International Journal of Drug Policy 14 (2003) 461–463

Short report

Delivering syringe exchange services through “satellite exchangers”:the Sacramento Area Needle Exchange, USA

Rachel Andersona,∗, Lynell Clancya, Neil Flynna, Alex Kralb, Ricky Bluthenthalc

a Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Medical Center,4150 V Street, Suit 500, Sacramento, CA 95817, USA

b Urban Health Studies, Department of Family and Community Medicine, UC San Francisco, CA, USAc Health Program, RAND& Center of AIDS, Research, Service, and Education, Department of Psychiatry,

Charles R. Drew University, Madison, NJ, USA

Received 1 December 2002; received in revised form 15 March 2003; accepted 11 July 2003

Abstract

An important operational aspect of Syringe Exchange Programmes (SEPs) is the venue of service delivery. This report describes theprogrammatic features of the Sacramento Area Needle Exchange (SANE), an illegal SEP operating in California, USA. SANE utilises“satellite exchangers” to distribute the bulk of its syringes and HIV risk reduction supplies. Advantages of relying primarily on DesignatedExchangers (DE) for delivery of SEP services are that it: (1) allows for coverage of a large geographical area; (2) keeps operational cost low;(3) provides syringes to clients who may not want to or cannot use fixed site programmes; (4) limits the possibility of detection of programmepersonnel and clients by law enforcement. Limitations are that: (1) it is not as conducive as fixed sites to providing a wide range of ancillaryservices; (2) it may not be optimal for drug users who do not want to be reliant on other people for access to syringes; (3) those who receiveservices from a satellite exchanger may not derive as much counselling and referral services as direct exchangers. The lack of legal status,political support and adequate funding threatens the programme’s existence.© 2003 Elsevier B.V. All rights reserved.

Keywords:Syringe exchange; Satellite/secondary exchange; Delivery; HIV prevention; Policy; Legal status

Introduction

Effectiveness studies of syringe exchange programmes(SEPs) are plentiful (Gibson, Flynn, & Perales, 2001), yetfew studies have considered how programme operationsmight have an impact on outcomes (Bastos & Strathdee,2000; Heimer, Bluthenthal, Singer, & Khoshnood, 1996;Riley, Wu, Junge, Marx, Strathdee, & Vlahov, 2000). Re-peated surveys of SEPs in the United States have revealedcontinuing and substantial differences in programmaticfeatures (Centers for Disease Control, 1995; Des Jarlais,Mcknight, Eigo, & Eigo, 2002; Paone, Clark, Shi, Purchase,& Des Jarlais, 1999). One important operational aspectof SEPs is the venue of service delivery. Service deliveryvenue affects who can gain access to the service, whattypes of services can be effectively delivered, programme

∗ Corresponding author.E-mail address:rjvanderson@ucdavis.edu (R. Anderson).

costs, and which funding sources are willing to fund theprogramme. Here we describe the programmatic features ofthe Sacramento Area Needle Exchange (SANE), an illegalSEP that utilises “satellite exchangers” to distribute the bulkof its syringes and HIV risk reduction supplies. We con-sider the advantages and limitations of this mode of servicedelivery. Satellite exchangers (sometimes called secondaryexchangers) are people who have access to an SEP anddistribute supplies (e.g. syringes) to other drug users (DesJarlais et al., 2002; Grund et al., 1992; Snead et al., 2003).

Programme description

SANE was established in 1993 as an IDU network-based,pager-initiated, mobile delivery programme that distributesand exchanges syringes on an as-needed basis. SANE hasbeen an illegal, underground SEP since it opened. In Cal-ifornia, a doctor’s prescription is required to purchase and

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462 R. Anderson et al. / International Journal of Drug Policy 14 (2003) 461–463

possess syringes unless a local governing body declares astate of emergency and sanctions an SEP. In such a case theSEP may operate legally, although IDUs may still be ar-rested for possessing syringes based on drug paraphernalialaws that make it illegal for drug users to possess materialsthat can be used for drug use. Neither the city nor countyof Sacramento has legalised the SEP (as of March 2003).Designated exchangers (DEs) are recruited and trained bySANE staff and volunteers in exchange protocol, infectiousdiseases and overdose prevention techniques, harm reduc-tion strategies, and given appropriate injection supplies.DEs represent networks that are geographically, economi-cally, professionally (e.g. government workers or students),medically (e.g. HIV) or socially defined (e.g. immigrants;similar drug of choice). Individuals contacting the pro-gramme for the first time are referred to the DE in theirarea after the first couple of visits or are assisted with estab-lishing their own exchange network. To serve homeless ormarginally-housed IDUs, SANE volunteers make weeklytrips through known drug-use areas in the region and home-less camps along the two rivers that flow through SacramentoCounty.

