Need and Implementation Assessment for a Syringe Exchange Program (SEP) in Jefferson County, New York

In partnership with Access Care and Resources for Health (ACR Health), this assessment seeks to show that based on current trends of injected drug use (IDU) in Watertown, New York there is a need for a syringe exchange program (SEP) in this area of Jefferson County. ACR Health is a not-for-profit, community-based organization providing prevention, education, and support to individuals with chronic diseases such as HIV/AIDS, diabetes, heart disease, obesity, asthma, substance abuse, and serious mental illnesses. ACR Health is a legacy of AIDS Community Resources and serves nine counties in the state of New York (ACR Health). IDU is increasing in the North County and needs to be addressed through the implementation of programs to reduce injection-related illnesses.

In the past five years, Watertown, New York within Jefferson County has seen a drastic increase in IDU by residents. According to law enforcement officers, prosecutors, judges, medical professionals, and clergy heroin has made a serious negative impact in Jefferson County. The drug, which was once considered rare and hard to obtain is now widely circulated. The popularity of heroin has caused the price to plummet to record lows. In September 2013, police had already prosecuted forty-two heroin-related cases. These cases represented 27 percent of its total caseload annually. The year before, in 2012, the task force prosecuted fifty-eight heroin-related cases, which was 23 percent of its total cases, which is nearly twice what it was a few years ago. Before 2012 heroin-related cases were usually eleven to twelve percent of the total caseload for the police task force in the county. The rise in heroin-related cases has demonstrated the rise in injection drug use in Jefferson County (Flatley, 2013).

At the end of 2010, it was estimated that 358 of every 100, 000 people were living with an HIV infection diagnosis in Jefferson County, NY(AidsVu). Furthermore, in Jefferson County, there is an additional 5 percent of newly diagnosed HIV positive individuals who self-identify as IDU, which is a part of a high-risk subgroup of HIV contractors. New York State Department of Health (NYSDOH) reports that chronic viral Hepatitis C (HCV) prevalence for Watertown is 59.7 cases per 100,000 individuals and is identified as having the highest rate among ACR Health 9-counties (NYSDOH). ACR’s Safety First SEP not only provides new sterile syringes and other safe injection supplies, but it also helps IDUs adopt behaviors which reduce their risk of contracting HIV or viral hepatitis while offering risk reduction counseling and referrals to HIV/STD/Hepatitis counseling and testing, health care, substance use programs, and social services. ACR’ SEP is a prevention strategy that has been proven to work by researchers(ACR Health). The AIDS Institute of NYSDOH estimates that the 21 established syringe exchange programs may be responsible for at least 50 percent and possibly as much as a 75 percent decline in rates of new HIV infection (NYSDOH). The numbers indicating the prevalence of HCV in Watertown and the number of HIV individuals who are IDUs show the need for a SEP that can reduce contraction rates by fueling safe injection usage and providing other services.

In the next two sections, a background and an assessment of SEPs will be provided. First, the background is meant to contextualize SEPs in understanding trends in IDU, HIV, HVC, the evolution of SEPs, and the rise of IDU in Watertown/Jefferson County. Second, the assessment is to evaluate existing SEP programs, the components, strengths, and limitations. Lastly, the conclusion will focus on the limitations of the assessment and potential areas of research in understanding the effectiveness of SEPs.

