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hello everyone and welcome to the webinar entitled during service program state and local perspectives on the role of policy funding and partnerships hosted by the office of the assistant secretary for health my name is Julie Cahoon and I am from Kauffman and associates assisting with today's webinar before the presentation begins I'd like to highlight the main features of your webinar interface you should all see the first slide of the PowerPoint presentation in the middle of the screen and to the bottom right of your screen is close captioning just to both closed captioning is the Q&A pod please enter a question for our presenters at any time in the Q&A pod questions will be addressed at the end of the presentation if you need technical assistance during the webinar please type the issue into the Q&A pod and one of our tech support staff will respond to you directly finally please be aware that also in lines have been muted and this presentation is being recorded I will now turn it over to Sharon Hicks with the office of the assistant secretary for health Sharon Thank You Julie and welcome to all of you it is my pleasure to greet you on behalf of the US Department of Health and Human Services and the office of the assistant secretary for health we are excited that so many of you have joined us today my name is Sharon Rix and I am one of 10 regional health administrators across the nation who work to catalyze public health actions on important issues through our regional expertise and network today we are pleased to be partnering with our office of infectious disease and hiv/aids policy to present the range service programs state and local perspective on the role of policy funding and partnerships this is the second in a three-part series and today we are traveling to Kentucky North Carolina and New Mexico to hear about their efforts to build and expand syringe Services program we will explore questions like how do you gain support and community buy-in how do you craft policy and bring it to practice and how do you leverage the power of data and partnerships our features include dr. Connie Gail white Deputy Commissioner for clinical services Kentucky Department for Public Health mr. Danny Staley former director of a North Carolina Division of Public Health and currently serving as chief of Caribbean operations at the association of State and territorial health officials and mr. Andrew James and Joshua squat tech managers focused on harm reduction and HIV at the New Mexico Department of Health unfortunately our assistant secretary for health at Merle Bret sure wha is not able to join us this afternoon but we can hear his enthusiasm and perspective on this topic by listening to a recording of our July 30th webinar at HIV just click on federal response and policies and issues and then syringe service programs the opinions findings and conclusions expressed by speakers during this webinar are strictly their own and do not necessarily represent the opinion views or policies of the office of the assistant secretary for health and the Department of Health and Human Services nor does mission of trade names commercial practices or organizations imply endorsement references to publications news sources and non-federal websites are provided solely for informational purposes and do not imply endorsement by OS for HHS o ash and HHS assume no responsibility for the sexual accuracy of the content of the individual organizations found at non-federal link now for logistics you are currently in listen-only mode if you have any questions during the presentation please type them into the Q&A pod in your control panel we have devoted time at the end of the webinar to answer some of those questions and we will respond to as many as possible also at the close of the webinar there will be a pop-up screen with six questions for you to complete this is your opportunity to share your thoughts about this and future webinar we will also send an email with a recording of the webinar a link to the presentation slides and the context information for your Regional Health administrator the topic of this webinar is extremely timely just this month we saw two major news stories that document the increase in HIV cases among individuals with opiate use disorders the Boston Herald reported that the number of new cases of HIV among people with substance use disorders is skyrocketing in Massachusetts and political reported the primary cause of a cluster of HIV cases in a rural county of West Virginia was from people who use drugs sharing contaminated needle now we're going to switch to another slide set our Department recognizes that syringe service programs are a key component in reducing the transmission of infectious disease and saving lakhs and although at Roger was unable to join us he is extremely enthusiastic about including SSPs in our strategy to end the HIV epidemic and I am pleased to prevent a few slides on his behalf the opioid epidemic is the most critical public health crisis of our time in 2017 we had more than 70,000 drug overdose deaths and 48,000 of those were caused by opioids these deaths include those related to prescription opioids heroin and synthetic opioids such as sentinels and every life we lose so this epidemic is one too many in addition to overdoses there are also profound infectious consequences among people with opioid use disorder who inject drugs this includes transmission of HIV and viral hepatitis both of which have significant lifelong impacts there is also the risk for bacterial infection such as endocarditis which affects your heart as well as skin bone and joint infections these infections are often very difficult to treat and require surgical intervention and weeks or months of antibiotics in order to cure the infection in order to end the HIV epidemic we must understand the population and geographic areas that are hardest hit there were more than 38,000 new HIV infections in 2017 and more than half of those 52 percent or in the South 56% or among gay and bisexual individuals and nine percent for among people who inject to us and we know we can prevent many of these new cases by increasing access to comprehensive SSP people who participate in ss these are five times more likely to enter drug treatment and three and a half times more likely to stop injecting compared to those who don't today's webinar is part of an effort led by the office of the assistant secretary for health to collaborate with federal state and county stakeholders to create and expand syringe service programs in vulnerable communities across the nation this is a map of the ten HHS regions that are currently engaged in this work and I am thrilled that our first two speakers represent my region HHS region 4 and our last two regions represent HHS region 6 both regions are disproportionately impacted by HIV and in desperate need of innovative strategy our first presenter is dr. Connie Gail white Deputy Commissioner for clinical services Kentucky Department for Public Health dr. white will share more about Kentucky's experience dr. way hi Thank You Sharon it's certainly an honor for me to chair the Kentucky experience and highlight the hard work done by our local health departments to fulfill the 2015 legislation allowing us to offer this life-saving service during service programs in Kentucky okay I mimics implement that Sharon has already shown you and it reflects the death rate of drug overdose deaths in Kentucky 15 percent decrease in deaths in 2018 would have equated to around two hundred and thirty people who survived the year and did not die but drug overdose but clearly our work is