Advantages

Given the setting and political realities, the methods usedby SANE have several advantages. First, by relying pri-marily on DE for delivery of SEP services allows SANEto cover a large geographical region. Sacramento County,where SANE operates, encompasses 1000 square miles(1609 square kilometres) and contains a population of 1.2million, with an estimated 14,000 IDUs (Newmeyer, 1995).To cover this large geographical area using other modali-ties would require either a large number of fixed sites or alarge number of staff with pagers and vehicles for deliv-ery. Despite this novel method of providing SEP services,SANE estimates that it reaches a small portion of IDUs inSacramento County.

Second, using networked-based DE with syringe deliverykeeps operational cost low (approximately US $75,000 peryear). At present, SANE consists of three staff working anestimated total 0.80 full-time equivalent. Almost all staffeffort is devoted to the actual delivery of services. The bulkof service delivery is conducted by DE who are volunteers.Between 1997 and 2000, the number of syringes deliveredincreased by 332% from 100,829 to 435,690 representing areduction in programme cost per syringe from 38 to 18 UScents. In 2002, 75% of available funds were expended onsupplies.

Third, this method also provides syringes to clients whomay not want to or can not use fixed sites programmes.In the few studies that report demographic characteristicsof SEP clients, women have represented 26% of clients inChicago (Brahmbhatt, Bigg, & Strathdee, 2000) and 34%in Baltimore (Riley et al., 2002). In the first nine months of

2002, 45% of SANE exchanges were conducted with womenand 13% of all exchanges were conducted with women ofcolour.

This approach also limits the possibility of detectionof programme personnel and clients by law enforcement.Many IDUs do not gain access to fixed site SEPs becauseof the fear of detection by police (Rich, Strong, Towe, &McKenzie, 1999). This is particularly true in cities whereSEPs are illegal (Bluthenthal, Kral, Lorvick, & Watters,1997). Fear of arrest may disproportionately affect peo-ple of colour and women with children, two importantsub-populations of IDUs. By conducting syringe exchangethrough delivery and having DE deliver the majority ofservices, SANE is able to reach a diverse population thatmight not have access to SEP if it operated using othervenues.

Further, this model makes it difficult for law enforce-ment agencies to intervene against the programme. AlthoughSANE has operated illegally for nine years, only once havepolice arrested the programme personnel. In June 2001, atrial judge convicted a SANE volunteer of illegal syringepossession. The volunteer, who was responsible for a largeportion of the exchange volume, was sentenced to three yearsprobation and ordered not to possess or exchange syringes.The loss of this volunteer’s service has adversely affectedthe level, timeliness and overall quality of the programme. In2001, 405,107 needles and syringes were exchanged whilein the first nine months of 2002, only 129,443 needles andsyringes have been exchanged (a 43% decrease from 2001).Additionally, one of SANE’s primary funders notified theprogramme that funding would not be continued due to theconviction. Finally, SANE has received many reports fromconsumers decrying the negative effect on service timelinessand quality.

Limitations

While having DE conduct the bulk of service deliveryhas several advantages over other modes of delivery, thereare also limitations. First, this model is not as conducive asfixed sites to providing a wide range of ancillary services,including first aid, HIV testing or advocacy. Second, usingDE for delivery of services may not be optimal for drugusers who do not want to be reliant on other people foraccess to syringes. Third, those who receive services from asecondary exchanger may not derive as much from the ser-vices as direct exchangers in terms of counselling, referralto social and medical services and education. SANE min-imises this limitation by training and educating DE in harmreduction strategies and infectious disease/overdose pre-vention.

The illegal, underground status of SANE representsanother limitation. Increasing numbers of SEPs in Cali-fornia receive funding from city and county governmentsfor non-syringe supplies and staff. SANE is limited to

R. Anderson et al. / International Journal of Drug Policy 14 (2003) 461–463 463

funding provided by private foundation grants and dona-tions from programme consumers, staff and communitymembers.

Discussion

We conservatively estimate that at least 3 million syringesper year should be exchanged or purchased by local IDUs.The use of DE has contributed significantly to the success ofSANE, yet its illegal status threatens to undermine the en-tire programme. The lack of political support and adequatefunding is threatening the programme’s existence. Accord-ing to the County Health Officer, a loss of SANE couldlead to a doubling of HIV seroprevalence among local IDUwithin five years. SANE will continue to work with localhealth officials, an ad hoc committee, and the Drug PolicyAlliance to obtain a local declaration of emergency and asanctioned programme.

The authors offer the following recommendations to oth-ers wanting to provide SEP services in similar settings: (1)recruit reliable volunteers; (2) work with local IDU on pro-gramme design, implementation and evaluation; (3) estab-lish stable funding (to the extent possible); (4) thoroughlytrain volunteers to train DE; (5) provide pager/delivery ser-vices in large geographic areas; (6) be as discreet as pos-sible (try to avoid antagonising law enforcement and drugdistributors); and (7) cultivate local political support.

Acknowledgements

Support for writing this manuscript was provided bythe Centers for Disease Control and Prevention (Grant No.RO6/CCR918667-01). The authors would like to thank thestaff and consumers of California SEPs for their generousparticipation in our research.

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