I. Background

A. IDU Trends

The National Household Survey on Drug Abuse, a survey of drug use among the U.S. population 12 years and older concluded in 2000-2002 that 1.5% of respondents reported being injected drug users. According to the survey approximately 3.4 million people used injection drug methods at least once. Within that 3.4 million people, 440, 000 people were reported injected drug users. In analyzing the survey results Armstrong (2007) noticed the mean age of injection drug users increasing substantially. People born between the late 1940s and early 1960s had the highest prevalence of IDU as compared to other age groups. Between 1979 and 2002 the age of IDUs within the past year increased from twenty-one to thirty-six years old. From 2000 to 2002, approximately 59% of all people with IDU were aged thirty-five to forty-nine years old (Armstrong, 2007, p. 160). Armstrong (2007) argues that the increasing mean age in IDU has to do with the epidemic of IDU starting in the 1960s and peaked in the 1970s and 1980s. Young adults are less likely to have used injection drugs because of the large decline in initiating IDU in the early 1990s. A survey was conducted among adolescents and young adults in the United States, which demonstrated the decline of illicit drug use among youth since the late 1970s (Armstrong, 2007, p. 111). Thus, concluding the significant relationship between those generations that were youth during the epidemic of IDU versus those that are youth now. The perception of drug use is not as popular as it was in the 1960s and 1970s where injected drugs were normalized and a part of youth culture. In contrast, drugs are certainly a part of youth culture but not drugs that require injection. In the 1960s and 1970s, HIV hadn’t erupted in society and injection drug use fatalities or injuries were attributed to overdose. However, today it is well known that IDU affects individuals through the transmission of blood-borne diseases that include HIV, Hepatitis C (HCV) and Hepatitis B. These three can cause chronic infections leading to several illnesses years after the infection began. This includes those that were injection drug users as youth and quit using drugs today. They are still at risk of gaining infections and subsequently, the illnesses associated with them (Armstrong, 2007, p. 160). The next sub-section will discuss trends in HIV, HVC and their relationship to IDU.

B. IDU, HIV/AIDS, and HVC

The CDC estimated that new HIV infections in the United States demonstrate the significance of HIV as a serious health problem. Approximately 47, 500 people were newly infected with the virus in the United States in 2010. Since the mid-1990s HIV incidence has remained stable at 50, 000 per year (MSM et al. 2012, p. 1). Although the numbers suggest a high level of incidence they indicate a reduction of HIV incidence by two-thirds since the U.S. HIV Epidemic. HIV prevention efforts have estimated to prevent more than 350, 000 HIV infections in the United States since then. Despite the increase of people living with HIV in the past decade new HIV infections have not increased, thus, showing the effectiveness of HIV testing, prevention and treatment options reducing the rate of transmission (MSM et al., 2012, p. 5). Programs working to reduce HIV transmission are succeeding in advocating prevention methods through awareness, protection, and other methods. The containment of HIV can allow the maintenance of the illness overall. IDU is said to drive HIV epidemics in many parts of the world. There is evidence that epidemics can be prevented and thwarted when HIV programs target drug users in their efforts. When countries implemented options for IDUs, often consisting of medication-assisted therapy along with needle and syringe programs, HIV epidemics among IDUs stabilized, stopped or reversed (Needle & Zhao, 2010, p. 5).

A second illness associated with IDUs is HVC, which is one of the most common diseases among IDUs (Backmund et al., 2001, p. 188). HVC is a blood-borne viral infection that causes the liver to inflame and lead to permanent scarring, also known as cirrhosis. Before widespread blood screenings were implemented as a health initiative in 1992, Hepatitis C was spread through transfusions and organ transplants. Infections today are linked to contaminated needles used in non-sterile tattooing and piercing. The second most common form of transmission is through intravenous drug use. The risk of transmission among IDUs is due to the belief that equipment can be cleaned using bleach or boiling, but these methods do not kill the virus on the equipment. Even if IDUs use clean needles with the old equipment the disease can still be transmitted (Constantouros et al. 2013, p. 12). There are a variety of treatment options for HCV infected IDUs including successful treatment options. Backmund et al. (2001)conducted a study that concluded the effectiveness of interferon treatments to treat chronic HCV infections if patients are closely supervised by physicians specialized in hepatology and drug addiction medicine (p. 188). This assessment will focus on SEPs that are preventative measures that help reduce the transmission of HVC and HIV among IDUs.