not done this map shows the state of Kentucky and the number of deaths by a county the darker colored counties the darkest colored is Jefferson County were the largest city in Kentucky is Louisville the other two darker counties are Lexington and at the very top of the state is our Northern Kentucky counties that is immediately crossed the Ohio River from Cincinnati and the gray line you see there separate the Appalachian from the non Appalachian County this gives an impression if you look at this map that the drug overdose crisis is an urban crisis in Kentucky however if you look at this slide this is a representation of using an overt opioid overdose risk index that we proposed when we wrote our Samsa proposal for the original SPR funding and you can see if you incorporate other factors such as overdose Edie visits and hospitalizations if you look at me male abstinence syndrome you look at the average enemy or morphine milligram equivalents per county the burden of the opioid epidemic is definitely a rule burden and in his very heavily affected our Appalachian region now this map has a lot of information packed into it so I want to take it to break it apart yeah Parviz piece in the upper left hand corner you see a US map that shows the counties who have been determined to have an increased vulnerability for HIV and hepatitis C infections among people who inject drugs or as I call them the green counties of the 250 counties in the US that meant that qualification 54 of those were in Kentucky now on the map the red stars show where there is currently an active syringe service program that has opened its March 2015 when legislation was path and signed into law the open red stars mean that the program has been approved but has not yet become operational Kentucky currently has 53 operating syringe service programs in 56 counties and we have three counties that have approval but they have not become operational yet the list that you see on the right side of the slide shows the 54 counties with those in red being the ones that have current operating SS Peas I want to take you through the history of the crisis in Kentucky and explain why we feel that these counties in Eastern Kentucky were ready and even eager to take this bold step fighting the overdose crisis go all the way back to 2001 the DEA developed a map by zip code of the highest opioid prescribing counties in the u.s. one of those was in Northern California one in Southern California the remaining seven or in Eastern Kentucky in West Virginia 2001 in 2003 our representative Hal Rogers which includes many of the counties in Western Kentucky that you see on that map from an article in the Lexington herald-leader newspaper that showed the expose the opioid epidemic in Eastern Kentucky in 2003 that prompted him to develop the organization operation unite unite stands for unlawful narcotics investigation treatment and education operation united 2004 opened a hotline or a helpline and on that line one out of ten people that called in reported using IV drugs at that time in 2010 representative Rogers and representative Mary Bono Mack developed the Congressional Caucus on prescription drug abuse a full nine years ago Congress did recognize that this was a battle that needed to be fought and in 2018 our operation unite helpline reported that of the calls that they received can ten of their callers were using their drugs IV the game has changed in Kentucky now so let's those are the legislative approval process our office of Drug Control Policy and the justice and public safety cabinet along with the chair of the Kentucky Senate Judiciary Committee determined that a host of legislative initiatives must be introduced to turn the tide on this epidemic but it failed to get out of committee next slide my screen has been blocked there you go thank you in 2015 a after a lot of homework done by the legislative research Commission a 14 chapter bill that was dubbed the heroin bill by the press was introduced we call it a public in public health we call that the harm reduction bill as it included legislation on pill mills it provided for a good Samaritan provision it loosened prescribing restrictions that we had on the lock zone in Kentucky it did legalize syringe service programs and also included a multiple of multitude of other important criminal justice reforms with Austin Indiana only 30 miles from our border just across the river from the city of Louisville along with our already skyrocketing Kentucky hepatitis C rate there is a sense of urgency in our General Assembly that something must be done we were able to emphasize that decreasing the risk for first responders from needle sticks with a local SSP along with decreasing those loose needles that you see around in your community and I pretty much agreement by everyone that treating the disease of substance use disorder in the criminal justice system had not been effective all of these is the perfect storm to get this pill passed it was initially expected that only about three counties the previously-mentioned counties with the largest populations will be the only places that we would adopt SSPs but with our time by this time fifteen years of drugs killing and disabling our families and friends people are ready to do something stan ingram our adjective director of the office of drug control policy that worked this bill through at the capitol said that when he opened his email the morning after the bill passed the first one he saw was from a pastor van was a little worried that maybe he had started receiving hate mail already on the contrary the pastor had read about the bill and he wanted to know what his congregation could do to help so the method for developing or creating a syringe service program in Kentucky has three parts of approval first the local Board of Health and the we must approve development of the SSP in their local health department this is quite a lift considering the fiscal restraints that our local boards of Health's have been feeling at this time after the Board of Health approved then you have to go to your City Council and the local health department must not only get the City Council members approval but they also must get approval of the Madras magistrates in the county government now this is a very complex problem as you can imagine because you also had to get buy-in from city police and the County Sheriff's Office many of our local health department directors and their staff were busy holding open forum meetings in the community for community input visiting Rotary clubs speaking to faith-based community members and also presenting to the local bank Board of Directors we're now beginning to see that after several years of acceptance by these three layers of governance elections that happened in the face of these bodies are changing ever it's a very important and crucial job to continue to introduce these people to the local data of their crisis and you're introduced into the principles of harm reduction so if the bill is specific to local control we at the state level decided our best first move would be to develop a document that could be used as a guide for the health department's and may be used as the template as they develop their program so we developed a document like this using assistance from national harm reduction organizations this is about harm reduction and it's not about needles and syringes only the 8 principles of harm reduction tell us that we must accept that there is a drug use and we can't ignore or condemn the clients that do this we have to understand that the drug phenomenon is very complex ranging everywhere from severe abuse to total absence can recognize that some