the highest risk populations. These programs should attempt to furnish needles on a one-to-one basis, should give out information on the risks of needle-using behavior, and, to the extent possible, give individuals information about treatment alternatives. The Task Force encourages one-to-one exchange, but recommends allowing clean needles to be furnished without exchange at the discretion of staff, mostly as a means to encourage ongoing participation in the program. The County programs that would participate in this include: the mobile clinic, the AIDS program's prevention and testing activities, and the community clinic network. It is believed that this activity will cover approximately 15-20% of the total need. | |
2) Operations: To cover the remaining 80-85% of the need, it is recommended that the County contract with an agency with staff dedicated to needle exchange activities. These staff will provide syringes, needles, and other related items (cotton, etc.), as well as information about substance abuse treatment, education and awareness about HIV/AIDS and HCV prevention, referrals to HIV/HCV testing and counseling, treatment services and other resources. | |
3) Operations: The Task Force recommends that other county departments participate in the needle exchange program to every extent possible. Specific activities include: Probation and Sheriff's office personnel should give out information about needle exchange to appropriate contacts. The Task Force recommends similar information be given out through other law enforcement personnel in the county. The Task Force also recommends participation by the County Alcohol, Tobacco & Other Drug Program (ATOD). Specifically, that the ATOD program support current and future contracted treatment providers to offer needle exchange as a harm reduction strategy in their list of treatment options. In addition, alcohol and drug counselors should distribute information about needle exchange and treatment alternatives. | |
4) Policy: The Task Force also recommends that the law enforcement statement of intent as written by the San Jose Police Department be promulgated by all law enforcement jurisdictions in San Mateo County. This recommendation is currently being reviewed by the Police Chief's Association. The recommended wording for this order follows: | |
Order | |
Effective immediately, Law Enforcement members will adhere to the following procedures when encountering persons in possession of hypodermic syringes and needles: | |
Law Enforcement members will not take enforcement action against any program staff or their volunteers found to be in possession of hypodermic needles for the sole purpose of participating in the Needle Exchange Program. Nor will enforcement action be taken against private citizens or organizations not associated with the County program found to be in possession of hypodermic needles for the sole purpose of participating in their own independent needle exchange program. | |
Law Enforcement members will continue to take enforcement action against individuals found to be in possession of a hypodermic needle or syringe and under the influence of and/or in possession of an illegal substance. Department members will use their own discretion in deciding whether or not to take enforcement action against persons solely in possession of needles by determining whether they are immediately participating in an exchange program. | |
5) Collection: The Task Force recommends that syringe disposal sites be placed in appropriate selected public areas taking into account safety and other community concerns. The Task Force recommends that sharps containers be distributed at all exchange sites. The Task Force recommends that sharps containers be accepted for disposal at the Public Health Mobile Clinic, the AIDS Program testing vans, the Public Health Laboratory, the San Mateo County Health Center and the community clinics. | |
6) Treatment Capacity: While not a part of this proposal, the Task Force realized that there needs to be a increase in drug treatment capacity in the county, especially in anticipation of an increase in education and referrals resulting from needle exchange | |
7) Budget: The Task Force recommends adoption of an annual budget as detailed below. The total cost of an effective needle exchange program in San Mateo County is $390,768 per year. It is proposed that these costs be shared. Health Services can cover $129,200 of those costs by reassigning work, by integrating needle exchange into existing programs, and covering administrative overhead. The Task Force requests that the board fund $180,000 of the $261,568 annual cost for the contractor. This is approximately the treatment cost of a single HIV and/or HCV patient. These funds will be used for a contract through Alcohol and Drug to provide services as described above. The shortfall of $81,586 will have to be made up from yet unidentified sources and will be the responsibility of the contractor to obtain. | |
Total Estimated Budget | |