C. Background on SEPs

Harm reduction refers to programs and policies aimed at reducing the harm associated with the use of drugs. People who support harm reduction programs view that elimination of drug use is an unrealistic objective and that rather health initiatives should focus on achievable measures that reduce the likelihood of harm. Harm is most often associated with the contraction of diseases and premature death attributed to drug use (Hunt, 2003, p. 4). Within the context of HIV prevention harm reduction includes the use of SEPs and drug addiction treatments. SEPs allow for sterile syringes to be available while enabling safe disposal of used syringes. These actions decrease the amount of contaminated injection equipment circulating among IDUs. The decrease in contaminated syringes reduces the chance of infection and decreases the risk of HIV transmission. Most SEPs are connected with HIV prevention efforts that include HIV counseling, testing, education, information on sexual and drug-use health risks, referral to drug addiction treatments and referral to medical and other services available for IDUs. Research shows that the implementation of SEPs is usually a part of a larger HIV/AIDS prevention strategy or a public health initiative related to the reduction of the spread of Hepatitis B and HVC (amfAR, 2007, p. 1).

WHO developed a ‘model essential package’ for HIV/AIDS prevention, treatment, and care that includes a component of harm reduction. The package promotes principles of equity and human rights and interventions that can be successful in settings limited in resources. It includes operational guidance to countries and officials on how to select and prioritize interventions and service models based o local situations and available resources. It also stipulated the need for complementary drug control measures in the global public health infrastructure. It advocates for policymakers and donors to examine the quality of harm reduction programs and other areas of public health opportunity. The model package for harm reduction includes interventions for reducing HIV transmission, HIV risk reduction information, education, counseling, HIV testing and counseling, sterile needle and syringe access, safe disposal of used syringes and needs, drug dependence treatment, condom programming, prevention of mother-to-child transmission of HIV and lastly, STI treatments (Ball, 2007, p. 688).

To better understand existing SEPs it is best to conduct a summary of the timeline from early initiatives to contemporary SEPs. The distribution of clean needles to IDUs was considered before needle exchange was a process. A lieutenant at the Berkeley Police Department in California recalled hearing about the distribution of sterile needles to IDUs in 1970 at San Francisco University. The lieutenant argued stated that giving sterile needles was a way of dealing with jaundice and abscesses developed from shooting heroin. The San Francisco needle exchange program that developed subsequently during the HIV epidemic started at the San Francisco General Hospital. There, doctors and nurses left ten-pack syringes in view of those that were IDUs. Although there was no communication between the IDUs and medical officials, this was an early introduction to needle exchange as a public initiative. In the mid-1980s studies indicated the growing number of IDUs concerned about their risk of injection-related HIV transmission and other infections. Many of the studies sought to study and create various strategies to avoid injection-related infections. The demand for clean equipment was so great that an underground market developed as a result. Unfortunately, as in most underground markets, unethical practices were rampant. These included the circulation of used needles and syringes that were rinsed and repackaged to appear sterile. They were sold on the street to customers who were unaware of their potential health risks (Kahn et al., p. 1). Public officials are willing to adopt pilot programs to test the effectiveness of needle exchange as an intervention. Many states have created legislation to authorize the creation of pilot programs for needle exchange initiatives. Needle exchange programs continue to be funded heavily as public officials and legal implementations demonstrate support of the programs. Some needle exchange programs involve activists that are dedicated to reducing IDU related infections, while others are strictly run by health professionals. The professionalization of needle exchange programs may certainly legitimize the perception of the program, however, as demonstrated by early initiatives of needle exchange it may expand the distance between clients and the staff. The importance of former drug users and advocates within communities is important in advocating for the clients and understanding where they are coming from (Kahn et al., p. 4). Syringe exchange programs seeking to reduce HIV harm have shown the following:

• Most injection drug users are not on treatment;

• Reaching these women and men is crucial in reducing sexual and injection risks HIV pose for them, their partners, and their children;

• Operating harm reduction outreach program with syringe exchange attracts injecting drug users to risk reduction, increases referral to treatment, and results in less HIV transmission;

• Syringe exchange programs significantly decrease the amount of discarded syringes in a community; and

• Syringe exchange programs have never been shown to increase drug use or cause other harm. (The Chicago Recovery Alliance, 2000, p. 1)

Additionally, SEPs have protected those in law enforcement from needle stick injuries. A Connecticut police officer study found that needlestick injuries were reduced by two-thirds after implementing SEPs in that community. SEPs also promote public health and safety by taking dirty syringes away from IDUs. They reduce the circulation of contaminated syringes, as mentioned above and provides a safe way to dispose of used syringes (amFAR, 2007, p. 1). One argument against SEPs is the notion that it increases crime and drug use. However, a study found that new SEP participants were five times more likely to go on drug treatment programs than non-participants. Researchers have also found that IDUs that had exchanged needles through the program were more likely than IDUs who did not to reduce or stop injecting later on (amFAR, 2007, p. 2).