methods of use are safer than others we have to establish criteria for successful interventions and policies to give people good qualities of life we have to deliver non-judgmental and non coercive or it methods to try to help them reduce their harm we have to empower them to make good decisions and / so that they can prevent their own harm and then they can share this information with others I skip to provide which is creating programs and policies to give these folks a voice I appreciate the harm-reduction community's mantra nothing about us without us we also have to acknowledge the social determinants of health because poverty and class racism social isolation past trauma sex-based discrimination effect vulnerability to and the capacity to be effective for a client to deal with these harm different types of drug related harm and finally we have to recognize that there are realities and danger in drug use and not to minimize or ignore these dangers both in a licit and illicit drug use so what do these SS these programs have in Kentucky and what services they provide well some do more than others some are open only one afternoon a week and some of them have figured out a way to incorporate this into their daily workflow we already have one of the highest rates of hepatitis C in the country so testing for a hepatitis C and HIV are critical especially as we've seen the pattern of drug use change to more and more IV use as we continue the battle gets one of the largest hepatitis a drought breaks in the country that targeted those that use illicit drugs and the homeless Kentucky SSPs or one of our important being used to be used to vaccinate we have a large push to provide our clients with free naloxone and we're doing so to our SSPs many LHC's have hired peer support specialist to be available during their SSB hours while some local treatment facilities allow them to be present while the program is operational the importance of assisting clients to receive treatment for their infectious diseases from infected infection sites to those ill potential sepsis leading to as Sharon said in a car Titus brain abscesses stop tissue infections bone infection as well as continuing treatment for HIV Hep C TV and other medical needs are vital and finally if a client is ready using our real-time treatment locator called Kentucky health help now org Kentucky help now org clients can have the opportunity to be connected with substance use disorder treatment so SSPs in kentucky how do we sustain them well first we have to go through the local approval process which is three-tiered as I told you it is somewhat complex funding is always an issue and our LH DS has become very creative finding local funding we here in Frankfort at the Capitol of work to provide available funding from the HIV program that allows for education and testing our sister agency in the department for behavioral health development on intellectual disabilities were the recipients of SAMHSA's SPR NSO our funding has been generous working with our SSS piece our Department for Public Health has also used some of our public health preventive block grant to fund communities to educate answer questions and develop community buy-in for SSPs grant funding to our universities has also been an excellent opportunity for assisting our syringe service programs and in true Public Health fashion one of our local health departments have no personnel costs associated with their SSP because they have to retired public health nurses that come in every Friday afternoon and voluntarily staff their program it's that important to them our first effort a data collection was cumbersome we have just revamped that system within the last three weeks you need to decide a data system that makes you aware of what data you're going to need legislators will want different information then the CDC will want which is very different than what the press might ask for redefine and revamp your data collection system accordingly and informing the public and your local legislators of the critical portance of what you do regular local data reports will help them to keep the importance of this program in the eye of local government Kentucky is new to this process the bill was just signed by the governor in March of 2015 at first the first SSP opened in Louisville in June of 2015 some of our 63 SSDs are less than six months old some of our bordering counties without SSPs have law enforcement personnel that don't honor the product provided by the neighboring SSP but we are learning and our citizens lives to felt dependent on this program we look forward to hearing from the other presenters at this webinar and again want to thank Josh for inviting us to participate Thank You Sharon thank you so much dr. white and I have personally visited syringe service programs in Kentucky and I was absolutely amazed with the care and the concern that was poured on every single person that walked through that door so your work is really inspiring our next presenter is mr. Danny Staley chief of Caribbean operations at the association of State and territorial health officials mr. Bailey is the former director than with Carolina Division of Public Health mr. Fairey thank you sir and then the pleasure to be with you today I want to start by saying no kudos to dr. light and how you know she's the perfect setup and I think that we shared many of the same experiences about the growth of trying to put together a SS and as a picogram in public health we all know we're no strangers to politics and probably one of the most sensitive that we have dealt with is the establishment of SS T's you can go back to the fact that North Carolina had this great privilege of working through great team with the outstanding community partners and I do appreciate the whole notion of nothing for us without us and that those principles of farm reduction ring true in our state as well so I really wanted to focus a little bit because I think the other presentations do a great job of highlighting the sort of great things mechanics about as I see but in North Carolina you know there's a challenging environment and and working in that challenging environment one to finish but we can make progress we can make a lot of progress toward our goal of helping to a multitude of endemic that were occurring and so really one to talk about the regulatory policy structures that were there and there's making those changes working with data and creating I would say impact for work in sustainable work so back when fingers to that the impact of other papers Orangeburg erbium truth hurt syringe first program is tremendous in the past i go back to my early career in public health in the 80s and 90s it was basically a conversation stopper to start talking about those through syringe exchange or needle exchange at the time was what we were using and I would say North Carolina was omit the billing with the opioid response that you would epidemic response and the conversation came up about injected drugs that people began to transition from the prescribed medication T Street medication which were more accessible and cheaper as as many of these controls have been put in place and what happened was the waterful a troll disease began to happen and then we begin to have a conversation opener people were really beginning to have to have the conversation around syringe services program and it was really nice the fact that we had partners who would come to us and helped us about some of their concerns some of the needs they have more the big players in this arena with law enforcement not a little bit more about the role and how critical they were as a partner for us and through