The FY2012 cost to operate the Needle Exchange Program was $148,294, of which, $115,766 was provided by the General Fund. Due to the reimposition of the ban on use of federal funds to support syringe exchange programs, the Needle Exchange Program is fully General Fund supported in FY2013. The loss of federal funding support was addressed in the approved FY13 budget for the Public Health Department’s STD & HIV Prevention and Control Program. No additional General Fund support is requested.
Economic studies have predicted that syringe exchange programs could prevent Human Immunodeficiency Virus (HIV) infections among clients, their sex partners and offspring at a cost of about $13,000 per infection averted. This is significantly less than the lifetime cost of treating an HIV-infected person, which was estimated to be $253,196 in 2005.
STD & HIV Prevention and Control performed a rudimentary cost effectiveness analysis of the Needle Exchange Program in 2009 using information from the University of California San Francisco - AIDS Research Institute, national estimates and local Santa Clara County data, and found comparable cost effectiveness of the local program.
Based on the number of primary and secondary clients served, the Santa Clara County Needle Exchange Program was estimated to have averted eight new HIV infections among its clients and their needle using and sexual contacts in 2008, at a lifetime savings of $2,025,568. Over the 17 year history of the Santa Clara County Needle Exchange Program, this translates to an estimated $34 million in averted cost - or $13 in averted cost for every $1 spent.
This analysis was limited to HIV and did not include the additional cost savings as a result of other averted blood-borne infections such as Hepatitis B or C. The cost effectiveness of needle exchange alone as a means of preventing Hepatitis B and/or C infection has not been clearly demonstrated; however, the potential savings from averted Hepatitis C infections alone may equal or exceed that of averted HIV infections.
REASONS FOR RECOMMENDATION
The syringe exchange program reporting established by AB547 (Ch. 692, Statutes of 2005) requires that, in counties implementing a needle/syringe exchange program, the local public health officer annually present a report detailing the status of the program, including any relevant statistics on blood-borne infections associated with needle sharing activity, at an open meeting of the Board of Supervisors. AB110 (Ch. 707, Statutes of 2007) amended the reporting requirement to include a report on the use of public funds for clean needle/syringe exchange programs. Although AB604 (Ch. 744, Statutes of 2011) now allows the report to be presented biennially, annual reports will continue to be submitted to ensure that the Board of Supervisors and the community have timely relevant information on the status of the Needle Exchange Program.
Presentation of this status report at an open meeting of the Board of Supervisors is necessary to satisfy the requirements of Section 121349.3 of the California Health and Safety Code.
The recommended action will have no/neutral impact on children and youth.
The recommended action will have no/neutral impact on seniors.
The recommended action will have no/neutral sustainability implications.
At its September 13, 1994 meeting, the Board of Supervisors adopted a Resolution declaring a state of local emergency within Santa Clara County due to the significant risk of the spread of HIV infection by injection drug users, and implemented a needle exchange program. The Board of Supervisors periodically reaffirmed the need to continue the local state of emergency, as required by State law, through January 11, 2000. On January 11, 2000, the Board of Supervisors adopted a Resolution declaring a state of local emergency within Santa Clara County due to the significant risk of the spread of HIV infection, Hepatitis C and other blood-borne pathogens among injection drug users, their sexual partners and offspring, and continued implementation of the needle exchange program in accordance with the provisions of AB136 (Ch. 762, Statutes of 1999); and periodically reaffirmed the need to continue the local state of emergency, as required by state law, through January 10, 2006.
AB547 (Ch. 692, Statutes of 2005), which took effect January 1, 2006, authorized counties to implement a clean needle/syringe exchange program without a declaration of a state of local emergency. This new law also required the local public health officer to annually present a report detailing the status of the program including any relevant statistics on blood-borne infections associated with needle sharing activity at an open meeting of the Board of Supervisors. The law further stipulates that law enforcement, administrators of alcohol and drug treatment programs, other stakeholders, and the public must be afforded an opportunity to comment during this annual report and the notice to the public shall be sufficient to assure adequate participation in the meeting by the public. This meeting shall be noticed in accordance with all state and local open meeting laws and ordinances, and as local officials deem appropriate. The Board of Supervisors adopted a Resolution at its January 10, 2006 meeting which authorized the continued implementation of the County's Needle Exchange Program pursuant to the provisions of Section 121349.1 of the Health and Safety Code.