D.Rise In injection drug use in Watertown/Jefferson County NY

ACR’ Health SEP Proposal written in November 2013 cited the fast trajectory of enrollment in its Safety First Syringe Exchange Program (SEP) as a demonstration of the success of its initiatives. As a result of its efforts staff have been able to accommodate the volume of 15-35 individual client interactions per day. The SEP provides new sterile syringes and other injection supplies, safe disposal of used syringes, educational information on syringe sharing, safe injection techniques and safe sex practices, as well as offers risk reduction counseling and other social services. Lastly, it provides male and female participants condoms, dental dams and other safe sex contraceptives as well as for instructions and demonstrations to ensure proper usage. ACR’s SEP consists of a mobile unit, SEP Staff and Peer Educators that participate in attaining the goals of the program. SEP services that they currently offer closest to Jefferson County, New York are in Syracuse. According to their research, 2% of SEP participants travel from North County to access their services in Syracuse because there isn’t a local SEP.

In the past five years, Watertown has had a rise in IDUs among residents, particularly the use of heroin and methamphetamine. ACR’s Safety First Syringe Exchange Program Supervisor, Nathan Barron, has worked with Jefferson County’ Raid ResponseCoalition for almost a year to address the need for sterile injection equipment and opiate overdose prevention programs in the area. In 2013 deaths in Jefferson County doubled in the two years that preceded it. Drugs like heroin don’t come with instructions or variation warnings and often one cannot distinguish the difference between a “good bag” and “bad bag,” increasing the risk of fatality in heroin-related drug use. In 2011 there were eighteen overdose deaths, fifteen from opiates, including two from heroin and four from morphine. In 2012, there were 16 overdose deaths where 12 was from opiates including three from heroin and three form morphine (Flatley, 2013).

In recent years, there has been a variety of articles written in the Watertown Daily Times detailing methamphetamine and heroin-related arrests at increasing amounts. The need to develop an SEP in Jefferson County is correlated to the increase in Hepatitis C and HIV attributed to dirty needles, which can be reduced through the implementation of an SEP program (W. Scee II, 2014). The increase in IDU in Watertown, New York has sparked the interest of residents in supporting SEP because they or someone they know has been affected by IDU. ACR Health’s June 2013 needs assessment demonstrated alarming opioid hospitalization discharge rates at 151 in Jefferson County and 320 in Watertown. In discharges that were cocaine-related hospitalizations, they were at a rate of 102 in Jefferson County and a rate of 212 in Watertown. In the next section, SEPs are assessed to demonstrate the components, strengths, and limitations of SEP implementation in communities.

II. Assessment of SEPs

The introduction of this paper introduced the problem of Jefferson County as the rise of IDUs and subsequent HIV infections associated with IDU rose as well. To solve this problem the assessment seeks to introduce an SEP in Watertown as a strategy in reducing the effect of increased IDU residents in the city. IDUs are vulnerable to HCV, HIV and other blood-borne infections because of the sharing of injecting equipment. It is estimated that 180 million people are living with HCV and 33 million people are living with HIV/AIDS worldwide (Torre, 2009, p. 119). The daunting nature of these numbers strikes the importance of SEP programs in reducing new infections annually worldwide. Needle exchange programs, as discussed in section I, subsection C, are important in distributing clean needles to IDUs and serve as a location where IDUs can discard used syringes. The primary reason that needles are shared among IDUs is the lack of access to needles because of supply or IDUs may not be able to afford available syringes (Swan, p. 1). Measures have developed as a result to improve access to sterile injecting equipment at SEPs in different settings. SEPs can operate in different settings including pharmacy-based distribution, sale or exchange schemes, strategies for disinfecting needles and syringes where they are reused or shared, vending or distributing machines, policies to safely dispose of used syringes and needles and many other capacities. According to WHO in 2004, SEP was operating officially in forty countries and increased to sixty in 2007 (Swan, p. 7).

