Harm reductionists, HIV/hepatitis C preventionists, and good people everywhere, rejoice! Last month Congressional Republicans rallied behind an effort to lift a decades-old ban against federal funding for syringe exchange programs. Syringe exchange programs swap out used syringes for clean ones while providing wraparound services such as HIV/hepatitis C testing, referrals to social services and access to drug treatment for people struggling with addiction. For decades now evidence has overwhelmingly concluded that syringe exchange programs are effective at reducing the transmission of HIV and hepatitis C among injection drug users, lowering needle-stick injury to law enforcement and members of the public, and connecting people who use drugs to social services and treatment options. Despite this, the outdated ban on federal funding for these programs has meant that most programs struggle to stay afloat and others are forbidden from being implemented at all. This Congressional action could mean that existing programs struggling mightily to provide adequate HIV/hepatitis C prevention, syringe disposal, and wraparound services might finally see some reward for their efforts. I chatted with Whitney Englander, policy advocate at the Harm Reduction Coalition, to see what the end of the ban might mean for organizations that provide syringe access services to people who use drugs.
TC: Can you describe when the ban on federal funding was introduced and its original intent?
WE: The ban on federal funding for syringe exchange programs (SEPs) has been in place since the 1980s. Several programs were springing up around the country at that time in response to the HIV epidemic and there was political backlash over what impact SEPs would have on drug use. At the time, many were concerned that SEPs would encourage riskier drug use or cause more people to initiate drug use. Even though there was already an overwhelming body of evidence to demonstrate these claims to be false, Congress implemented a ban on federal funding for these programs. Because of that, many states and municipalities also declined to provide funding.
In 2009 after Obama took office, Congress briefly lifted the ban, but it was reinstated again in 2011 when the House flipped back to Republicans. I think the frustration [within the harm reduction movement] was that it seemed that even though we certainly had champions, neither Democrats nor Republicans really prioritized syringe exchange funding when competing with other hot button policy riders such as abortion or Obamacare funding. It was used as a trading chip by both sides to win other things. The opioid epidemic's spread across the country has changed the paradigm.
To be clear, Congress did not fully repeal the ban on federal funding for syringe exchange programs. There are some caveats. For example, they still will not fund the syringes themselves, but they will fund all the additional program elements from the staff to the facilities, as well as the other wraparound services provided to participants. The area has to demonstrate risk for an outbreak of HIV or HCV, there needs to be some collaboration with the CDC, etc. But this is still a major step. With the current opioid epidemic, it's pretty easy to demonstrate risk for an HCV or overdose outbreak and syringes are usually the most affordable element of a syringe program.
TC: What were some of the arguments used to convince Congress to repeal the ban now?
WE: Ironically, refusing to allow federal dollars (and by extension in many cases, state and municipal dollars) to fund syringe exchange programs, Congress was actually ensuring that any programs that did exist were likely to only provide syringes and not the other wraparound services that make up a comprehensive disease prevention program. With limited funding many programs can only provide syringes to participants, since syringes are relatively cheap. What they couldn't provide was HIV testing, drug treatment referrals, substance use counselors, job training, linkage to the health care system, and other services that are far more costly. A ban on government funding meant that Medicaid couldn't reimburse these services, so it created a disincentive for programs to provide them. That was a key argument that resonated with Congress.
TC: What caused Republicans to lead the effort to repeal the ban after decades of imposing it?
WE: The short answer is Scott County, Indiana. In early 2015 we saw the ravages of an HIV outbreak among people who inject drugs. The tiny town of Austin, in Scott County, saw 170 new cases of HIV among a population of 4,000. That kind of an outbreak was unheard of before, but it's starting to happen, especially in rural counties where they don't have the infrastructure to handle these kinds of medical emergencies. Urban areas have long had drug issues and have built the infrastructure to address outbreaks, but rural areas, where drug use is shifting to, are unprepared.
Given that Scott County is right across the border from Kentucky, which Senate Majority Leader Mitch McConnell represents, there was good reason to fear that the outbreak might spread to Kentucky. There was actually a research project out of the University of Kentucky that modeled what that might look like. I think that resonated with Senator McConnell and Chairman Rogers, also representing a rural Kentucky district that is already hard hit by hepatitis C, who were the champions behind the efforts to repeal the ban. Both policymakers deserve a lot of credit for heralding in this reform and making it a reality.
TC: What are the next steps to encourage syringe exchange efforts in the U.S.?
WE: We have had this devastating policy rider in place for over three decades. Amending it and modifying it was an important step, but it's important to note that no new funding has been attached to it. The next important step is to do the hard work to get the federal dollars flowing and directed where they can help the most. I am hoping that this will give states flexibility to support existing syringe exchange programs. Now that the ban is lifted, it will give some existing programs the validation they need to continue in areas that have been hard hit by the opioid epidemic, HIV and hepatitis C.
This is an important step forward for harm reduction. We have long been blacklisted as not part of the mainstream health care continuum and I think this was the final push towards lifting that stigma. It is important to address the opioid epidemic using a full spectrum of services, including primary prevention, treatment, capacity to integration into primary care, overdose prevention, HIV/hepatitis C testing and referrals, etc. Harm reduction efforts such as syringe exchange are now being integrated into all the other important strategy pieces to address the opioid epidemic. Hopefully this will be another step forward for health agencies to learn how they can integrate harm reduction into other programs as well.