Syringe services programs

There is strong evidence that syringe services programs (SSPs) reduce HIV infection (Palmateer 2022, Tonin 2024, Fernandes 2017) and injection risk behavior such as needle or syringe re-use, borrowing, sharing, renting, and lending among people who inject drugs (PWID) (Palmateer 2022, Tonin 2024, Fernandes 2017, Sawangjit 2017).

SSPs reduce the risk of HIV transmission among PWID that use the services (Aspinall 2014), with greater effects when services are provided without restrictions or combined with substance use medications (Broz 2021). 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). 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, opioid agonist therapy, or implemented with supportive syringe policies and laws can reduce HCV infection among PWID in some cases (Palmateer 2022, Tonin 2024, Cochrane-Platt 2017, Abdul-Quader 2013). Pharmacy-based SSPs can reduce syringe sharing behavior among PWID (Thomson 2019, Palmateer 2022), 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, Bartholomew 2021). PWID who receive SSP-based HCV treatment show better outcomes compared to those who do not get treatment through SSPs (Yoder 2025). Providing buprenorphine treatment in SSP sites may lead to a decrease in fatal overdose and an increase in treatment engagement among PWID (Adams 2022b).

SSPs may increase use of drug treatment and health services, HIV testing, and reduce drug injection among PWID (CDC-SSP 2024, Broz 2021, Jakubowski 2023). Such interventions also appear to increase public safety, protect first responders, and reduce opioid overdose deaths (CDC-SSP 2024).

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). Lack of health insurance, limited appointment availability, distance from home to treatment programs, and work or childcare responsibilities appear to be obstacles that prevent SSP participants from starting treatment (Jakubowski 2023). Gaining support from law enforcement and communities, securing funding, engaging participants in planning, program monitoring and evaluation, removing program restrictions, and building strong partnerships with local communities are recommended strategies for successful SSP expansion and sustainable implementation (NACO-Carroll, Resiak 2021, Pridgen 2025, Sharp 2020, Healy 2024). Researchers recommend tailoring SSP services by participants’ risk and substance use characteristics (Moon 2023) and taking outreach-based and needs-based approaches in syringe distribution to increase participant enrollment, engagement, and program outcomes (Austin 2025, Turner-Bicknell 2021).

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 about half of a 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).

Syringe services programs (SSPs) have the potential to decrease disparities in HIV and HCV infection and transmission as well as the potential to increase access to harm reduction services (Lambdin 2022, Rural SSP guide, Packham 2022). Opening new SSPs can benefit people who inject drugs (PWID) who face higher financial and transportation barriers (Packham 2022). SSPs have the potential to improve equity and access to opioid treatment by expanding telehealth services that connect people with opioid use disorders (OUD) to buprenorphine treatment (Lambdin 2022). Expanding SSPs in rural areas is recommended to meet the needs of PWID living there (Rural SSP guide). Scaling up SSPs in rural areas, including mobile SSP units, is recommended to serve PWID in rural communities and help them overcome barriers to revisiting SSPs; these barriers include long distance to SSPs, underdeveloped infrastructure, lack of resources, and stigma against PWID (Batty 2023, Thakarar 2021). In rural communities, homelessness may not decrease the use of SSPs among PWID; however, housing instability may decrease the frequency of SSP use (Ballard 2023). Low funding levels are a major barrier to scaling up SSPs in rural and suburban areas (Facente 2024).

Studies report disparities in SSP participation across racial and ethnic groups. Black, Hispanic, and Indigenous individuals are less likely to use SSPs for syringe exchange and services than non-Hispanic white individuals (Ezell 2024, Salow 2023, Zolopa 2025). Black SSP participants are more likely to experience biased response from law enforcement at SSPs than other participants (Morrissey 2022). To increase SSP participation among Indigenous groups, tailoring SSPs to their cultural needs is recommended (Zolopa 2025). Among those from ethnically minoritized groups, men are more likely to use pharmacy-based SSP services than women; more research is needed to confirm the impact of gender on SSP use (Thomson 2019). Low SSP use in the U.S. is likely due to legal and regulatory issues, insufficient funding, and misunderstanding of the safety of SSPs that prohibit effective SSP establishment in communities (LAPPA-SSP 2025).

The estimated incidence rate of HIV among PWID in 2022 is highest in white populations, followed by Black and Hispanic populations for both males and females (CDC HIV Surveillance 2024). The acute HCV incidence rate in 2022 is higher among American Indian/Alaska Native people and rural states compared to other races/ethnicities and urban areas (CDC HCV Surveillance 2024).

Implementing SSPs for people involved in the justice system may increase their access to health care (Armstrong-Mensah 2021).

Opioid overdose deaths have been increasing since 1999 (Freeman 2018). The rise in opioid overdose deaths began in the 1990s with a substantial increase in the prescription of both natural and semi-synthetic opioids because they were effective at managing chronic pain and falsely marketed to health care providers as non-addictive (CDC-Understanding the epidemic, Bennett 2021, Haffajee 2020). Prescription opioid sales increased fourfold between 1999 and 2008 (Judd 2023). Many patients who became addicted to prescribed opioids turned to non-prescribed forms of opioids, such as heroin, which lead to a second wave of opioid overdoses in 2010. In 2013, a third wave began when synthetic opioids such as fentanyl, which are much more potent than other forms of opioids, were combined with other drugs or counterfeit prescription pills, often unknown to the purchaser (CDC-Understanding the epidemic). Synthetic opioids like fentanyl have contributed to nearly 74,000 overdose deaths in 2022, a 4% increase from the previous year (CDC-Fentanyl). In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. Four years later, in 2017 the opioid epidemic was declared a national public health emergency (Salmond 2019). Between 2020 and 2021, the opioid overdose death rate increased by over 15% and the synthetic opioid overdose death rate increased by over 22% (CDC-Understanding the epidemic). However, between 2022 and 2023 there has been a decrease in opioid related deaths for some groups, but increases are seen for non-Hispanic Black individuals and Native Hawaiian or Other Pacific Islander Non-Hispanic people (CDC-Drug overdose deaths in the US).

