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

Abstract

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
Effectiveness studies of syringe exchange programmes
(SEPs) are plentiful (Gibson, Flynn, & Perales, 2001), yet
few studies have considered how programme operations
might have an impact on outcomes (Bastos & Strathdee,
2000; Heimer, Bluthenthal, Singer, & Khoshnood, 1996;
Riley, Wu, Junge, Marx, Strathdee, & Vlahov, 2000). Re-
peated surveys of SEPs in the United States have revealed
continuing and substantial differences in programmatic
features (Centers for Disease Control, 1995; Des Jarlais,
Mcknight, Eigo, & Eigo, 2002; Paone, Clark, Shi, Purchase,
& Des Jarlais, 1999). One important operational aspect
of SEPs is the venue of service delivery. Service delivery
venue affects who can gain access to the service, what
types of services can be effectively delivered, programme
∗Corresponding author.
E-mail address: rjvanderson@ucdavis.edu (R. Anderson).
costs, and which funding sources are willing to fund the
programme. Here we describe the programmatic features of
the Sacramento Area Needle Exchange (SANE), an illegal
SEP that utilises “satellite exchangers” to distribute the bulk
of its syringes and HIV risk reduction supplies. We con-
sider the advantages and limitations of this mode of service
delivery. Satellite exchangers (sometimes called secondary
exchangers) are people who have access to an SEP and
distribute supplies (e.g. syringes) to other drug users (Des
Jarlais et al., 2002; Grund et al., 1992; Snead et al., 2003).
Programme description
SANE was established in 1993 as an IDU network-based,
pager-initiated, mobile delivery programme that distributes
and exchanges syringes on an as-needed basis. SANE has
been an illegal, underground SEP since it opened. In Cal-
ifornia, a doctor’s prescription is required to purchase and

