Colocating Syringe Services, COVID-19 Vaccination, And Infectious Disease Testing: Baltimore’s Experience

People who inject drugs (PWID) face significant challenges that contribute to their poor health, as well as increased morbidity and mortality. Challenges include drug overdoses, HIV, and hepatitis C infections. PWID account for 7 percent of new HIV infections and 57 percent of new hepatitis C infections annually in the United States.^1,2 In addition, recent surveillance data indicate that hepatitis C infection rates continue to increase annually, despite the availability of curative treatment.³ For these conditions, PWID require high-quality prevention and treatment services, but traditional public health and health care systems are not always well suited for delivering these services because of structural barriers and lack of trust.

PWID face many challenges and complications accessing traditional health care services. These include difficulties with obtaining health insurance, difficulty navigating complicated health systems, limited access to transportation, and internalized and enacted stigmatization.⁴ Alternative health care service delivery programs have helped PWID meet these challenges. These include syringe services programs, which have established track records with PWID and have earned their deep trust. The programs are often funded and managed by local health departments^5,6 and were initially designed to provide harm reduction in the form of offering education, clean needles, and a means of needle disposal. Newer program models have integrated the use and distribution of naloxone for opioid overdose reversal, wound care services and supplies, medication for opioid use disorder, and referrals to primary and specialty care services.^5,7

During the COVID-19 pandemic, syringe services programs and other harm reduction programs suspended services initially, but they quickly made plans to reopen, recognizing the essential services that they provide to PWID.⁸ Decreases in testing for infectious diseases and referrals to treatment during this time prompted concern among health care leaders that infectious disease outbreaks and increased morbidity from untreated disease would occur in this population.⁹ In addition, PWID interviewed during the COVID-19 pandemic reported increased mental health issues, increased sharing of needles, polysubstance use, and decreased access to their usual harm reduction or syringe services programs.¹⁰

The burden of COVID-19 infection was also higher for people who use drugs compared with the general population, leading to increased hospitalization and mortality.^11,12 However, PWID were not prioritized for COVID-19 vaccination, despite having co-occurring conditions that qualified them for vaccination before the general population (for example, HIV infection and age).¹³ Venues where vaccines were offered, including large medical centers, and mass vaccination events that required online sign-up presented insurmountable logistical barriers for some PWID. Without targeted funding to colocate vaccination within health care sites that PWID trusted and commonly used, the barriers to health care services and stigma persisted among them.

In this article, we describe a collaboration between Johns Hopkins Medicine and the Johns Hopkins University School of Nursing to colocate infectious disease testing and linkage to treatment and COVID-19 vaccination with the Baltimore City Health Department Syringe Services Program, in Maryland, to address unequal access to COVID-19 vaccines by PWID, as well as the decreased access to wraparound infectious disease screening services for this population. This aim of this effort was to respond to the need to equitably distribute COVID-19 vaccinations and engage PWID for additional preventive services that were disrupted during the pandemic. In addition to describing the program, we present descriptive data on the population, number of vaccinations, infectious disease tests and linkage outcomes, and syringe services, to understand services accessed by PWID when services are colocated at a trusted source. Findings from this work can inform the future delivery and expansion of preventive and low-barrier care colocated within syringe services programs, as the public health system reimagines how to meaningfully reach this population.

Program Description

The Baltimore City Health Department Syringe Services Program operated on a set schedule with a mobile van visiting Baltimore City neighborhoods that had high overdose rates, providing needle exchange, harm reduction counseling, naloxone training and distribution, and overdose reversal. The program operated continuously during the COVID-19 pandemic to provide these essential services. The Center for Infectious Disease and Nursing Innovation, a Johns Hopkins School of Nursing center that cultivates scientific and programmatic infectious disease expertise in nursing, and the Johns Hopkins mobile vaccine unit partnered with the Baltimore City program to conduct infectious disease testing and administer COVID-19 vaccinations at locations where the program operated, leveraging its consistency in delivering services.

Between April 2021 and June 2022, ten colocated clinics were conducted in conjunction with syringe services program services; no appointments were required. People receiving syringe services program services were offered free COVID-19 vaccinations and infectious disease testing. The Johns Hopkins mobile vaccine unit offered both mRNA (Moderna and Pfizer) and viral vector (Janssen) vaccines. Those who were interested in vaccination signed a consent for the vaccination and were registered within the Johns Hopkins mobile vaccine unit electronic health record to collect demographic information and document the vaccination. Their vaccination status was verified in the health information exchange linked to the electronic health record to determine whether they were eligible for a first, second, or booster dose. People who received the first dose of the mRNA series were scheduled to return to the syringe services program for their second vaccination during a scheduled colocated clinic and were provided with information on how to receive a COVID-19 vaccination at locations outside the syringe services program if they missed their colocated appointment. Gift card incentives were not initially offered for COVID-19 vaccinations, but later, $10 gift cards were offered after full Food and Drug Administration approval for COVID-19 vaccines occurred August 23, 2021.