that we were able to have the conversations to begin to align political will science and community and and if you've ever been in that little sweet spot where those things start to a why not you know big things are about to happen it's great the UH the fact was look on how a lot of barriers to in written regulations and walls as well as community and perception errors that we begin to break down and it took a lot of help from a multitude of partners to really get in there and until there five seconds for you if you will and it was not something that we fall you'll see in the next slide that we could do with one fell sweeping piece of legislation it actually took us a couple of tries to did it war we needed it might not be perfect but it was progress and then really the other thing when the biggest use for States communities is finding the right people to carry your message and helping helping them craft rich messages that really get around the lead the point and while we as a community need to address this I think Kanye looted to the fact that politics are local and when you're working and a state office it really does require a lot of community engagement to help change those local politics one of the things that we bump in soon as we were going along the way with around policy changes so I don't want this in my backyard and I don't ever underestimate the sway of one negative book or one negative comment a community when they're really kind and sensitive about a topic and so there's a lot of Education and a lot of working repeating with people not something that always helps officer to do but usually what pastors and others to do to help bring about community change in perception so I've mentioned briefly the Taman in the second ago and really wanted to say that evolution of our policy began because of the fact that we have law enforcement coming to us with accidental needle sticks not a lot but a few and we had been engaging the law-enforcement community on the number of other issues and they basically said well I would do anything to protect my officers and they begin to have the conversation with us about well if I tell you if I disclose that I have a needle or a syringe in my pocket then or you be are you gonna charge me with drug paraphernalia and that led us up to some early legislations with a pilot which allowed us to not to exclude from prosecution provided self-disclosure that gains the strength because most of our policy change and efforts with college you have to report back which always gives you an opportunity to continue your song if you will and that allowed us to get our foot back in the door and have the conversation with the legislators and and tell them exactly yeah well we have this community but it also helps us to build to build better relationships with other communities who have heard about the power and they were wanting to have authorization so they wanted to go down the road of not having enough neither possession of a criminal act so maybe one of our big phone voices going back to the legislature in 2016 we went back and had statues which of change in statues which allows for needle exchange program for 2 inch service program and then we built upon that again in 370 which allows us to utilize non-state funding that allow local government to get seeded own ways they could fund services in their community thinking about bringing our partners together we found that when we start talking we had providers we had behavioral health we had harm reduction community we had the recovery community we had nonprofits we had pharmacists all of which who wanted to do something in this space and we all had this common mission about wanting to help community members and willing to reduce the harm and reduce the collateral to the diseases that we were experiencing and really trying to bring pieces and parts together we want to have compete messages out there and we tore used this topic called moral foundation theory fascinating work you have time to to a researcher but what we felt we would do is go beyond just talking about it's the right thing to do or going beyond the fact that we're wanting to protect people what we wanted to do was to utilize public health data that we have and to start hitting upon all the aspects of everything from the cost of the collateral disease because associated with treatment all through our community in an Nam in real dollars and helped to bring about a rich message which did more than to say it's the right thing to do as we go there ready as we look at reporting requirements up we felt like that was going to be the key to giving us data looking at um what is it when you set up a syringe services program do you need to demonstrate and show the value so that when you're going back the next year or the next year for changes or to to talk to the people that say not in my backyard and you want to say hey I've got a safety component the police are aware of this they are engage in our work they will have a presence in your community what kind of David if we need to develop sustainability because people's mind Eddie and allow us to make sure that what we were doing the efforts that we were going are the right efforts and just give you a few bullets there that we have out there we know that not all counties are covered by our program by the FSC nor all the same types of SSP do we have one of Britain's six we have mobile units or they to me overcome combined with traditional services or they routinized if you will into care and that was one of the things that we kind of collect data all in London over so population we were serving and what does that demographic look like are you providing information and referral which is required and where are you providing that food educational materials it's important for us to be able to help have a good education firm out there as well and in the basics so how many supposed to do dispute were you diff were you providing analog phones and what was that what does that reflect in the community and what were you doing around infectious disease testing treatment and prevention those data points really became important in trying to tell the whole story of what the syringe services programs do for our community along the way we really are going to point you back to our website at North Carolina pay for syringe initiative there's the link and in the PowerPoint and also a use of Public Health guide to ending the epidemic is Chuck now coming out and it combines a lot of the great things that states and communities are doing in relation to safer syringe programs and with that Sharon I want to turn it back over to you thank you so much mr. Fairley for that excellent peek into the journey to expand SSPs across North Carolina your partnership with law enforcement and your look at that moral theory was really really insightful we really appreciate it our next presenters are mr. Andrew Gann HIV STD and hepatitis section manager and mr. Joshua swath tech hepatitis and harm reduction program manager at the New Mexico Department of Public Health just again thank you so much and we really appreciate New Mexico being invited by OS and the Regional Health administrators to this exciting discussion mimicks was a little different than our partners in Kentucky North Carolina in that our program has been around for 20 years and the original basis for it was not the recently emerging increase in the opioid epidemic but it was really based on HIV and Hep C ray and a lot of people look over those two the model program as a model program because over the 22 years that we've operated we've expanded a lot over time we've made a lot of progress and I would say our message