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标题：Life After the Ban: An Assessment of US Syringe Exchange Programs’ Attitudes About and Early Experiences With Federal Funding
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作者：Traci C. Green ; Erika G. Martin ; Sarah E. Bowman 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2012
卷号：102
期号：5
页码：e9-e16
DOI：10.2105/AJPH.2011.300595
语种：English
出版社：American Public Health Association
摘要：Objectives. We aimed to determine whether syringe exchange programs (SEPs) currently receive or anticipate pursuing federal funding and barriers to funding applications following the recent removal of the long-standing ban on using federal funds for SEPs. Methods. We conducted a telephone-administered cross-sectional survey of US SEPs. Descriptive statistics summarized responses; bivariate analyses examined differences in pursuing funding and experiencing barriers by program characteristics. Results. Of the 187 SEPs (92.1%) that responded, 90.9% were legally authorized. Three received federal funds and 116 intended to pursue federal funding. Perceived federal funding barriers were common and included availability and accessibility of funds, legal requirements such as written police support, resource capacity to apply and comply with funding regulations, local political and structural organization, and concern around altering program culture. Programs without legal authorization, health department affiliation, large distribution, or comprehensive planning reported more federal funding barriers. Conclusions. Policy implementation gaps appear to render federal support primarily symbolic. In practice, funding opportunities may not be available to all SEPs. Increased technical assistance and legal reform could improve access to federal funds, especially for SEPs with smaller capacity and tenuous local support. Syringe exchange programs (SEPs) are effective and cost-effective interventions that prevent HIV and hepatitis infections and link drug users to important services. 1 However, their number and impact in the United States have been limited by federal, state, and local laws and law enforcement practices. 2 The SEPs have remained controversial since their inception, with variable financial and political support. 3,4 As of March 2009, there were 184 SEPs in operation in the United States, Washington, DC, and Puerto Rico 5 distributing syringes to drug users through a variety of methods including stationary sites, mobile vans, delivery services, and backpack or walked routes. The Consolidated Appropriation Act (December 2009) modified the 2-decade-long ban on use of federal funds to support SEPs. 6 Estimates from 1997 suggested that expansion rather than banning of funding for SEPs early on in the HIV epidemic would have reduced US HIV incidence by 15% to 33%, at enormous cost savings to society. 7 Concerted advocacy helped lift the ban, with hopes that it would provide local governments with greater flexibility and capacity to reduce HIV transmission. 8,9 The new law formalized the federal government's recognition of SEPs’ role in community-based disease prevention, allowed federal public health agencies to research and provide technical assistance to these programs, and provided a new source of SEP funding during fiscal year 2010. Currently, 79% of SEP funding comes from state and local governments with the remainder from private sources. 5 In the past, limited funding has been reported as the most common problem facing SEPs. 3 The ban on funding existed as a rider to the annual Labor–Health and Human Services Appropriations bills. 10 If the rider is not inserted, federal funds can be used for SEPs. As a consequence, the ban's removal is not permanent, and it may be reinstated if approved by Congress. Differences between laws on the books and laws on the streets result from a policy transformation process, in which various implementation challenges may ultimately limit the net impact of public health laws. 11 For the SEP funding ban, this process involves not only the federal agencies responsible for administering grants, but also local and state agencies. Final implementation guidelines from the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) are being formulated. In the meantime, the policies are being implemented under the guidance of “draft implementation guidelines,” which may later be revised. The HHS draft implementation guidelines recommending that grantees contact local program offices for information on SEP funding bans prohibit “the use of funds for SEPs in any location that local public health or law enforcement agencies deem to be inappropriate” 12 ^(p1) and require that SEPs obtain annual certifications from local public health and law enforcement (hereafter referred to as the certification requirement). Preliminary CDC implementation guidelines indicate that federal grantees must be part of a “comprehensive service program that includes, as appropriate, linkage and referral to substance abuse prevention and treatment services, mental health, and other support services,” 12 ^(p1) which may be more rigorous criteria than those traditionally used within states. Given inconsistent legal authorization, 13 political opposition, professional hostility, and interference by law enforcement agencies to SEP operations in some locales, 14,15 it may be difficult for some SEPs to procure certification. Beyond certification requirement challenges, other real and perceived barriers may also shape SEPs’ efforts to request funding or technical assistance for their federal fundraising efforts, further limiting the law's public health impact. We aimed to study discrepancies between the promise of the law and its street-level impact in the initial stages of implementation. We examined (1) whether SEPs currently receive federal funding explicitly for syringe exchange and distribution activities, (2) whether SEPs anticipate pursuing federal funding, and (3) the experienced and perceived barriers to acquiring federal funds, under the preliminary HHS guidelines.