The Center for Infectious Disease and Nursing Innovation provided point-of-care testing for HIV, hepatitis C, and syphilis. PWID who were interested in testing provided written consent, completed a demographics questionnaire, and received testing results during the encounter. People who tested positive were offered linkage to a treatment provider and had their appointment attendance confirmed. Self-collected oral, penile, vaginal, and rectal swabs were offered to test for gonorrhea and chlamydia, with a private tent available for on-site specimen collection. Vaginal testing also included testing for trichomoniasis. Swabs were tested within forty-eight hours at an off-site lab. Participants were notified of their results by a Center for Infectious Disease and Nursing Innovation team member via telephone. Participants also received a card with the telephone number of a team member whom they could call to receive their test results. For positive test results, either participants were linked to treatment (for gonorrhea) or a prescription was sent to a local pharmacy for treatment (for chlamydia and trichomoniasis). Prescriptions were billed to the participant’s insurance, and uninsured people were linked to the Baltimore City Health Department’s sexual health clinic for free treatment. Initially, participants received a $10 gift card for each completed infectious disease test. After the first five clinics, the Center for Infectious Disease and Nursing Innovation changed this incentive to a $20 gift card for any testing, regardless of the number. Lessons learned from the first five clinics have been published elsewhere.¹⁴

Partnership And Funding

The Baltimore-based Johns Hopkins mobile vaccine unit was a partnership among the health care institution, local government, and the health department. Comprising health care personnel, including clinicians, pharmacists, logistics and administration staff, and students, this team was responsible for implementing mobile strategies to increase COVID-19 vaccination. To reach PWID for COVID-19 vaccination, the Johns Hopkins mobile vaccine unit then partnered with the Baltimore City Health Department Syringe Services Program. The Center for Infectious Disease and Nursing Innovation’s partnership with the other organizations provided the infrastructure of field-based infectious testing; storage for the COVID-19 vaccine while on site; and nursing student volunteers who assisted with vaccination, infectious disease testing, and directing PWID between the colocated clinics based on desired services.

This work was supported in part by braiding together grants, contracts, and Center for Infectious Disease and Nursing Innovation resources, all of which also supported other efforts to independently provide infectious disease testing and COVID-19 vaccination. The center used its funds to support the mobile van for infectious disease testing and vaccine storage, gas, Wi-Fi, privacy tents, and clinical consumables such as gloves and wound care supplies. A grant from the Urban Health Institute at Johns Hopkins University allowed for five additional clinics to be conducted in 2022 and supported these costs. Contracts to the Center for Infectious Disease and Nursing Innovation from the Baltimore City Health Department supported the infectious disease testing services, including the cost of point-of-care and send-out tests, as well as staff support. The Johns Hopkins mobile vaccine unit was funded through a combination of federal pandemic relief funding support covering some personnel and essential supplies and the Baltimore City Health Department provisioning vaccines and related supplies such as needles.

Data Collection And Analysis For Evaluation

We present the results of an internal evaluation of the program, including demographic characteristics of PWID and descriptive data on infectious disease tests completed by test type, the frequency of positive test results, successful care linkage, and syringe services program services. For privacy reasons, the syringe services program does not collect individual-level data. The program tracked aggregate data of syringes distributed and returned, naloxone training, and kits distributed at each colocated clinic. However, vaccine and infectious disease metrics were tracked separately and abstracted, with procedures detailed below.

Vaccination data (including date and type of vaccine) for completing primary series and booster doses were tabulated for each person receiving at least one COVID-19 vaccine at a colocated clinic. The data were extracted from the electronic health record and Maryland’s immunization registry to determine whether people completed primary and booster doses outside the colocated clinics.

Infectious disease testing results were entered into CAREWare, the software maintained by the Health Resources and Services Administration’s (HRSA’s) Ryan White HIV/AIDS Program. Test results and demographic information were abstracted for each colocated clinic. Linkages between both data sets were made on the basis of first and last name and date of birth.

Demographic information was collected on a strictly voluntary basis, so the record of demographic information is not complete. When possible, however, these data were abstracted from the two data sources if available. This evaluation was determined to be not human subjects research by the Johns Hopkins University Medicine Institutional Review Board (IRB No. 00288290).

Evaluation Results

PWID Who Accessed Any Clinical Service

There were 347 unique PWID accessing Baltimore City Health Department Syringe Services Program services who received at least one COVID-19 vaccination or infectious disease testing service at the ten colocated clinics during April 2021–June 2022. The majority of people were male ($n=239$, 69 percent), Black ($n=265$, 76 percent), non-Hispanic or -Latino ($n=323$, 93 percent), and a mean age of fifty-one years (standard deviation: 13) (exhibit 1). Of these people, 63 percent ($n=218$) accessed at least one dose of the COVID-19 vaccine and 58 percent ($n=202$) received one infectious disease test from a Syringe Services Program colocated clinic (data not shown).