is don't be intimidated all of our programs across the country are learning and growing and expanding in spite of or with the support of the regulatory political environment so we didn't get where we were are today right at the beginning and we've made a lot of progress and there's still stuff we would like to see improve in our state as well so we don't have every we have a lot but we don't have instant access to medication assisted therapy for example so so we also learn from our other colleagues just a few objectives that what we're going to talk about we're going to talk about what we see as the best gold standard harm reduction is storage service program that's comprehensive high and centered if you could have everything on your wish list what would you ask for a little bit about our history how we got to where we are today some of the strategies we use to be responsive and client centered as well as to feel the stigma because even in a state where certain services has been around a long time as generally accepted in the community there are still a lot of barriers and stigma and concerns that our participants still face and finally wanted to share a few wins on in public health from our program so I'm sure everyone on the line I'd seen this many times before strange service program isn't just about sterile syringes but I like to share it occasionally just to to highlight so in addition sterile syringes safe disposal is hugely important it's also important political or regulatory talking points when you signed it 20 years of national data showing that there are fewer discarded syringes in the community when you get really strategic about adding smoothie drop boxes giving small portable sharps containers to your participants to bri g back work and syringes all that stuff is very popular we have a lot of support from law enforcement partly due to training it partly because what I what I heard about you know officers not wanting to get stuck when they've had somebody down that that has been really important in our state as well overdose prevention obviously is something we've been layering on our home reduction service and then we believe in navigation so when we started we would do referrals and try to attract them and didn't get much navigation is where you really get somebody to these services productions excellent as an entry point so we're I like to share some of our materials we have a searchable statewide website and an HIV guide and we're using it on all of our materials to point people toward finding the resources they need HIV STD hepatitis announcement service drop boxes across the state are searchable on our website so we started with data from the fair prevalence study wow this is 25 years ago now and people read this differently for very high rates of hepatitis B and C very low rates of HIV and at the time we didn't realize that the low rates of HIV might be due to the types of heroin we had and the types of cooking and the mixes of population people saw this including policy makers and said holy cow if we don't do something fast our HIV rates are going to look like are at CVG rate luckily that didn't happen we also have did you know we have done a lot of targeted surveillance for people under age 30 more likely to be a cuter recent infections of Hep C and C means big increases so all of this is supporting the need for certain services but this again predated the big jump nationwide at opioids so our law passed in 1997 and very importantly I know as states are working and try to figure out what's feasible some of you have accepted some restrictions that you didn't necessarily want so I think about Kentucky you've got to go through every city and county we we luckily have a statewide law so we do listed committee feedback but we don't need to get every city and county to buy in to open a new site so we are authorized compiled data there is immunity for possession of syringes going to and from harm reduction sites it's very important to our participants and then we have to approve every provider across the state and we begin operations will over 20 years ago so we are also started with some limitations that as we've learned and collected data and presented it back to our policy makers we have made improvements but originally we had insane data requirements that were in state law rule because we thought proving our program was successful was originally important and maybe 20 years ago with less than special data it was eligibility is only for those aged 18 and over and residents some educational messages were actually written into state regulations can you believe bleach is still appearing we got that written out a few years ago thank goodness and then exchange was written based on histories about it science is only one for one over the limit of 200 syringes per interaction meaning somebody traveling from a rural area for an hour could necessarily do the ideal of a secondary exchange so we've grown really quickly and I will turn it over to my colleague Josh to share some of our stats and information good afternoon everyone so this will give you a little bit of my background what our program looks like now so currently in the state of Mexico we serve around 12,000 13,000 people every year through our syringe service program and as you can see on the slide that's the significant growth especially from just a couple of years ago a part of that was in part due to our lowering of barriers so the model questionnaire that andrew had mentioned we've actually been shortened that even more as a very short questionnaire as we move reduced interviews and survey fatigue so people are more willing to come in we've also had over forty five thousand registered recession let me that of these twelve fourteen thousand people that are coming to our syringe service programs we have 45 thousand interactions with them during that fiscal year 2018 that's 45,000 times they have contacted either one of our health officers service programs or our contracts this program so oftentimes this is the first entry into any sort of healthcare which has been quite nice and it has some really great results we've got some service locations throughout the state and serving many different communities really rural and even some frontier areas as well in our urban areas and Android also mentioned we integrated overdose prevention with our search service programs very early on originally it was only clinicians nurses nurse practitioners behave and DS who are able to dispense naloxone and in 2016 we actually signed legislation that allowed us to overcome that Oh as you can see here the need was very high for it we have the highest overdose rates for a decade and then in 2016 it drop began dropping it in 2017 and continue to drop oh and through our reduction programs that's especially to access folks who are who really need and utilize their services that the folks who are coming in for syringe services and they're the most like leads that have issues overdose and need the messaging for overdose prevention and education and a little bit more history we're the first state to a lot enact our legislation allowed for third-party distribution meaning that Watson was able to be used on someone other than who it was prescribed for and quite strange services we had a very very long interview we had a three hour long training the beginning because that was some of the the confessions that we made to be able to provide a prescription medication Oh tour community oh and 2005 in children things be really short back to a 15 and 20 minute grade book and we've been working to shorten that even more so 15-20 minutes look good for a group now we can do