Abstract
Many syringe services programs (SSPs) have established trusting, long-term relationships with their clients and are well situated to provide COVID-19 vaccinations. We examined characteristics and practices of SSPs in the United States that reported providing COVID-19 vaccinations to their clients and obstacles to vaccinating people who inject drugs (PWID). We surveyed SSPs in September 2021 to examine COVID-19 vaccination practices through a supplement to the 2020 Dave Purchase Memorial survey. Of 153 SSPs surveyed, 73 (47.7%) responded to the supplement; 24 of 73 (32.9%) reported providing on-site COVID-19 vaccinations. Having provided hepatitis and influenza vaccinations was significantly associated with providing COVID-19 vaccinations (70.8% had provided them vs 28.6% had not; P = .002). Obstacles to providing vaccination included lack of appropriate facilities, lack of funding, lack of trained staff, and vaccine hesitancy among PWID. SSPs are underused as vaccination providers. Many SSPs are well situated to provide COVID-19 vaccinations to PWID, and greater use of SSPs as vaccination providers is needed.
Keywords: syringe services programs, HIV, hepatitis C, COVID-19, vaccination
People who inject drugs (PWID) should be a key population for COVID-19 prevention and treatment. Individual, social, and structural factors associated with higher-than-average COVID-19 incidence and mortality 1 are common among PWID. However, PWID have suboptimal engagement with health care services and are often treated poorly in traditional health care settings,2,3 which can create barriers to receiving COVID-19 vaccinations. Syringe services programs (SSPs, also known as syringe exchanges) have become important frontline health care service organizations for PWID in many places in the United States. In addition to providing supplies of sterile syringes to reduce transmission of HIV, hepatitis C virus, and other bloodborne pathogens, SSPs also provide naloxone for reversing opioid overdoses, HIV and hepatitis C testing, hepatitis A and B vaccinations, and other health and social services.4,5 In contrast to many other health care service providers, many SSPs have gained the trust of PWID and have established long-term relationships with them. In this study, we examined the association between characteristics and practices of SSPs and whether they provided on-site COVID-19 vaccinations and perceived obstacles to vaccinating clients.
Methods
We collected data on COVID-19 vaccination practices in September 2021 through a supplemental survey of SSPs participating in the 2020 Dave Purchase Memorial (DPM) survey, 6 a survey of SSPs that has been conducted annually in the United States since 1994. The DPM sampling frame consists of programs known to the North American Syringe Exchange Network, which includes most (85%-95%) 7 of the SSPs in the United States. For the 2020 DPM survey, conducted in August and September 2020, we obtained responses from 153 of the 211 (73.0%) programs known to be active in 2019 and 2020. The 2020 DPM survey asked about program operations during calendar year 2019 and at the time of survey completion in 2020; eligibility was limited to programs that were operational in both years. The September 2021 supplemental survey on COVID-19 vaccination was sent only to the 153 programs that had completed the 2020 DPM survey; the 2020 DPM survey collected data on organizational characteristics and practices that were used in the analyses of the supplemental survey data. The Mount Sinai School of Medicine Institutional Review Board determined that the survey of SSPs does not qualify as human subjects research and is exempt from review.
We tabulated survey responses and summarized SSP organizational characteristics (program size, budget size, region, and type of organization), practices (provision of hepatitis A/B or influenza vaccination in 2019, before the COVID-19 pandemic), interest in providing COVID-19 vaccinations in 2021, perceived obstacles to providing COVID-19 vaccinations in 2021, whether incentives were given to clients to encourage them to get a COVID-19 vaccination, and, if incentives were given, the type of incentive. We also collected information on staff perceptions of clients’ reasons for not getting vaccinated against COVID-19. We used the Fisher exact test to examine the association between these factors and whether SSPs reported providing on-site COVID-19 vaccinations after approval of COVID-19 vaccines for the general public in the United States in April 2021. 8 We used R (R Foundation for Statistical Computing) for all statistical analysis.
Results
We received 73 responses to the supplemental survey from the 153 SSPs (47.7% response rate); 49 (67.1%) of 73 programs reported that all staff were fully vaccinated for COVID-19 at the time of completing the survey in September 2021. Forty-six programs (63.0%) encouraged their clients to get COVID-19 vaccinations by initiating conversations about the vaccine and providing referrals, but 23 (31.5%) did not talk to clients about vaccinations unless they were asked, and 43 (58.9%) did not make appointments for clients to get the COVID-19 vaccination elsewhere. Most (n = 60; 82.2%) SSPs had face mask mandates for staff, regardless of staff vaccination status, and most (n = 66; 90.4%) required clients to wear face masks indoors.
