Syringe services programs

Syringe services programs (SSPs) are community-based programs that provide access to sterile needles, syringes, and other injection equipment free of cost to people who inject drugs (PWID) and promote safe disposal of used injection equipment. SSPs often provide PWID with other supporting services, including overdose risk education, provision of condoms and naloxone, vaccinations, infectious disease testing, and referrals and links to substance use treatment and social support services. SSPs vary by size, scope, geographic location, and setting (e.g., community, hospital, or mobile sites). SSPs, also called needle exchange programs, syringe exchange programs, and needle syringe programs, can be part of a comprehensive prevention program at the state or local level (CDC-SSP).

Expected Beneficial Outcomes (Rated)

  • Reduced HIV infection

  • Reduced injection risk behavior

Other Potential Beneficial Outcomes

  • Reduced hepatitis C infection

  • Increased substance use disorder treatment

  • Reduced drug use

  • Improved neighborhood safety

  • Reduced overdose deaths

Evidence of Effectiveness

There is strong evidence that syringe services programs (SSPs) reduce HIV infection (Fernandes 2017*) and injection risk behavior such as needle or syringe re-use, borrowing, sharing, renting, and lending among people who inject drugs (PWID) (Fernandes 2017*, Sawangjit 2017*).

SSPs reduce the risk of HIV transmission among PWID that use the services (Aspinall 2014*). Studies report mixed effects of SSPs alone on hepatitis C virus (HCV) infection, with no effects or an increased risk of HCV infection in PWID (Davis 2017a, Cochrane-Platt 2017*). SSPs combined with opioid substitution therapy or implemented with supportive syringe policies and laws can reduce HCV infection among PWID in some cases (Cochrane-Platt 2017*, Abdul-Quader 2013*). Pharmacy-based SSPs can reduce syringe sharing behavior among PWID, though additional research is needed to confirm effects of pharmacy-based SSPs on HIV and HCV infection and safe syringe disposal (Sawangjit 2017*). SSPs are more beneficial when implemented in multi-component harm reduction interventions and include 100% coverage (i.e., all injections are done with a new clean needle or syringe), and when the policy and legal environment promotes access to and use of SSPs among PWID (Fernandes 2017*, Abdul-Quader 2013*). SSPs reduce injection risk behavior in hospital, pharmacy, community, and mobile settings; effects of SSPs on syringe re-use may vary depending on syringe dispensing policies (Jones 2010b*).

SSPs may increase use of drug treatment and health services and reduce drug injection among PWID (CDC-SSP 2019). Such interventions also appear to increase public safety, protect first responders, and reduce opioid overdose deaths (CDC-SSP 2019).

Available evidence suggests that fear of law enforcement encounters and arrest is a common barrier to using SSPs among PWID (Beletsky 2014, Davis 2019*). Program location and transportation difficulties also appear to be barriers to regular attendance of SSPs among PWID in rural areas (Davis 2018a). Gaining statewide support, buy-in from law enforcement and communities, and building strong partnerships with local communities are recommended strategies to successful SSP expansion and implementation (HIV.gov-SSP expansion).

Expanding SSPs appears to be cost-effective in preventing HIV among PWID (Bernard 2017). The cost to establish and operate a comprehensive SSP varies by number of clients served and geographic location; cost estimates range from $0.4 million for a rural SSP (serving 250 clients per year) to $1.9 million for an urban SSP (serving 2,500 clients per year) (Teshale 2019). Expanding SSPs in rural areas is recommended to meet the needs of PWID living in those areas (RHIhub-Rural SSP, HRC-Rural SSP guide).

Impact on Disparities

Likely to decrease disparities

Implementation Examples

As of August 2019, 31 states and Washington, DC have laws explicitly authorizing syringe services programs (SSPs) in locations throughout the state; disposal services and drug abuse treatment are required to be provided at SSPs in 13 states and 6 states, respectively (LawAtlas-SSP). Washington State, for example, has about 30 SSPs operated through local health departments, community organizations, and tribal entities (WA-SSP). California provides a wide range of services in more than 50 syringe exchange programs statewide (CA-SEP).