PWID Who Accessed Infectious Disease Testing Only

Of the 202 people who received at least one infectious disease test, the majority received a point-of-care HIV test ($n=174$, 86 percent), followed by hepatitis C ($n=129$, 64 percent) (exhibit 2). Syphilis testing ($n=76$, 38 percent), throat swab for gonorrhea and chlamydia ($n=69$, 34 percent), and genital swab for gonorrhea and chlamydia ($n=50$, 25 percent) were less frequent. All eight patients with positive HIV diagnoses (5 percent of those tested for HIV), one of whom was newly positive, were linked to treatment. An additional person reported HIV exposure within the past seventy-two hours, tested negative with a rapid HIV test, and was prescribed postexposure prophylaxis and provided linkage for follow-up clinical services. Of the twenty-one people (16 percent) who newly tested positive for hepatitis C and required linkage to treatment, only six (28 percent) could be documented to have a successful linkage visit. All six people requiring follow-up for their presumptive point-of-care syphilis test were successfully linked to confirmatory testing and treatment if indicated. None of those tested for chlamydia or gonorrhea tested positive. One person’s swab tested positive for trichomoniasis, and they were successfully treated.

PWID Who Accessed Vaccination Services Only

There were 218 PWID (63 percent) who accessed at least one dose of the COVID-19 primary or booster series at the colocated clinics. The majority opted to receive a two-dose mRNA vaccination for their primary series ($n=141$, 65 percent). Of these patients, 128 (of 141 total, 91 percent) completed the two-dose series (exhibit 3). Booster doses had lower uptake. All PWID were eligible for a first booster vaccine at the time of data abstraction, but only sixty-six people (30 percent) received at least one additional dose.

PWID Who Accessed Harm Reduction Services

Counts of syringes distributed and returned and naloxone trainings conducted and kits distributed at colocated clinics between April 2021 and June 2022 are presented in exhibit 4. Across the eight colocated clinics with Syringe Services Program data available, an average of 3,057 syringes were distributed, 1,437 syringes were returned, and 24 naloxone kits were distributed with training.

SOURCE Authors’ analysis of data collected and reported by the Baltimore City Health Department Syringe Services Program. NOTES There were 10 total clinics between April 2021 and June 2022, but data were available for 8 of the clinics only. Training for the use of naloxone, a drug that rapidly reverses the effects of an opioid overdose, also included the distribution of naloxone kits.

Discussion

Using colocation of COVID-19 vaccination, infectious disease testing, and care linkage services with a syringe services program works. Particularly striking in the Baltimore City initiative we evaluated was the rate of second-dose uptake of the primary COVID-19 vaccination series (205 of 218 patients, 94 percent), which exceeded that of the general population.¹⁵ Given the well-documented low uptake by PWID of services and prevention interventions,^16,17 this high completion rate and the high completion rate for a two-dose series (91 percent) strongly indicate the vital role played by the inclusion of trusted partners. It is also noteworthy that booster dosing declined to 30 percent ($n=66$ of 218) with the return to a traditional service model (exhibit 2), which is lower than the uptake of first booster doses among the general US population during the same period (approximately 50 percent).¹⁸

Low uptake of health care services makes PWID a priority population. The reasons for this low uptake are complex and interwoven, but they include poverty, poor health care experiences, stigma, racism, and lack of transportation.¹⁶ Syringe services programs have proved to be an important vehicle for service provision, as confirmed by their high use and effectiveness in preventing disease transmission, decreasing overdose deaths, and facilitating treatment access.¹⁹ When other clinical services are colocated within syringe services programs, our evaluation suggests that this relationship can be leveraged to provide other essential public health services, including HIV and sexually transmitted infection testing, and COVID-19 vaccination. Our data contradict concerns regarding treatment adherence and vaccine completion rates for this population,¹⁸ as 91 percent completed the two-dose series of COVID-19 vaccinations, potentially driven by the colocation with a syringe services program.^20–22

The multifaceted approach in our intervention for PWID is justified on the basis of the documented intersection between injection drug use and the transmission of many bloodborne and respiratory infections. Globally, PWID account for approximately 10 percent of all new HIV diagnoses and an estimated 23–39 percent of new hepatitis C diagnoses.²³ Comprehensive syringe services programs have demonstrated their effectiveness in preventing the transmission of bloodborne diseases such as HIV, hepatitis C, and infectious endocarditis, as well as resources for collaborative prevention of sexually transmitted infections.⁵ Offering additional services, including infectious disease testing and linkage to treatment and COVID-19 vaccination, is an essential innovation responsive to the ongoing high incidence of HIV, hepatitis C, and sexually transmitted infections in this population while providing the opportunity for mitigating COVID-19 risk. This model of colocation of services could prevent further disease transmission and ensure that newly diagnosed people are treated promptly, thus saving money while improving the quality and quantity of life for affected people.