In assessing the effectiveness of SEPs overall it is best to understand the critical components that make it successful in any given community. These components include the prioritization of satisfying IDU needs for sterile syringes; maximization of number and variety of access points where IDUs can obtain new and sterile syringes; maintenance of anonymous nature of participation in SEP; insurance that IDUs can access sterile syringe provision; and the minimization of data collection burden on SEPs and IDUs (Bluthental et al., 2009, p. 6). Satisfying IDU needs for a particular community requires the analysis by SEPs of individual characteristics of local IDUs and the environment in which the service will be delivered. IDUs in communities tend to form subgroups according to specific individual characteristics. As a result, these subgroups should have specialized services that cater to their specific needs. The most effective SEPs have developed these additions to their service to further satisfy the needs of IDUs in the respective community they serve (Bluthental, 2009, p. 8). SEPs maximize the number of access points including secondary, or satellite distribution which is when a SEP participant visits an SEP and obtains syringes and distributes them to IDUs who cannot or do not visit SEP. However, in some areas, it is discouraged or prohibited by law. SEPs have found that in places where it occurs the participant from SEP often provides safe injection information to those that do not access SEPs, thus, increasing awareness of safe injection practices and opportunities. SEPs maintain the anonymity of IDUs that use their services by having no oral or written identification of name or identity. Those that come to exchange needles are guaranteed confidentiality of their involvement and are not required to participate in the SEP’ other services. Additionally, the hours of service and locations are specified to IDU population characteristics of that community (Bluthental et al., 2009, p. 7). IDUs sometimes use exchange services of SEP’ but not the others, however, when SEPs provide provisions of other services IDUs may seek more services. These services include food and clothing distribution, as well as medical screening and vaccinations (as well as primary care), social services outreach and counseling for IDUs. Lastly, the reduction of data collection on participants should be minimal and not detract from the mission of the program. The priority of SEPs is to provide sterile syringes to IDUs so this data should be more important than others when collecting data (Bluthental et al., 2009, p. 8).

These components that contribute to SEP’s success at the community level are reiterated in communities where SEPs have been implemented. Two of the most important policies and procedures implemented in New York State was the program evaluation and distribution and collection of syringes. SEPs are required to conduct an outcome evaluation of the program's services and conduct client satisfaction surveys annually. This allows for the program and other necessary parties to gauge the effectiveness of the program and its reception among IDUs. Each year SEPs create a plan to attain goals for each of its program services, which is approved by the State Health Commissioner. The outcome evaluation criteria and client satisfaction surveys document progress in attaining the previously established goals (NYSDOH, 2009, p. 23). When SEP agencies are established they create protocols described in authorized SEP waiver applications which were also approved by NYSDOH. This application includes the number of syringes can be requested per single transaction. They are not allowed to request more unless a written request to the Aids Institute Harm Reduction Unit articulates the justification for the change. To account for large transactions SEP staff are required to explain entries in the transaction log that exceed 600 syringes (NYSDOH, 2009, p. 24). The policies and procedures states create to manage SEP’s contribute to its effectiveness as they are also created with the intent of focusing on the mission of reducing harm among IDUs.

New Jersey has shown the effectiveness of SEP implementation in communities of need. The “Bloodborne Disease Harm Reduction Act” was signed into law on December 19, 2006, in the state of New Jersey. It allowed the establishment of six syringe programs to test the effectiveness of implementing SEPs throughout the state. The Division of HIV, STD and TB Services, within the Public Health Services Branch of the Department of Health (DOH) was in charge of implementing the law by identifying municipalities most in need. The five municipalities that were chosen were based on the high prevalence of HIV related to IDU (O’Dowd, 2012, p. 3). From November 2007 to November 2011 a total of 9, 912 participants enrolled in New Jersey SAPs (Syringe Exchange Access Program). In the time between April 2009 to November 2011, 22% of SAP participants to successfully admit themselves in drug treatment through the DOH. Also, about 1, 570 non-SAP IDUs received clean syringes through secondary exchanges from November 2007 to November 2011. Approximately 59% of SAP participants were linked to prenatal care and/or drug treatment from January 2010 to November 2011. SAPs provided on-site pregnancy tests to 337 female IDUs and of those who were tested 23 were pregnant. Nine female IDUs who knew they were pregnant were referred to prenatal care and drug treatment. An estimate of 825 SAP participants was provided on-site HIV testing from November 2007 to November 2011. Those that were positive were linked to care specific to HIV positive infections. Out of the total SAP participants, 423 were referred to as HCV testing services from November 2007 to April 2011 (O’Dowd, 2012, p. 8-9).