AB110 (Ch. 707, Statutes of 2007) amended the local public health officer's annual reporting requirement, specified in Section 121349.3 of the Health and Safety Code, to include a report on the use of public funds for clean needle and syringe exchange programs.
AB604 (Ch. 744, Statutes of 2011) amended the required frequency of the local public health officer’s reporting to biennial, and added the California Department of Public Health – Office of AIDS to the list of list of government agencies which may authorize a syringe exchange program.
STATUS OF SYRINGE EXCHANGE PROGRAM
Santa Clara County's Needle Exchange Program, a function of the STD & HIV Prevention and Control program within the Public Health Department, is one of twenty-four (19 county and 5 city) authorized needle exchange programs in California (as of June 2011); and is California's 4th longest serving needle exchange program. The program has been at the forefront of public health science's efforts to promote safer behaviors proven to reduce new infections of HIV and other blood-borne viruses.
Needle exchange programs are community or street-based programs that provide sterile needles and other injection equipment to injecting drug, hormone, steroid, vitamin, and insulin users. Exchanges are done on a "one-for-one" basis (clients must deliver a used syringe for every sterile syringe provided to reduce the number of discarded syringes). Needle exchange clients may be primary (individuals exchanging their own needles) or secondary (individuals exchanging needles for friends or a group of people) users. Materials, such as alcohol swabs are also provided to help prevent abscesses and other bacterial infections. In addition, services offered include information and referrals regarding sexual and injection risk reduction education; substance abuse treatment; screening for Hepatitis B and Hepatitis C; and other health and social services. Needle Exchange Program staff have also been cross-trained to provide HIV testing and counseling (including rapid testing) at all needle exchange sites.
A Community Advisory Board (CAB) was established from the inception of the program and continues to incorporate community perspectives into the structure and direction of the program. The CAB is composed of clients and representatives from community-based organizations, the San Jose Police Department, Santa Clara County Sheriff's Office, the Santa Clara County District Attorney's Office, other service providers and interested members of the community.
During FY2012, the Needle Exchange Program operated at six sites:
· Knox Avenue, San José
· Second Street and Highway 280, San José
· Crane Center, 976 Lenzen Avenue, San José
· Jose Figueres Avenue and Alexian Drive, San José
· Little Orchard Road, San José
· Highland Avenue, San Martin
Program and Client Statistics
According to the National Survey on Drug Use and Mental Health, among respondents 12 years and older, the prevalence of "ever" engaging in injection drug use was 1.1%; and "current" injection use (of cocaine/heroin) was 0.7%. This translates to approximately 20,000 who have "ever" used injection drugs and 13,000 current injection drug users in Santa Clara County.
Nationally, the estimated number of current injection drug users has been declining since 2006. The most significant factor in the decline is an increasing tendency toward non-injection drugs as the drug of choice (e.g., methamphetamine and/or orally administered drugs).
The anonymous nature of the Needle Exchange Program creates a number of challenges to capturing client data; however, we continue to make improvements in our ability to report unduplicated client counts and their demographic information.
During the period July 1, 2011 through June 30, 2012, the Needle Exchange Program:
· Served approximately 19% of the estimated number of injection drug users in Santa Clara County
· Served 364 unduplicated primary clients
· Served 2,131 secondary clients (potentially duplicated)
· Had 1,131 client visits (duplicated)
· Exchanged 122,441 syringes (an average of 10,203 per month).
Of the 364 unduplicated primary clients served through the Needle Exchange Program in FY2012:
· 61.5% were male, 28.4% were female, and <1% were transgendered.