Twenty-four of the 73 programs (32.9%) were providing on-site COVID-19 vaccinations in September 2021; of these, 17 (70.8%) were providing the Johnson & Johnson/Janssen vaccine (a single-dose vaccine at that time) and 11 (45.8%) were providing the 2-dose Moderna or Pfizer/BioNTech vaccines. Ten (41.7%) programs that provided COVID-19 vaccinations reported using incentives, which were almost always gift cards. Of the 49 (67.1%) programs that were not providing COVID-19 vaccinations, 21 (42.9%) reported that they were interested in providing vaccinations, 15 (30.6%) reported that they were not interested, and 13 (26.5%) did not know if their program would be interested in providing COVID-19 vaccinations.
Among the 73 SSPs that responded to the supplemental survey, program size, budget size, region, and type of organization were not significantly associated with providing COVID-19 vaccinations (Table). Providing COVID-19 vaccinations in 2020 was associated with having provided other vaccinations (hepatitis A/B and/or influenza) in 2019 (P = .002). Among the 24 programs providing COVID-19 vaccinations in 2020, most (17 of 24; 70.8%) had provided hepatitis A/B or influenza vaccinations in 2019. Among the 49 programs that did not provide COVID-19 vaccinations in 2020, 32 (65.3%) had not provided other vaccinations in 2019. Data were missing for 3 programs not providing COVID-19 vaccinations in 2020.
Table.
Factors associated with providing COVID-19 vaccination at syringe services programs (SSPs) in the United States, September 2021 a
| Characteristic | Total no. of responses | No. (%) of responses | No. (%) of SSPs providing vaccination (n = 24) | No. (%) of SSPs not providing vaccination (n = 49) | P value b |
|---|---|---|---|---|---|
| Program size in 2019 (syringes distributed) | 71 | >.99 | |||
| Small/medium (1-55 000) | 27 (38.0) | 9 (37.5) | 18 (38.3) | ||
| Large/very large (≥55 001) | 44 (62.0) | 15 (62.5) | 29 (61.7) | ||
| Budget size in 2019, $ | 70 | .73 | |||
| <25 000 | 25 (35.7) | 7 (31.8) | 18 (37.5) | ||
| 25 000-100 000 | 18 (25.7) | 7 (31.8) | 11 (22.9) | ||
| >100 000 | 27 (38.6) | 8 (36.4) | 19 (39.6) | ||
| Region | 71 | .83 | |||
| Northeast | 16 (22.5) | 5 (20.8) | 11 (23.4) | ||
| Midwest | 19 (26.8) | 7 (29.2) | 12 (25.5) | ||
| South | 14 (19.7) | 6 (25.0) | 8 (17.0) | ||
| West | 22 (31.0 | 6 (25.0) | 16 (34.1) | ||
| Organization type in 2019 | 73 | .32 | |||
| Health department | 14 (19.2) | 7 (29.2) | 7 (14.3) | ||
| Nonprofit | 45 (61.6) | 14 (58.3) | 31 (63.3) | ||
| Other | 14 (19.2) | 3 (12.5) | 11 (22.4) | ||
| Provided hepatitis A/B or influenza vaccinations in 2019 | 73 | .002 | |||
| Yes | 31 (42.5) | 17 (70.8) | 14 (28.6) | ||
| No | 39 (53.4) | 7 (29.2) | 32 (65.3) | ||
| Don’t know | 3 (4.1) | 0 | 3 (6.1) | ||
| Interested in providing COVID-19 vaccinations in 2021 | 49 | — | |||
| Yes | 21 (42.9) | NA | 21 (42.9) | ||
| No | 13 (26.5) | NA | 13 (26.5) | ||
| Don’t know | 15 (30.6) | NA | 15 (30.6) | ||
| Reported obstacles to providing COVID-19 vaccinations in 2021 | 73 | ||||
| Lack of facility capabilities (eg, space, refrigerators) | 42 (57.5) | 5 (20.8) | 37 (75.5) | <.001 | |
| Lack of funding | 34 (46.6) | 3 (12.5) | 31 (63.3) | <.001 | |
| Lack of trained staff | 33 (45.2) | 5 (20.8) | 28 (57.1) | .007 | |
| Willingness of clients to obtain the vaccine | 34 (46.6) | 16 (66.7) | 18 (36.7) | .03 | |
| Other | 11 (15.1) | 6 (25.0) | 5 (10.2) | .16 | |
| Provided incentives to clients for getting a COVID-19 vaccination in 2021 | 24 | ||||
| Yes | 10 (41.7) | 10 (41.7) | — | — | |
| No | 14 (58.3) | 14 (58.3) | — | — | |
| Types of incentives in 2021 | 10 | ||||
| Money to cover transportation costs | 0 | 0 | — | — | |
| Gifts or gift cards | 9 (90.0) | 9 (90.0) | — | — | |
| Money beyond transportation costs | 1 (10.0) | 1 (10.0) | — | — |
Abbreviations: —, not asked; NA, not applicable.