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0955-3959(03)00146-4
462 R. Anderson et al. / International Journal of Drug Policy 14 (2003) 461–463
possess syringes unless a local governing body declares a
state of emergency and sanctions an SEP. In such a case the
SEP may operate legally, although IDUs may still be ar-
rested for possessing syringes based on drug paraphernalia
laws that make it illegal for drug users to possess materials
that can be used for drug use. Neither the city nor county
of Sacramento has legalised the SEP (as of March 2003).
Designated exchangers (DEs) are recruited and trained by
SANE staff and volunteers in exchange protocol, infectious
diseases and overdose prevention techniques, harm reduc-
tion strategies, and given appropriate injection supplies.
DEs represent networks that are geographically, economi-
cally, professionally (e.g. government workers or students),
medically (e.g. HIV) or socially defined (e.g. immigrants;
similar drug of choice). Individuals contacting the pro-
gramme for the first time are referred to the DE in their
area after the first couple of visits or are assisted with estab-
lishing their own exchange network. To serve homeless or
marginally-housed IDUs, SANE volunteers make weekly
trips through known drug-use areas in the region and home-
less camps along the two rivers that flow through Sacramento
County.
Advantages
Given the setting and political realities, the methods used
by SANE have several advantages. First, by relying pri-
marily on DE for delivery of SEP services allows SANE
to cover a large geographical region. Sacramento County,
where SANE operates, encompasses 1000 square miles
(1609 square kilometres) and contains a population of 1.2
million, with an estimated 14,000 IDUs (Newmeyer, 1995).
To cover this large geographical area using other modali-
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,
SANE estimates that it reaches a small portion of IDUs in
Sacramento County.
Second, using networked-based DE with syringe delivery
keeps operational cost low (approximately US $75,000 per
year). At present, SANE consists of three staff working an
estimated total 0.80 full-time equivalent. Almost all staff
effort is devoted to the actual delivery of services. The bulk
of service delivery is conducted by DE who are volunteers.
Between 1997 and 2000, the number of syringes delivered
increased by 332% from 100,829 to 435,690 representing a
reduction in programme cost per syringe from 38 to 18 US
cents. In 2002, 75% of available funds were expended on
supplies.
Third, this method also provides syringes to clients who
may not want to or can not use fixed sites programmes.
In the few studies that report demographic characteristics
of SEP clients, women have represented 26% of clients in
Chicago (Brahmbhatt, Bigg, & Strathdee, 2000) and 34%
in Baltimore (Riley et al., 2002). In the first nine months of
2002, 45% of SANE exchanges were conducted with women
and 13% of all exchanges were conducted with women of
colour.
This approach also limits the possibility of detection
of programme personnel and clients by law enforcement.
Many IDUs do not gain access to fixed site SEPs because
of the fear of detection by police (Rich, Strong, Towe, &
McKenzie, 1999). This is particularly true in cities where
SEPs are illegal (Bluthenthal, Kral, Lorvick, & Watters,
1997). Fear of arrest may disproportionately affect peo-
ple of colour and women with children, two important
sub-populations of IDUs. By conducting syringe exchange
through delivery and having DE deliver the majority of
services, SANE is able to reach a diverse population that
might not have access to SEP if it operated using other
venues.
Further, this model makes it difficult for law enforce-
ment agencies to intervene against the programme. Although
SANE has operated illegally for nine years, only once have
police arrested the programme personnel. In June 2001, a
trial judge convicted a SANE volunteer of illegal syringe
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.
The loss of this volunteer’s service has adversely affected
the level, timeliness and overall quality of the programme. In
2001, 405,107 needles and syringes were exchanged while
in the first nine months of 2002, only 129,443 needles and
syringes have been exchanged (a 43% decrease from 2001).
Additionally, one of SANE’s primary funders notified the
programme that funding would not be continued due to the
conviction. Finally, SANE has received many reports from
consumers decrying the negative effect on service timeliness
and quality.
Limitations
While having DE conduct the bulk of service delivery
has several advantages over other modes of delivery, there
are also limitations. First, this model is not as conducive as
fixed sites to providing a wide range of ancillary services,
including first aid, HIV testing or advocacy. Second, using
DE for delivery of services may not be optimal for drug
users who do not want to be reliant on other people for
access to syringes. Third, those who receive services from a
secondary exchanger may not derive as much from the ser-
vices as direct exchangers in terms of counselling, referral
to social and medical services and education. SANE min-
imises this limitation by training and educating DE in harm
reduction strategies and infectious disease/overdose pre-
vention.
The illegal, underground status of SANE represents
another limitation. Increasing numbers of SEPs in Cali-
fornia receive funding from city and county governments
for non-syringe supplies and staff. SANE is limited to
 R. Anderson et al. / International Journal of Drug Policy 14 (2003) 461–463
funding provided by private foundation grants and dona-
tions from programme consumers, staff and community
members.
Discussion
We conservatively estimate that at least 3 million syringes
per year should be exchanged or purchased by local IDUs.
The use of DE has contributed significantly to the success of
SANE, yet its illegal status threatens to undermine the en-
tire programme. The lack of political support and adequate
funding is threatening the programme’s existence. Accord-
ing to the County Health Officer, a loss of SANE could
lead to a doubling of HIV seroprevalence among local IDU
within five years. SANE will continue to work with local
health officials, an ad hoc committee, and the Drug Policy
Alliance to obtain a local declaration of emergency and a
sanctioned programme.
The authors offer the following recommendations to oth-
ers wanting to provide SEP services in similar settings: (1)
recruit reliable volunteers; (2) work with local IDU on pro-
gramme design, implementation and evaluation; (3) estab-
lish stable funding (to the extent possible); (4) thoroughly
train volunteers to train DE; (5) provide pager/delivery ser-
vices in large geographic areas; (6) be as discreet as pos-
sible (try to avoid antagonising law enforcement and drug
distributors); and (7) cultivate local political support.
Acknowledgements
Support for writing this manuscript was provided by
the Centers for Disease Control and Prevention (Grant No.
RO6/CCR918667-01). The authors would like to thank the
staff and consumers of California SEPs for their generous
participation in our research.
463
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