· 4.1% of the clients were between 18 - 24 years of age; 10.4% were between 25 – 34 years of age; 19.5% were between 35 - 44 years of age; 27.2% were between 45 – 54 years of age; 17.0% were 55-64 years of age; and 4.4% were 65 years of age or older. 17.4% of the clients declined to provide their age.
· Caucasians (48.9%) and Latinos/as (25.4%) comprised the majority of the client population, with 17% of clients not reporting their race/ethnicity.
· 21.4% of the clients reported being homeless (a significant increase from the 12.1% who reported being homeless in FY2010).
· 21.4% of the clients reported yes to “Ever been in drug treatment” (the percentage of clients reporting having ever been in drug treatment has remained steady over the preceding three years [approximately 20%] following a sharp decline compared to FY2008 [41.8%]).
HIV Prevalence Among Needle Exchange Clients
Needle exchange programs were created to minimize the risk of HIV infection among injection drug users (IDUs) and to reduce the spread of Hepatitis B and Hepatitis C among IDUs, their sexual partners and offspring. In Santa Clara County, 7.9% of all HIV cases reported since April 2006 were associated with injection drug use. The prevalence of HIV infection among Needle Exchange Program participants is unclear, and less than 3% of Needle Exchange Program participants reported knowing their HIV status (positive or negative). A 2010 focused assessment of Needle Exchange Program participant HIV status indicated an HIV prevalence far higher than the general population. The low percentage of HIV status awareness among Needle Exchange Program participants, and disproportionate prevalence of HIV infection warrant continued emphasis on routine HIV testing of the Needle Exchange Program participant population. While difficult to state conclusively, the Needle Exchange Program appears to have been and continues to be successful in reaching injection drug users at greatest risk for transmitting HIV.
STATISTICS ON BLOOD-BORNE PATHOGENS ASSOCIATED WITH INJECTION DRUG USE
As of December 2011 (the latest data available), 861 cases of HIV and 4,512 AIDS cases have been reported into the Electronic HIV/AIDS Reporting System (eHARS). Overall, 3,126 persons are reported to be living with HIV disease (HIV and/or AIDS) in Santa Clara County. Of these:
· 90.3% of cases were among men, and 9.7% among women.
· 43.3% of cases were among Whites, 11.8% among Blacks, 35.3% among Hispanics and 8.5% among Asians/Pacific Islanders.
· Nearly 45% of all living cases are among those 50+ years of age.
· Men who have sex with men (MSM: 72.6%) followed by men who have sex with men and use injection drugs (MSM/IDU: 14.2%) are the leading modes of exposure among those living with HIV disease.
Hepatitis B Statistics
Nationally, it is estimated that 4.3% - 5.6% of the population has ‘ever’ been infected, with 800,000 - 1.4 million persons living with chronic Hepatitis B infection. In 2010, 3,374 new acute symptomatic Hepatitis B (HBV) cases were reported nationally; however, after asymptomatic infection and under-reporting were taken into account, it was estimated that there had been 38,000 new infections in the U.S. California reported an incidence rate of 0.7 per 100,000 population in 2010. In Santa Clara County, 1306 chronic Hepatitis B infections were reported in 2010. Of the 364 unduplicated clients who accessed needle exchange services between July 1, 2011 and June 30, 2012, <3.8% reported having a HBV infection diagnosis.
Hepatitis C Statistics
Nationally, incidence of acute Hepatitis C declined 91% between 1982 and 2010. Approximately 2.7 – 3.9 million persons in the U.S. are chronically infected with Hepatitis C (HCV). However, it is widely believed that new cases of HCV are significantly under-reported (estimated nationally at 17,000 in 2010). In 2010, the incidence rate for reported acute Hepatitis C in California was 0.1 per 100,000 population, with 2,421 cases of chronic Hepatitis C reported. Hepatitis C laboratory testing results are difficult to interpret and confirmatory tests are often not requested. Thus, the counts of new infections reported to Santa Clara County are likely and underrepresentation of true values. Of the 364 unduplicated clients who accessed needle exchange services between July 1, 2011 and June 30, 2012, 25.8% reported having an HCV infection diagnosis.