SSPs were surveyed in September 2021 to examine COVID-19 vaccination practices through a supplement to the 2020 Dave Purchase Memorial survey. 6
Association between characteristic and provision of COVID-19 vaccination was determined by Fisher exact test; P < .05 was considered significant.
The 49 programs that were not providing COVID-19 vaccinations reported multiple obstacles to providing the COVID-19 vaccination; 37 (75.5%) reported lacking appropriate facilities, 31 (63.3%) reported lack of funding, and 28 (57.1%) reported lack of trained staff. Thirty-three (67.3%) programs reported ≥2 obstacles. The most common obstacle reported by programs that were providing COVID-19 vaccinations was a lack of willingness of clients to be vaccinated; 16 of 24 (66.7%) programs reported this obstacle.
When asked about the reasons that clients gave for not getting vaccinated, 37 of 73 (50.7%) programs reported that clients wanted to wait until more information was available on the safety of vaccines, 54 (74.0%) reported that clients believed they had been mistreated and did not trust medical authorities, and 56 (76.7%) reported that clients believed in conspiracy theories surrounding the COVID-19 vaccine (eg, microchips or magnets placed in vaccines, vaccines cause infertility).
Discussion
SSPs in the United States have the potential to overcome barriers to providing COVID-19 vaccinations to PWID because of their long-term trusted relationships with their clients. Given the current need for booster vaccination doses, SSPs may play an increasingly important role in the delivery of COVID-19 vaccinations to PWID. Our results showed that while most SSP staff members were vaccinated, on-site vaccinations were not provided at most (67.1%) of the SSPs that responded to the supplemental survey. SSPs that had provided other vaccinations before COVID-19 (vs not) were more likely to offer COVID-19 vaccinations.
This study had several limitations. Because some SSPs operate outside the North American Syringe Exchange Network, the sample of SSPs obtained for this analysis may not be representative of all SSPs in the United States. We also believe that the stresses of operating SSPs during the pandemic limited the number of SSPs that responded to the survey. Our findings raise several questions for immediate investigation. How did SSPs that did not previously provide vaccinations develop the capacity to provide COVID-19 vaccinations? How many program obstacles could be removed simply by providing funding to acquire resources and to hire and train staff? Can SSPs that have appropriate facilities and resources form partnerships with other organizations that might provide the needed staff and supplies to conduct on-site COVID-19 vaccinations? Can SSPs that are uncertain about offering vaccinations be encouraged to do so by providing culturally appropriate consultations to clients that would directly address clients’ vaccine hesitancy?
Approaches to overcoming vaccine hesitancy or resistance among clients of SSPs need to be systematically explored. Our survey showed that more than 60% of SSPs were already engaging clients in vaccination conversations, but further engagement with PWID is needed to address vaccine hesitancy and disseminate accurate information. Strategies for leveraging the potential for SSP staff to serve as role models should be investigated. Expanded funding to support noncoercive incentives might also be valuable in improving vaccination uptake. Work will be needed to continue to assess current PWID vaccine uptake as the COVID-19 pandemic evolves.
Conclusion
The COVID-19 pandemic has starkly illustrated many of the health disparities in the US health care system, and we need to ensure that these disparities are not exacerbated. 9 As a socially disadvantaged group, PWID are likely to experience further disparities in access to care because of the COVID-19 pandemic. SSPs are providers of critical health care services for PWID, and their potential for mitigating the negative health outcomes of the COVID-19 pandemic should be fully used to ensure equitable access to vaccines for PWID.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this study was provided by National Institutes of Health grants (R01DA027379, P30DA040500, P30DA011041, and K01DA048172). The funding agency had no role in the design, implementation, data analyses, or preparation of this article.
ORCID iD: Don C. Des Jarlais, PhD 
https://orcid.org/0000-0002-0157-8168
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