watch on overdose prevention education shall have you also in really about 10 minutes or less so we've done really well with shorting that decreasing that time barrier this 2016 as I had mentioned we have the we have a wall that was passed that allowed distribution blocks on but late individuals by standing order as soon as that went into effect as soon as we have the regulations all set up we require all of our syringe service programs energy integration lots of distribution and overdose prevention into all of their programming um as I had mentioned earlier do our education you'd be very brief and understable and geared towards what the caps clients are concerned about we ask lots of questions we try to see what the clients are interested in and we get really the facts about overdose prevention education we have a lot of myths that we have to overcome and we do a good job of that prevention side as well we also need to make sure that those better game you want some aren't just the folks that you think that the folks that are around them to really get them in the community and ensure that folks that are around people that are giving some people have access to naloxone because parents brothers sisters mothers you know even law enforcement um and we also really success for data collection so we get our information on lock some usage when people come back in and report that they have used their lotto so when they come back in to get more they will report what it was useful as you can see here programs grown quite significantly almost 24,000 those watchon distributive and in 53 or 19 almost 3,500 successful reversals are reported by our community members to our programs and this is just what come through harm reduction not including other partners at state government videos give you to law enforcement cetera yeah this is outside the ser a yo grab the although sales addresses the outside it is just true harm reduction programs directly we also move toward navigation has Kentucky we also have very high rates of hepatitis C so we're working towards navigating folks at the highest risk from addict tyrosine into treatment into confirmatory testing and treatment as per our statewide elimination plan we've also been able to provide vaccinations through our harm reduction programs for hepatitis A and B this has allowed us to respond to a recent outbreak that we had quite successfully we also have nm HIV guide which allows both our providers and people in the community to find these locations throughout the state so they can find one that works conveniently for them we've also had additional drop boxes that we donated the City of Albuquerque at they've recently come on board to help with a syringe disposal and as part of our program several locations also providing wound and abscess care on-site when they have medical capability and almost all of our locations is providing food and water program participants as they come in and some of our programs are actually going helping the community and delivering food and water to communities who don't really have access to transportation to get into town this these wraparound services have really made our syringe service program quite popular and a reduced log barrier which is whitening the number of the group that you've seen over the years so what we'll just ship and give you a few lessons I know there's a couple of minutes left but on training is certainly key we have integrated our HIV and Hep C test counselor training we certify all our Hardware diction reductionists across the state and we certification for harm reduction is one-day training for HIV Hep C counselors 3 and then we do take the trainers so we have a lot of partners we work with our AIDS education and training center and so on all of our materials are in English and Spanish this is bragging on things now is for rapid HIV and Hep C testing we presented together sometimes mcs a motivator for people who eject and they learn about HIV it's the other way around a few of our strengths include negotiating exchange we are not a one-for-one program anymore the best science does not say to do one for one we respond to our client needs we try to be as comprehensive as possible we're fortunate to be a centralized state health department so the majority of our local public health offices operated by our state health department have harm reduction services and they're also well integrated and when people ask was it okay to have a wicked harm reduction in the same building we always respond with yeah because it might be for the same client we try to be too low thresholds as Josh mentioned reducing our survey and data collection burden do we really need to ask people about their sexual history when they're coming to serve you change the first time and while we're confidential be unique we use unique ID codes for our clients so that they can be stay from have immunity from prosecution just for possessing syringes again they're doing other activities that are locations that they're don't have immunity for that we work really hard to try to reduce barriers of stigma as Kentucky said there's a huge need in rural areas there's a lot of overdose and people are further from places that can help so making sure that frontier rural areas are served in some places mobile units are really cool we've actually found that a lot of clients will prefer a sick site location so if you walk into a public health office nobody knows what service you're walking in for whereas a mobile unit might be strictly for that's the needle place and we try to be active and client centered and then one thing that's extremely important that we're all working on together is continue to reduce stigma around drug use around the language and you know how do we talk about to help the community we have a lot of phrases we use in terms of harm reduction you know prisoner health is public health people using substances are people in our communities they're members of families so we ask open-ended questions we use affirming language if they use a language for drug or use the links to subscribe themselves we're going to use similar language but we're never going to use certain words that are not productive because clients are not going to come back if they don't feel respected even if they need the service you're offering and our harm reduction sites are really truly the ideal entre point for all the services we want somebody might be scared or intimidated to get into a residential out flow drug program but they came to a production for a long time that they met somebody they'd really like to trust and that's the person I asked that question so if we're ready to listen to them and they're ready for the next step we can help them and one of our wins is Josh mentioned in an FA outbreak it was among people experiencing homelessness but a lot of them overlap with our clients so we were able to get a lot of vaccine right into that population because either people were come and CLE and then our HIV rates remain Billy love now quite as those that were the syrup Elvis does it you the 90s dista similar of stop there thank you so much mr. Gansler mr. suave tag you guys started this two decades ago and when you've been in the movement that long there's so much you can share with other states who can benefit from your experiences Thank You general you're welcome and thank you to all of our presenters and now we get an opportunity to hear from our participants and I'm so glad that we have a lot of time left for that because we really want to address your questions if you haven't already please type your questions into the Q&A pod and we'll address as many as we can if we don't get an