Injection drug use remains the most commonly identified risk factor for HCV infection, representing nearly half of the reported cases nationwide in 2007. Forty-two percent of reported cases had more than one sex partner during the incubation period, 10% of acute HCV cases were among those who had sexual contact with a known HCV patient, and another 10% were MSM. Nearly eight percent (7.6%) of acute HCV was among those who had a percutaneous injury (e.g., needle stick injury).
USE OF PUBLIC FUNDING
AB110 (Laird) authorized public entities, including counties, that receive State General Fund money from the California Department of Public Health - Office of AIDS for HIV prevention and education to use that money to support clean needle/syringe exchange projects.
Section 120780.1 of the Health and Safety Code stipulates that the money may be used for, but is not limited to, the purchase of sterile hypodermic needles and syringes as part of a clean needle exchange program only if:
· the State General Fund money used for purchasing the sterile hypodermic needles and syringes does not supplant any other public or private funds or other resources for this purpose;
· the amount of State General Fund money used does not exceed 7.5% of the total amount of State General Fund money received for HIV prevention and education;
· each dollar of State General Fund money used for purchasing the sterile hypodermic needles and syringes is matched by forty-three cents ($0.43) of money from non-state public funds or private funds; and
· the allocation of State General Fund money is based upon the epidemiological data reported to the Office of AIDS in the local HIV prevention plan.
The Governor's FY2010 budget reductions included the elimination of all State General Fund money for HIV prevention (including syringe exchange); and no State General Fund support for HIV prevention (including syringe exchange) has been included in subsequent state budgets.
President Obama signed into law an end to the longstanding ban on most Federal funding for needle exchange programs on December 16, 2009. However, the Health Resources and Services Administration, which oversees the Ryan White HIV/AIDS Program, did not release its guidance to its grantees on the allowable use of funds until December 28, 2010, effectively delaying use of federal funding until after that date. Congress subsequently included reinstatement of the ban on federal funding for syringe exchange programs in the Labor Health and Human Services appropriations bill language as part of the final federal FY 2012 appropriations package. The reinstated ban became effective December 31, 2011. Only a limited amount of federal funding was used to support needle exchange in FY2012, the loss of which was able to be absorbed within the FY2013 STD & HIV Prevention and Control budget without additional General Fund support or service reductions.
FY2011 Needle Exchange Program Expenditures:
Santa Clara County General Fund
0.93 FTE Public Health Community Specialists (E04)
Sterile hypodermic needles and syringes
Paraphernalia (bleach, tape, sharps containers, etc.)
Fleet (vehicle operation)
Methadone Treatment Intake Fee
State of California General Fund
0.23 FTE Public Health Community Specialists (E04)
Sterile hypodermic needles and syringes
Paraphernalia (bleach, tape, sharps containers, etc.)
Compared to FY2011, the total FY2012 cost of the Needle Exchange Program decreased by $3,532.82; however, the General Fund portion of the Program cost increased by $5,081.45 due to the reinstatement of the ban on use of federal funding. Operational improvements have reduced the total annual cost of the Needle Exchange Program by more than 25% ($59,184.19) compared to FY2009 ($207,479), while increasing the number of syringes exchanged by 30% (28,274) compared to FY2009 (94,167).
SB1159 (Chapter 608, Statutes of 2004), which became effective January 1, 2005, allows counties or cities to authorize a "Disease Prevention Demonstration Project". Local pharmacists who opt into the project are allowed to sell ten (10) or fewer hypodermic needles or syringes to persons over 18 years of age. The Demonstration Project requires any pharmacist who furnishes or sells needles in a county or city that has been authorized to register with the local health department and certify that, at the time of sale to the customer, they will provide information on (1) how to access drug treatment, (2) how to access testing and treatment for HIV and Hepatitis C and (3) how to safely dispose of needles. In addition, the legislation requires local health departments to maintain a list of all pharmacies that have registered with them and make available to pharmacists written information on the above three items. Public Health Pharmacists continue to assist pharmacies that are interested in joining the project.