The impact of the implementation of New Jersey’s SEP provides evidence of how successful SEPs can be in reducing harm among IDU populations. SEPs not only provide access to sterile injection equipment but also provide on-site testing for pregnancy, HIV, sexually transmitted diseases, viral hepatitis, and immunizations. Additionally, they refer IDU participants to services, if needed, such as prenatal care, drug treatment, counseling, and other social services.

SEP has been proven to be effective, but it has its limitations as well. First, many SEPs have developed to reflect the true mission of harm reduction through the decrease of contaminated syringes in circulation. Others have been established to align with stakeholders’ concerns rather than the IDUs of the community it serves. These practices are said to undervalue the progress toward achieving the SEP mission (Bluthenthal et al., 2009, p. 9). Second, many studies on the efficacy of needle and SEPs can be affected by many factors that are generally not assessed in findings. For example, a small area analysis revealed that program implementation in areas where people are often receptive to health education programs explain the positive environment of SEP implementation. Similarly, another area could reveal the opposite, thus, affecting the success of SEPs in that region. Stakeholders are not the only ones that can negatively affect the direction of SEPs there are a variety of other influencing factors. However, SEPs must maintain focus on their general mission. Also, it would be important for state actors to analyze areas that may be favorable for new health initiatives in correlation with IDUs so that SEPs can be better received in communities (Belani & Muennig, 2008, p. 238).

III. Conclusion

This needs assessment sought to demonstrate the relationship between IDUs, HIV and HCV contraction. This relationship is important in understanding the overall mission of SEP to focus on harm reduction for IDUs that are at risk of contracting HIV and HCV due to dirty needle usage when IDUs share needles. SEPs have been demonstrated to not be correlated with IDUs, needle-sharing or changes in drug use methods from noninjection to injection. Findings concluded that neighborhoods with SEPs experienced lower rates of drug use compared to those where high levels of drug use and no SEPs available (Gay Men’s Health Crisis, 2009, p. 9). SEPs can benefit communities because of the reduction of the spread of HIV through the reduction in the spread of blood-borne illnesses through syringe usage.

The philosophy behind SEPs is to focus on minimizing the medical and social consequences of drug use for the IDUs, the communities, and society as a whole. Many other strategies have developed as a result of SEP to target IDUs in the greater community. SEPs advantage over other harm reduction programs is its economically efficient way of preventing illness and subsequently decreasing the cost of health care for participants (Gay Men’s Health Crisis, 2009, p. 7). The rise in IDU in Jefferson County and the rise in HIV contraction related to IDU satisfy the needs for implementing an SEP program in that region. Watertown, NY is an example of the significant increase in IDUs that have contributed to overdose deaths, arrests, and drug-related hospitalizations. The role of SEP could decrease the new infection rate of IDUs in Watertown, NY and increase safe injection practices among IDUs. Additionally, IDUs will have the chance to be tested on-site to determine their HIV status and be referred to the necessary services. Other services such as pregnancy testing, sexually transmitted diseases and counseling, as well as referral to external social service programs, can be provided at a local SEP.

References

ACR Health. (n.d.). Who we are. Retrieved from http://www.aidscommunityresources.com/content.cfm/AboutUs/index.

ACR Health. (n.d.). Safety first syringe exchange. Retrieved from http://www.aidscommunityresources.com/content.cfm/Services/syringe-exchange.