opportunity to address your question today we will be reviewing all of the questions and comments and analyzing the types of issues and questions that were raised from various sectors and regions of the country and this will help us to inform our approach to expanding access to SSP and the content of future webinars so with that said I'm going to turn the mic over to miss Corrina dann and she will facilitate the Q&A are you speaking yet Corrina yes Sharon can you hear me now yes I can great all right something odd happened with the microphone but I wanted to thank the speakers for sharing some excellent examples and also to the the participants we've already got some really terrific questions in in the queue and so with that I want to ask I think we had a couple directed to Connie as the first presenter Connie the folks are asking what what you've learned about best practices for optimal hours of the day hours of the day days of the week to optimize a service program coverage well we found that each individual health department has to do with what they have capacity to do in financial times that we have now it's very difficult we have some of our larger syringe service programs in our larger health department that not only do they are they open and incorporated into their program but they also have mobile units and I like the point about how these mobile units that they're using do don't do just a syringe exchange they do other things as well so you don't get pegged as oh you went to that mobile unit you must be looking for needles but it's interesting we have a small health department that has five employees in a very small County in Eastern Kentucky and they have incorporated it into their daily activity so they have an environmentalist and a director and a front desk person and a nurse and another nursing assistant and they've managed to find a way to incorporate that it takes a lot of creativity we really haven't pushed anybody to do only what they feel like they have capacity to do most doesn't start it very small and most of them has built on that so that kind of reflects the limited hours of that whole that this thing has to be local another question someone asked was how long are these health departments approved to run to operate a syringe service program well they're approved until they're unapproved just afterward so they're allowed to provide the service until someone votes that can't happen and fortunately knock on wood that hasn't happened to any of our other health departments every time Thank You Connie uh we got a good question about the wasn't directed to any of he speakers and possibly several may have some insight into working with angry neighbors who the needle litter around and have have you all or has any of this speaker seeker worked with those angry neighbors or helped through in-service programs to address the concerns of needle litter and other things that are associated generally with during service programs at least in people's mind thanks this is a Andrew and Josh in New Mexico we're 22 years in 21 years in and we still have questions and you know I think you you have to present evidence to people based on their their feelings some people just will never be comfortable with the idea that there are people experiencing homelessness in the same place they live or people using substances in the same place they live and some people actually hear the data and be impressed so I think both the national data on how syringe Services works and you know that it turns syringes into a commodity values they have to come back because that we do is we had one recently and we just presented the data for the closest syringe service sites to the Little League field that was getting this attention and shows that that particular site but had a collection rate over a hundred percent because we don't just count what comes into exchange we also count our drop boxes we don't count the once per one by safety but you know we track what's coming in and with the committee members heard that actually more was coming off the street because of our program they actually then just started talking about how do we participate in needle cleanup and solve the issue so depends on whether you're dealing with some people will complain no matter what but some people really want a sexual answer and we have the data dish to present terrific thank you Andrew in I guess New Mexico also got a question about the participant cards that you very service program their gift out does that seem to work fairly well for participants and do the law enforcement really embrace the participant love Riveter cultures cut out a little bit about law enforcement so oh our our card bullet works fairly well we give them out to everyone at the exchange location if they don't have one we make sure they make them do it it's a simple laminated card and part of that is also education of law enforcement so we have advocates in our law enforcement community and also in a group that trains law enforcement and we have them go out and talk to law enforcement and train them on the law side usage and part of their training on law so uses is also training on how the harm reduction program works the benefits and the sort of regulations behind it which is really nice so let's reduce the amount of negative interactions that we've had that our participants attend with police because our law enforcement is really concerned and of course it is with enforcing the law and they're you know don't want to spend their time on a paraphernalia charge especially if someone that operate within the confines of the law another part of that program that's really important is that we have verification letters that we railroads provides participants and judges so if we get a method alert where one of our folks got and got a citation when they might make they shouldn't have they might not have had their card on them we can actually write a letter to the court saying that this person has been engaged in the program and verify their participation and trade show this program thank you one of the questions we just got Danny Daly I believe can can speak to some of the techniques that have been most persuasive to engage or work with law enforcement in your state yeah thank you for the question one of the things that we have found is first Lawton much of work in public health it is a relationship and relationship with law enforcement at they were partnering getting the bill passed but they've been a partner also in doing the locks on distribution and in doing response in communities as injuries have occurred and so the first thing I would say is develop a relationship with them where they feel like they can come to you the other is when we went and asked about what occasionally we would see a officer coming into the work well compartment with a needle stick and so they're now all post-exposure treatment and at that point you know we we started asking the law enforcement community well what do we do to help prevent the stick from the beginning and you know we found out pretty quickly that law enforcement doesn't always want to report these things the officers in the field for whatever reason maybe it's an idea I'm an officer I shouldn't really found a weakness if I was that I got stuck or whatever that was the first thing that we started working almost yeah you know let us know so we get good data and then that was the start of this whole preventing thick issue and a disclosure finding out this simply how if you tell us you've got it then we're gonna you know not charge you with a paraphernalia trip which is where all did basically we need the barrier so it for us it was about relationships