Date Published: April 26, 2019
Publisher: Public Library of Science
Author(s): Eyasu H. Teshale, Alice Asher, Maria V. Aslam, Ryan Augustine, Eliana Duncan, Alyson Rose-Wood, John Ward, Jonathan Mermin, Kwame Owusu-Edusei, Patricia M. Dietz, Gabriele Fischer.
To estimate the cost of establishing and operating a comprehensive syringe service program (SSP) free to clients in the United States.
We identified the major cost components of a comprehensive SSP: (one-time start-up cost, and annual costs associated with personnel, operations, and prevention/medical services) and estimated the anticipated total costs (2016 US dollars) based on program size (number of clients served each year) and geographic location of the service (rural, suburban, and urban).
The estimated costs ranged from $0.4 million for a small rural SSP (serving 250 clients) to $1.9 million for a large urban SSP (serving 2,500 clients), of which 1.6% and 0.8% is the start-up cost of a small rural and large urban SSP, respectively. Cost per syringe distributed varied from $3 (small urban SSP) to $1 (large rural SSP), and cost per client per year varied from $2000 (small urban SSP) to $700 (large rural SSP).
Estimates of the cost of SSPs in the United States vary by number of clients served and geographic location of service. Accurate costing can be useful for planning programs, developing policy, allocating funds for establishing and supporting SSPs, and providing data for economic evaluation of SSPs.
Syringe services programs (SSPs) are community prevention programs that provide access to sterile needles and syringes at no cost to their clients and facilitate safe disposal of used needles and syringes [1–3]. SSPs also offer a range of other prevention services, such as education on safe injection practices, wound care, overdose prevention with naloxone, referral to substance use disorder treatment, and testing for infections like human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) [2)]. In addition, these programs provide linkage to medical services, such as HIV or HCV treatment, referral to mental health services, and onsite or referral to hepatitis A and B vaccination. SSPs, especially when combined with medication-assisted treatment for opioid use disorder, can play a substantial public health role by preventing acquisition and transmission of blood borne infections, including HIV and HCV [4–7]. Use of SSPs has also been associated with reduced frequency of injection . SSPs are beneficial to the community by reducing used syringes in public spaces, which carry the risk of accidental needle prick injury . SSPs do not increase crime or drug use .
For the purpose of this study, we defined a ‘comprehensive SSP’ as a program that provides sterile injection equipment and disposal of used equipment, and offers a variety of preventive and medical services including: onsite HIV and HCV counseling and testing; first aid/wound care; overdose prevention education and naloxone kits; onsite provision or referral to hepatitis A and hepatitis B vaccination; referrals to sexually transmitted infection (STI) testing, tuberculosis (TB) screening, substance use disorder treatment, and care and treatment of HBV, HCV, and HIV. Comprehensive SSPs may also provide referrals to primary care, mental health services, reproductive health services, and social services.
The total cost for the first year of a comprehensive SSP ranged from $0.4 (range $0.3-$0.6) million for a small rural program to $1.9 (range $1.4-$2.3) million for a large urban SSP (Table 1). The components of a comprehensive SSP, detailed information on cost by item, and sources of costs are provided in Appendix A. The estimated cost of SSPs per syringe distributed varied from approximately $1 for a large rural SSP to $3.4 for a small urban SSP, and the estimated cost per client per year varied from $661 for a large rural SSP to $2008 for a small urban SSP. Based on volume of clients, the estimated number of syringes to be distributed by small, medium, and large SSPs were 0.15 million, 0.75 million, and 1.5 million per year, respectively (Table 2). The cost per syringe distributed and per client per year was almost three times as high for small SSPs compared to large SSPs. The percent increase in cost per syringe distributed from a large urban to a small urban SSP reached 183%.
We estimated the cost of establishing and maintaining a comprehensive SSP for different geographic locations in the United States. With an average cost of $1 to $3 per syringe, a syringe service program can inexpensively prevent serious infectious diseases in those who are not infected, help identify and link those already infected to care, and prevent overdose and other related harms associated with the opioid epidemic by linking to preventive services (such as referral to treatment for opioid use disorder). The cost of a comprehensive SSP depends on the program size, location, and types of services provided. Some services are intrinsically costly (e.g., provision of naloxone), whereas other services require delivery by specially trained staff (e.g., peer navigation, conducting HIV and HCV tests, and providing wound care). Larger SSPs serve more clients and thus, incur higher total costs. However, costs per-syringe distributed and per-client were considerably lower for large SSPs compared to small SSPs.