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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 Anderson a,∗ , Lynell Clancy a , Neil Flynn a , Alex Kral b , Ricky Bluthenthal c
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, USA
c 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


An important operational aspect of Syringe Exchange Programmes (SEPs) is the venue of service delivery. This report describes the
programmatic 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 Designated
Exchangers (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 programme
personnel and clients by law enforcement. Limitations are that: (1) it is not as conducive as fixed sites to providing a wide range of ancillary
services; (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 receive
services 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 costs, and which funding sources are willing to fund the
programme. Here we describe the programmatic features of
Effectiveness studies of syringe exchange programmes the Sacramento Area Needle Exchange (SANE), an illegal
(SEPs) are plentiful (Gibson, Flynn, & Perales, 2001), yet SEP that utilises “satellite exchangers” to distribute the bulk
few studies have considered how programme operations of its syringes and HIV risk reduction supplies. We con-
might have an impact on outcomes (Bastos & Strathdee, sider the advantages and limitations of this mode of service
2000; Heimer, Bluthenthal, Singer, & Khoshnood, 1996; delivery. Satellite exchangers (sometimes called secondary
Riley, Wu, Junge, Marx, Strathdee, & Vlahov, 2000). Re- exchangers) are people who have access to an SEP and
peated surveys of SEPs in the United States have revealed distribute supplies (e.g. syringes) to other drug users (Des
continuing and substantial differences in programmatic Jarlais et al., 2002; Grund et al., 1992; Snead et al., 2003).
features (Centers for Disease Control, 1995; Des Jarlais,
Mcknight, Eigo, & Eigo, 2002; Paone, Clark, Shi, Purchase,
& Des Jarlais, 1999). One important operational aspect Programme description
of SEPs is the venue of service delivery. Service delivery
venue affects who can gain access to the service, what SANE was established in 1993 as an IDU network-based,
types of services can be effectively delivered, programme pager-initiated, mobile delivery programme that distributes
and exchanges syringes on an as-needed basis. SANE has
∗Corresponding author. been an illegal, underground SEP since it opened. In Cal-
E-mail address: (R. Anderson). ifornia, a doctor’s prescription is required to purchase and

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
462 R. Anderson et al. / International Journal of Drug Policy 14 (2003) 461–463

possess syringes unless a local governing body declares a 2002, 45% of SANE exchanges were conducted with women
state of emergency and sanctions an SEP. In such a case the and 13% of all exchanges were conducted with women of
SEP may operate legally, although IDUs may still be ar- colour.
rested for possessing syringes based on drug paraphernalia This approach also limits the possibility of detection
laws that make it illegal for drug users to possess materials of programme personnel and clients by law enforcement.
that can be used for drug use. Neither the city nor county Many IDUs do not gain access to fixed site SEPs because
of Sacramento has legalised the SEP (as of March 2003). of the fear of detection by police (Rich, Strong, Towe, &
Designated exchangers (DEs) are recruited and trained by McKenzie, 1999). This is particularly true in cities where
SANE staff and volunteers in exchange protocol, infectious SEPs are illegal (Bluthenthal, Kral, Lorvick, & Watters,
diseases and overdose prevention techniques, harm reduc- 1997). Fear of arrest may disproportionately affect peo-
tion strategies, and given appropriate injection supplies. ple of colour and women with children, two important
DEs represent networks that are geographically, economi- sub-populations of IDUs. By conducting syringe exchange
cally, professionally (e.g. government workers or students), through delivery and having DE deliver the majority of
medically (e.g. HIV) or socially defined (e.g. immigrants; services, SANE is able to reach a diverse population that
similar drug of choice). Individuals contacting the pro- might not have access to SEP if it operated using other
gramme for the first time are referred to the DE in their venues.
area after the first couple of visits or are assisted with estab- Further, this model makes it difficult for law enforce-
lishing their own exchange network. To serve homeless or ment agencies to intervene against the programme. Although
marginally-housed IDUs, SANE volunteers make weekly SANE has operated illegally for nine years, only once have
trips through known drug-use areas in the region and home- police arrested the programme personnel. In June 2001, a
less camps along the two rivers that flow through Sacramento trial judge convicted a SANE volunteer of illegal syringe
County. possession. The volunteer, who was responsible for a large
portion of the exchange volume, was sentenced to three years
probation and ordered not to possess or exchange syringes.
Advantages The loss of this volunteer’s service has adversely affected
the level, timeliness and overall quality of the programme. In
Given the setting and political realities, the methods used 2001, 405,107 needles and syringes were exchanged while
by SANE have several advantages. First, by relying pri- in the first nine months of 2002, only 129,443 needles and
marily on DE for delivery of SEP services allows SANE syringes have been exchanged (a 43% decrease from 2001).
to cover a large geographical region. Sacramento County, Additionally, one of SANE’s primary funders notified the
where SANE operates, encompasses 1000 square miles programme that funding would not be continued due to the
(1609 square kilometres) and contains a population of 1.2 conviction. Finally, SANE has received many reports from
million, with an estimated 14,000 IDUs (Newmeyer, 1995). consumers decrying the negative effect on service timeliness
To cover this large geographical area using other modali- and quality.
ties would require either a large number of fixed sites or a
large number of staff with pagers and vehicles for deliv-
ery. Despite this novel method of providing SEP services, Limitations
SANE estimates that it reaches a small portion of IDUs in
Sacramento County. While having DE conduct the bulk of service delivery
Second, using networked-based DE with syringe delivery has several advantages over other modes of delivery, there
keeps operational cost low (approximately US $75,000 per are also limitations. First, this model is not as conducive as
year). At present, SANE consists of three staff working an fixed sites to providing a wide range of ancillary services,
estimated total 0.80 full-time equivalent. Almost all staff including first aid, HIV testing or advocacy. Second, using
effort is devoted to the actual delivery of services. The bulk DE for delivery of services may not be optimal for drug
of service delivery is conducted by DE who are volunteers. users who do not want to be reliant on other people for
Between 1997 and 2000, the number of syringes delivered access to syringes. Third, those who receive services from a
increased by 332% from 100,829 to 435,690 representing a secondary exchanger may not derive as much from the ser-
reduction in programme cost per syringe from 38 to 18 US vices as direct exchangers in terms of counselling, referral
cents. In 2002, 75% of available funds were expended on to social and medical services and education. SANE min-
supplies. imises this limitation by training and educating DE in harm
Third, this method also provides syringes to clients who reduction strategies and infectious disease/overdose pre-
may not want to or can not use fixed sites programmes. vention.
In the few studies that report demographic characteristics The illegal, underground status of SANE represents
of SEP clients, women have represented 26% of clients in another limitation. Increasing numbers of SEPs in Cali-
Chicago (Brahmbhatt, Bigg, & Strathdee, 2000) and 34% fornia receive funding from city and county governments
in Baltimore (Riley et al., 2002). In the first nine months of for 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- References

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participating in a needle exchange program. American Journal of Drug
the Centers for Disease Control and Prevention (Grant No.
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