it was about we worked with police to begin with on training and education on a number of our Cup issues whether it's preparedness and white powder exposure that they would get from nil when they're doing no investigation or a you know a threat investigation and then also from the treatment so we were also having a contact with treatment and then we started providing them data so they became a one where they valued our relationship and resource that was how that began and that we found it to be very helpful and their story I mean whenever they would tell us their stories about how they got stuck or what but then we would ask them can we share this because I think it's a learning opportunity for us officers and so that became an opportunity for us to be engaged with them on a different level terrific and then the Kentucky we were very lucky in Kentucky that this this whole process was pretty much led by our Office of Drug Control Policy with Van Ingram who is a former president of the state I want to say sheriff's office and that's not the current board but but he is now he is statewide known and respected and when Van gets up and says this is important people do listen so that having that right person is someone said earlier that that is so key to have the right person talk to the right audience thank you so much honey that's terrific one of the questions we got were it is whether hersa provides guidance for hersa funded health centers on starting a foreign service program and I'd like to refer the participants today to webinar number one during which we had a personal leadership on the line providing examples of programs that SSP that health centers are involved with in terms of SSP support or even potentially housing or co-locating SSPs in a health center there were some great examples given and that archived webinar is available to view @ww HIV flash it's under federal response and syringe services program so encourage folks to go back and take a look at that we had hersa CDC and Samsa on that webinar and it was terrific almost as good as this one so another question we got from folks was about one of the first questions we got was around what our office is doing to put more legal through services programs in place and I was thinking that the Regional Health administrator Sharon Rick's may be able to speak for briefly about about that work here at the office of the assistant secretary for help thanks Corinna and we are excited across the nation we have ten regional health administrators working with state and local communities to discuss what is needed around advancing access to access SSPs increasing hours putting SSPs in places that don't currently have them and also increasing those types of services that are provided at SSPs so we're in the early stages of gathering information by December we'll have a really good idea of what the needs are in communities and what HHS resources and information might be helpful as we strategize on how to increase access and starting in January we'll be able to put some of that stuff to work and see if we can work with communities locally to expand access terrific Thank You Sharon so I heard especially from New Mexico but would love to hear responses from any of the speakers about what what you're doing in your state to respond to the rising rate rates of hepatitis C I think we've also seen outbreaks of hepatitis A it's been a huge increases in hepatitis C and it may be easy to kind of lump those together and ask the speakers what what you're doing to respond to those increases in infectious diseases these would be the foreign service programs that we're talking about today well this is Connie I mean we see the folks that this touches backing into our offices up every week and so I think using this opportunity to ask about testing recommend tasks if they say no rats the next time you ask the next time when I was in private medical practice I would ask the same questions often about spousal abuse and get the same answer every time until finally someone understood I really did care and really just wanted to hear that answer and when you start getting that honest answer I think offering those vaccinations and offering that testing in Kentucky we are as an expansion state so we have the opportunity to get these folks not only the camera but actually meaningful care that Carol is now so we're very energized with this opportunity to help cure the patients and we're looking at our Medicaid data to see how many people with positive diagnosis actually get treated those numbers are not something we're proud of and that something will welcome very strong strongly with our hepatitis C Broadus program and this is ne I think one of the things that could follow up on the question about reading pictures to see all the things that we began doing if we sort of set up the B programs and the guidance to establishing a program was to routinize SP because we all know that if you don't know your status and or in an encouraging innovation where for immunizations are warranted if you don't know your status that's the problem and so one of the things that we have to do is to break down stigma and and make things like testing more routine and even if we can figure out the ways and mediators to make it an opt-out of 50 to help bring it more of richness thanks so much Connie and Danny I also want to reassure our participants that we see certain services programs as a critical way to reach individuals at risk for infectious diseases and to provide education when appropriate vaccinations as well as screening and referral and you know we're in the development phase of the next iterations of the National viral hepatitis and HIV strategic plans and our expect that syringe service programs will be part of those of those national strategic plans moving forward because there's such important prevention opportunities for infectious diseases we got a really interesting question I think Connie may be able to help us understand if there is any data on the impact of print service programs on health care cause when we looked at that a couple of years ago just there are three service programs had gotten started and we're really looking at that and what we're going to do is take our Medicaid data look at folks with a substance use disorder diagnosis and then we'll get kind of morbidity that is the cost to these folks and we're going to start looking at if the person's residence this is in 30 miles of a syringe service programs are their cost different than folks who have an su D diagnosis and are not close to a service program that data is being crunched right now and I think that's going to be very helpful information for us to share with our legislators thank you so much Connie I am really sorry that we are out of time for the question and answer because we have so many more great questions but I want to turn it back over now to Sharon Rick thank you for in and thank you to our planning committee to our presenters and to you our participants for joining today together we can combat the nation's opioid crisis and in the HIV epidemic in one way is to achieve these goals through expanding access to SSPs on your screen you will notice that six questions have popped up please take some time now to let us know your thoughts about this and future webinars we will follow up with the recording of the webinar a link to the presentation slides and the contact information for your Regional Health administrator thank you for your participation and I trust that you are leaving better informed about state and local perspectives and inspire to do what you can to increase access to excess fees in your community enjoy your day