Flatley, D. (2013, September 22). Aftermath of an overdose: heroin use on the rise in jefferson county. Watertown Daily Times. Retrieved from http://www.watertowndailytimes.com/article/20130922/NEWS03/709229866.

AidsVu. (n.d.). Map|aidsvu. Retrieved from http://aidsvu.org/map/?state=NY.

NYSDOH. (n.d.). About the aids institute - hepatitis c. Retrieved from http://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/.

NYSDOH. (n.d.). About the aids institute - prevention and support services. Retrieved from http://www.health.ny.gov/diseases/aids/general/about/prevsup.htm.

Armstrong, G. L. (2007). Injection drug users in the United States, 1979-2002: an aging population. Archives of internal medicine, 167(2), 166-173.

MSM, W. M. B., Women, B. H., Hispanic, M. S. M., Men, B. H., Women, W. H., IDUs, B. M. & IDUs, B. F. (2012). New HIV Infections in the United States.

Needle, R. H., & Zhao, L. (2010). HIV Prevention Among Injecting Drug Users: Strengthening US Support for Core Interventions. CGHP Center. Washington, DC.

Backmund, M., Meyer, K., Von Zielonka, M., & Eichenlaub, D. (2001). Treatment of hepatitis C infection in injection drug users. Hepatology, 34(1), 188-193.

Constantouros, J., Erickson, J., Hughes, E., Jackson-Spieker, K., & Masi, K. (2013). Needs assessment for aids community resources, inc.: Hepatitis c virus testing, treatment, and ancillary services. Maxwell School of Citizenship and Public Affairs.

Hunt, N., Ashton, M., Lenton, S., Mitcheson, L., Nelles, B., & Stimson, G. (2003). A review of the evidence-base for harm reduction approaches to drug use. London: Forward Thinking on Drugs.

Ball, A. L. (2007). HIV, injecting drug use and harm reduction: a public health response. Addiction, 102(5), 684-690.

Kahn, M. D., Lee, P. R., Lurie, P., Reingold, A. L., & Sorenson, J. Needle Exchange: A Brief History. amfAR. (2007, November). amfar fact sheet: The effectiveness of harm reduction in preventing the transmission of hiv/aids. Retrieved from http://www.amfar.org/uploadedFiles/In_the_Community/Publications/The%20effectiveness%20of%20harm%20reduction.pdf.

W. Scee II, T. (2014, March 25). Jefferson county asac: Syringe exchange program an 'excellent measure'.Newsjunky.com. Retrieved from http://www.newzjunky.com/news2014/0325asac_syringe.htm.

Torre, C. (2009). Syringe Exchange Programmes in the Context of Harm Reduction. Arquivos de Medicina, 23(3), 119-131.

Swan, K. Needle Exchange Programs: Making a Risky Behavior Safer.

Bluthenthal, R., Clear, A., Des Jarlais, D., Friedman, S. R., Grove, D., Hagan, H., Heimer, R., Heller, A., Kral, A., Sherman, S. & Tolbert, R. (2009). Recommended Best Practices for Effective Syringe Exchange Programs in the United States. Retrieved from http://www.cdph.ca.gov/programs/Documents/US_SEP_recs_final_report.pdf.

NYSDOH (2009). POLICIES AND PROCEDURES SYRINGE EXCHANGE PROGRAMS. Retrieved from http://www.health.ny.gov/diseases/aids/consumers/prevention/needles

O’Dowd, M. E. (2012). New Jersey Syringe Access Program Demonstration Project. Retrieved from http://nj.gov/health/aids/documents/syringe_access_program_rpt_2012.pdf.

Belani, H. K., & Muennig, P. A. (2008). Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New York City. Journal of HIV/AIDS & Social Services, 7(3), 229-240.

Gay Men’s Health Crisis (2009). Syringe Exchange: An Effective Tool in the Fight Against HIV and Drug Abuse. Retrieved from http://www.gmhc.org/files/editor/file/SEP_report.pdf.

The Chicago Recovery Alliance (2000). Harm Reduction Outreach with Syringe Exchange Guidelines and Operating Procedures. Retrieved from www.anypositivechange.org/guideOP.pdf.