The dramatic increase in opioid sales was the result of pharmaceutical companies that overproduced and oversupplied opioid drugs for huge profits, pharmacies that filled the prescriptions, and health care providers who overprescribed the medications (Judd 2023). In rural areas many physicians overprescribed opioids to patients who travel long distances for treatment, do not have the ability to attend frequent appointments, and do not have alternative pain management interventions in their area (Judd 2023). In addition, Black individuals have historically experienced lack of access to preventive and management resources, due to structural deficits, provider bias, socioeconomic obstacles, geographic barriers, and collective stigma and distrust (Ezell 2024).

Increasing overdose deaths highlight the need to connect communities to appropriate resources and to expand prevention methods. Syringe services programs (SSPs) began in the late 1980s in response to the HIV epidemic (Broz 2021). The early SSPs in the 1990s were funded privately or by state and local health departments (Facente 2024). U.S. federal funding for SSPs is still limited and has many restrictions in the 2020s (Facente 2024).

• Does your community provide syringe services programs (SSPs)? How are the SSPs implemented in your community? What are the disparities in SSP use in your community? What groups are most affected?
• Who can you partner with to create or expand SSPs in your community? How can you engage people who inject drugs in the planning, implementation, and evaluation of SSPs?
• What are legal and regulatory restrictions in providing services and treatment in SSPs in your community? What changes can the state and local governments make to expand access to SSPs services?
• How can communication campaigns related to SSPs in your community be adjusted to reduce stigma and distrust?

As of March 2025, 37 states and Washington, D.C. have laws either explicitly or implicitly authorizing syringe services programs (SSPs) in locations throughout the state; seven states require participants to register or enroll in SSPs (LAPPA-SSP 2025). Washington State, for example, has about 30 SSPs operated through local health departments, community organizations, and tribal entities (WA-SSPs). California provides a wide range of services in more than 90 syringe exchange programs statewide (CDPH-SSP). New Mexico provides SSPs and a variety of health and social services through community organizations and federally qualified health centers (FQHCs); New Mexico’s harm reduction efforts are intended to reach vulnerable populations (e.g., including PWID, those in SUD treatment or having infectious disease) and reduce stigma and obstacles to care and treatment (ASTHO-NM SSP). As of March 2025, there are over 550 operational SSPs, including 25 mobile sites, in 45 states, Washington, D.C., and Puerto Rico: five states – Kansas, Mississippi, Nebraska, South Dakota, and Wyoming – do not have an operational SSP (NASEN). As of September 2022, there are 21 SSPs located in tribal communities in the U.S.; eight of them also provide on-site medications for opioid use disorder (Allen 2025).

The Consolidated Appropriations Act of 2018 permits the 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).

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* Journal subscription may be required for access.

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Adams 2022b* - Adams, J. W., Savinkina, A., Fox, A., Behrends, C. N., Madushani, R. W. M. A., Wang, J., Chatterjee, A., Walley, A. Y., Barocas, J. A., & Linas, B. P. (2022). Modeling the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine–naloxone treatment at syringe service programs. Addiction, 117(10), 2635-2648.

Allen 2025 - Allen, S.T., Keane, E., Alexander, C., Day, S., Kebec, P., Medley, A., Johnson, F., Hughes, P., Barney, B., & Walls, M. (2025). Tribally-affiliated syringe services programs in the United States: A brief report. Harm Reduction Journal, 22, 143.

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Ballard 2023 - Ballard, A.M., Falk, D., Greenwood, H., Gugerty, P., Feinberg, J., Friedmann, P. D., Go, V. F., Jenkins, W.D., Korthuis, P. T., Miller, W. C., Pho, M. T. , Seal, D. W., Smith, G. S., Stopka, T. J., Westergaard, R.P., Zule, W.A., Young, A.M., & Cooper, H.L.F. (2023). Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: A cross-sectional analysis. Harm Reduction Journal, 20, 157.

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Batty 2023* - Batty, E. J., Ibragimov, U., Fadanelli, M., Gross, S., Cooper, K., Klein, E., Ballard, H, A. M., Young, A. M., Lockard, A. S., Oser, C. B., & Cooper, H. L. F. (2023). A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives. The Journal of Rural Health, 39(2), 328-337.

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Jakubowski 2023 - Jakubowski, A., Fowler, S. & Fox, A.D. (2023). Three decades of research in substance use disorder treatment for syringe services program participants: A scoping review of the literature. Addiction Science & Clinical Practice, 18, 40.

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Moon 2023 - Moon, K.J., Bryant, I., Trinh, A., Hasenstab, K. A., Carter, B., Barclay, R., & Nawaz, S. (2023). Differential risks of syringe service program participants in Central Ohio: A latent class analysis. Harm Reduction Journal, 20, 97.

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