ORLANDO, Florida — A syringe-exchange program established as part of the Infectious Disease Elimination Act (IDEA) has been successfully connecting injection-drug users with healthcare in Miami–Dade County.
Some people in this vulnerable population "may never have seen a doctor," said Austin Coye, a medical student at the University of Miami. The exchange program makes it easy to bring those with infectious diseases like HIV and hepatitis C into care.
"I have walked people to the emergency department or the clinic, and we get them, the same day, onto treatment," said Kasha Bornstein, another medical student at the University of Miami.
"By having that link, they can come to the exchange, they can come to the clinic, they can get their meds safely," he told Medscape Medical News. "That's a huge benefit of having a program like this, where the barriers are so low."
Participants with unstable housing can keep their medications at the clinic so they won't be stolen, and repeated presentation to the same care center means that patients can often be diagnosed during the acute phase of disease.
Coye and her colleagues shared their experience from the first 18 months of the IDEA exchange program here at the United States Conference on AIDS 2018, and presented the data that helped to convince legislators to approve the syringe program.
Identifying Hotspots and Solutions
Florida has had one of the highest rates of HIV in the United States for decades, and Miami–Dade County has been one of the hotspots for most of that time. Although the majority of new HIV infections are not the result of dirty syringes, the prevalence of injection-drug use without access to clean syringes is not helpful.
Years ago, when Hansel Tookes, MD, from University of Miami Miller School of Medicine, was a third-year medical student, he recognized that drug laws in the county and the state made it impossible for people who injected drugs to get clean needles, which can eliminate the risk for HIV, hepatitis C, and other viral transmissions.
"We had this tool we were withholding from this vulnerable population," Tookes said on a video shown during the presentation.
So Tookes and some other medical students got together and wrote a resolution to the House of Delegates, asking them to amend criminal laws to make it possible for syringe-access programs to operate in Florida.
They backed up their request with data. Tookes and his team studied syringe disposal in San Francisco, where a syringe-exchange program existed, and Miami, where no program existed (Drug Alcohol Depend. 2012;123: 255-259). They found 11 improperly discarded syringes in San Francisco and 328 in Miami (syringe prevalence, 0.3 vs 4.9 per 1000 people) — a difference of 163%.
The team then looked at healthcare costs related to injection-drug use. Just two diseases — endocarditis and bacteremia — cost the local safety-net hospital $5,824,461. In addition, skin and soft tissue infections cost $1.6 million and osteomyelitis cost more than $1 million.
"This doesn't count infectious diseases, like HIV or hepatitis C," said Coye. "Those obviously cost millions more."
The Florida governor signed IDEA in the spring of 2016, and the exchange program was born.
Gateway to Care
The law that makes the syringe program possible is set to expire in 2021. So Bornstein, Coye, and others are doing follow-ups of the studies spearheaded by Tookes.
So far, 12% of the approximately 800 participants in the syringe-exchange program have been diagnosed with HIV, 47% have been diagnosed with hepatitis C, and 16% have asked to enroll in drug rehab.
In addition, the program has collected 20,000 more syringes than it has given out, reported Emi Martinez, outreach coordinator for the syringe-exchange program.
And since the program started giving out naloxone to reverse drug overdoses, overdose deaths in the county have declined by 38%. This is in the context of rising injection-drug use in the area, Bornstein told Medscape Medical News.
Donna Mello and Katie Riconda, both from the AIDS Support Group of Cape Cod in Massachusetts, said they left the session feeling inspired. Earlier this year, the Massachusetts Department of Public Health released information on an HIV outbreak in Lowell and Lawrence linked to the reuse of syringes.
It's not necessarily a surprise, said Mello. The rise of fentanyl in everything from heroin to cocaine has made every injection more likely to lead to overdose. And because the half-life of fentanyl is half as long as that of heroin, people are injecting twice as often. The Upper Cape has the highest rate of hepatitis C in people 15 to 24 years of age, she said.
The ability of the Florida presenters to link syringe access to the healthcare system in general validates what they are already doing in Massachusetts. "Syringe-access programs are the entry way" into healthcare for this population, Riconda told Medscape Medical News.
"I consider us a primary-care program for people who are not typically engaged in the healthcare system," she explained. "We provide referrals, we provide connection to care, connection to treatment. That short-term navigation process is really important for people to stay alive and stay healthy."
The IDEA exchange program is funded by private donations. The research by Tookes and his colleagues was funded by the San Francisco Department of Public Health, the National Institute of Drug Abuse, the CDC–National HIV Behavioral Surveillance, and the Departmental Center for AIDS Research. Coye, Bornstein, Martinez, Mello, and Riconda have disclosed no relevant financial relationships.
United States Conference on AIDS (USCA) 2018. Presented September 9, 2018.
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