The "Disease Prevention Demonstration Project" began in Santa Clara County on February 21, 2006. To date, there are 57 pharmacies that have registered with the project. The registered pharmacies are comprised of chain pharmacies such as Walgreens and Long's Drugs as well as independent pharmacies, the Public Health Pharmacy, and one Santa Clara Valley Medical Center pharmacy. In that SB1159 also deleted the requirement to maintain records of non-prescription sales of syringes by registered pharmacies, there is no data available on the number of participating clients or needles sold.
The "Disease Prevention Demonstration Project" authorized under SB1159 was due to sunset December 31, 2010. AB1701 (Chapter 667, Statutes of 2010) was approved by the Governor on September 30, 2010, extending the sunset date of the existing Disease Prevention Demonstration Project, without making any other changes, to December 31, 2018.
SB41 (Chapter 738, Statutes of 2011), approved by the Governor October 9, 2011, permits licensed pharmacists throughout the state to sell or furnish up to 30 syringes without a prescription to customers over the age of 18, and allows customers 18 years of age and older to purchase and possess up to 30 syringes for personal use when acquired from an authorized source. The bill specifies that pharmacists, physicians, and syringe exchange programs (SEPs) are authorized sources of nonprescription syringes for disease prevention purposes. SB 41 also requires pharmacies and SEPs which offer non-prescription syringe sales to provide options for safe syringe disposal.
AB604 (Chapter 744, Statutes of 2011), also approved by the Governor on October 9, 2011, adds the California Department of Health, Center for Infectious Diseases, Office of AIDS (OA) to the list of government entities that may authorize syringe exchange programs. Beginning January 1, 2012 until January 1, 2019, OA has authority to establish a program that allows entities to provide syringe exchange services anywhere in the state where OA determines that the conditions exist for rapid spread of HIV, viral hepatitis, or other blood-borne diseases. Following consultation with local health officers (LHOs), local law enforcement officials, local neighborhood associations, and after a 90-day public comment period, OA may authorize a syringe exchange program for two years, and is required to send a written and electronic mail notice to the chief of police, the sheriff, or both, as appropriate, of the jurisdiction in which the program will operate. OA may also reauthorize the program in consultation with the local health officer and local law enforcement officials.
Hepatitis C Screening
AB1382 (Chapter 643, Statutes of 2011), which was approved by the Governor on October 9, 2011, authorized HIV test counselors trained by the Office of AIDS to perform skin punctures for the purpose of withdrawing blood for HIV, HCV or combination HIV/HCV testing using a Clinical Laboratory Improvement Act (CLIA) waived test. OraSure Technologies, the maker of the rapid HIV test, received US Food and Drug Administration approval of its rapid hepatitis C screening test on June 25, 2010; however, the rapid HCV test kits have only just begun to be available, and training from the Office of AIDS on the rapid HCV test is not scheduled to begin until sometime in October 2012. Although the Centers for Disease Control and Prevention published an August 16, 2012 recommendation that all persons born between 1945 and 1965 be tested for HCV (Morbidity and Mortality Weekly Report (Volume 61, Number RR-4), injection drug use remains the most commonly identified risk factor for HCV infection, representing nearly half of the reported cases nationwide in 2007. The availability of rapid HCV testing provides an opportunity to extend HCV screening services (currently provided at the Crane Center) to the high risk clients served at the Needle Exchange Program sites.
STD & HIV Prevention and Control Program continues to explore other opportunities to enhance the services provided through the Needle Exchange Program, particularly those opportunities, such as rapid HCV testing, where services can be enhanced within the existing resources and/or through collaborations and partnerships with other agencies.
It is anticipated that these efforts will facilitate the continued evolution of a syringe exchange program that is both responsive to current and emerging needs of the existing client base, and is accessible to a wider demographic of the substance using population.
STD & HIV Prevention and Control also continues to work closely with representatives from local law enforcement and the community to identify and implement other potential changes/enhancements where appropriate.
CONSEQUENCES OF NEGATIVE ACTION
Failure to accept the recommended action may impact the County's ability to comply with Section 121349.3 of the California Health and Safety Code.