The Consolidated Appropriations Act of 2018 permits use of federal funds from the Department of Health and Human Services (DHHS) to support SSPs. State, local, tribal, and territorial governments that intend to implement new SSPs or expand existing programs can request permission to use federal funds to support certain components of SSPs (e.g., syringe disposal services, screening and treatment for HIV and HCV, and referrals to substance abuse prevention and treatment services), with the exception of purchasing sterile needles or syringes. DHHS and the Centers for Disease Control and Prevention provide guidance for funding and program implementation (CDC-SSP funding).

Implementation Resources

CDC-SSP resources - Centers for Disease Control and Prevention (CDC). Additional resources on syringe services programs.

RHIhub-Rural SSP - Rural Health Information Hub (RHIhub). Rural prevention and treatment of substance use disorders toolkit: Syringe services programs.

HIV.gov-SSP expansion - HIV.gov. Regional Health Administrators webinar series: Facilitating expansion of SSPs.

HRC-Rural SSP guide - Belle RL. A guide to establishing syringe services programs in rural, at-risk areas. Harm Reduction Coalition (HRC); 2017.

Addictions-Treatment - Addictions.com. Addiction treatment options.

Citations - Evidence

* Journal subscription may be required for access.

Fernandes 2017* - Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs - An overview of systematic reviews. BioMed Central (BMC) Public Health. 2017;17:1-15.

Sawangjit 2017* - Sawangjit R, Khan TM, Chaiyakunapruk N. Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: A systematic review and meta-analysis. Addiction. 2017;112(2):236-247.

Aspinall 2014* - Aspinall EJ, Nambiar D, Goldberg DJ, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: A systematic review and meta-analysis. International Journal of Epidemiology. 2014;43(1):235-248.

Davis 2017a - Davis SM, Daily S, Kristjansson AL, et al. Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: A systematic review with meta-analysis. Harm Reduction Journal. 2017;14(1):25.

Cochrane-Platt 2017* - Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database of Systematic Reviews. 2017;(9).

Abdul-Quader 2013* - Abdul-Quader AS, Feelemyer J, Modi S, et al. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: A systematic review. AIDS and Behavior. 2013;17(9):2878-2892.

Jones 2010b* - Jones L, Pickering L, Sumnall H, et al. Optimal provision of needle and syringe programmes for injecting drug users: A systematic review. International Journal of Drug Policy. 2010;21(5):335-342.

CDC-SSP 2019 - Centers for Disease Control and Prevention (CDC). Summary of information on the safety and effectiveness of syringe services programs (SSPs). 2019.

Beletsky 2014 - Beletsky L, Heller D, Jenness SM, et al. Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspective. International Journal of Drug Policy. 2014;25(1):105-111.

Davis 2019* - Davis SM, Kristjansson AL, Davidov D, et al. Barriers to using new needles encountered by rural Appalachian people who inject drugs: Implications for needle exchange. Harm Reduction Journal. 2019;16.

Davis 2018a - Davis SM, Davidov D, Kristjansson AL, Zullig K, Baus A, Fisher M. Qualitative case study of needle exchange programs in the central Appalachian region of the United States. PLoS ONE. 2018;13(10):e0205466.

HIV.gov-SSP expansion - HIV.gov. Regional Health Administrators webinar series: Facilitating expansion of SSPs.

Bernard 2017 - Bernard CL, Owens DK, Goldhaber-Fiebert JD, et al. Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. Public Library of Science (PLOS) Medicine. 2017;14(5):1-19.

Teshale 2019 - Teshale EH, Asher A, Aslam MV, et al. Estimated cost of comprehensive syringe service program in the United States. Public Library of Science (PLOS) ONE. 2019;14(4):1-10.

RHIhub-Rural SSP - Rural Health Information Hub (RHIhub). Rural prevention and treatment of substance use disorders toolkit: Syringe services programs.

HRC-Rural SSP guide - Belle RL. A guide to establishing syringe services programs in rural, at-risk areas. Harm Reduction Coalition (HRC); 2017.

Citations - Implementation Examples

* Journal subscription may be required for access.

LawAtlas-SSP - LawAtlas. Syringe services program laws.

WA-SSP - Washington State Department of Health. Syringe service programs (SSP).

CA-SEP - California Department of Public Health. Syringe exchange programs in California (SEP).

CDC-SSP funding - Centers for Disease Control and Prevention (CDC). Federal funding for syringe services programs.

Date Last Updated