Adequate and consistent funding for expanded services within syringe services programs and other harm reduction sites is central to success.

Adequate and consistent funding for these expanded services within syringe services programs and other harm reduction sites is central to success. Programs that start and then stop because of funding disruptions are perceived as unreliable and thus will not exhibit the necessary consistency that builds trust for successful service provision. This project used a variety of funding sources, including Ending the HIV Epidemic in the U.S. funding through HRSA, allowing for the creation of seamlessly (from the perspective of the end user) interwoven prevention and treatment services. However, this was not without constraints. The collaborators had to ensure that the pools of money that were tapped supported the services for which the funding was allocated. This created additional administrative and reporting difficulties and constrained the leadership’s ability to be nimble when responding to the needs of PWID in administering the colocated clinics. The Baltimore City Health Department’s long history of forward-facing services, including its Syringe Services Program, proved an important infrastructure for rapidly assembling and administering these colocated clinics.²⁴ Academic partnerships allowed for leveraging funding, content experts, and volunteers to participate in this effort, and they were key to administering this project. However, without sustained funding directed toward supporting the colocation of services to be delivered to this population, relying on relationships alone is unsustainable. Even with a motivated group, only ten clinics were conducted, which is less than one per month during the entire period of this partnership. Future research including costing analyses would be helpful in determining the level of funding needed to sustain these forward-facing prevention and treatment services at syringe services programs for PWID.

Funding from local, state, and federal partners that is focused on providing effective prevention, care, and treatment services for people who use drugs must also provide funding that allows for the expansion of care services provided by syringe services programs and other harm reduction programs. The Comprehensive Addiction Resources Emergency Act, introduced in Congress but not passed, proposed the creation of programmatic infrastructure and support for people diagnosed with a substance use disorder.²⁵ The extent of program support needed by this population is extensive, spanning from social service intervention to case management, medical care, drug treatment, care linkage, and more. Funding for comprehensive and holistic care services can be channeled through care sites such as ours, which already have proved their acceptability and trustworthiness for people who use drugs. Finally, these program interventions are needed to initiate remediation of the disparities experienced by this population. Colocated program interventions cost far less than the $400–$900 billion that health disparities cost the US annually—an expense that is not sustainable.²⁶

The success of providing comprehensive services with a syringe services program highlights the benefits of programs that are inclusive and nonjudgmental.

The success of providing comprehensive services with a syringe services program such as that described in this article highlights the benefits of programs that are inclusive and nonjudgmental, especially when serving underresourced communities such as PWID. To enhance services for PWID, novel approaches that leverage service colocation and the use of trusted partners can be expanded to include other health care interventions. These range from pre-exposure prophylaxis, HIV and hepatitis C treatment, providing wound care and dispensing supplies, diabetes and hypertension screening and treatment, mental health counseling, and medications for opioid use disorder, to name a few. PWID view syringe services programs as a potential “one-stop shop” that could provide other health care services.²⁷ These services could be quickly leveraged during future public health emergencies to deliver testing and other critical medical countermeasures, facilitating better health care access and public health control measures.²⁸ During the COVID-19 pandemic, integrating COVID-19 vaccination into existing syringe services program services not only reduced barriers to vaccine access but also provided an opportunity for dissemination of factually accurate and important information during a time of great misinformation.²⁹

Conclusion

Colocation of preventive and health care services in syringe services programs and harm reduction programs offers a unique and effective way to address the needs of PWID as part of the remediation of decades of neglect. Our evaluation of a colocation initiative in Baltimore, Maryland, during the COVID-19 pandemic provides evidence of success, and it can serve as a model for other jurisdictions as they address the complex problems of this population in a way that is ethical, respectful, and effective.

ACKNOWLEDGMENTS

The authors acknowledge grant support for this work from the Early Intervention Services Grant through the Baltimore City Health Department; the Johns Hopkins University School of Nursing Center for Infectious Disease and Nursing Innovation Community Support Grant; and the Urban Health Institute at Johns Hopkins University. Omeid Heidari is supported by the National Institutes of Health/National Center for Advancing Translational Sciences (Grant No. KL2TR002317). The data and conclusions are those of the authors and do not necessarily represent the official views of or an endorsement by the funders. Heidari, Victoria Cargill, and Jason Farley acknowledge the Baltimore City Health Department; Johns Hopkins mobile vaccine unit; Lisa Parker; the Johns Hopkins nursing student volunteers; and coauthors Kelly Lowensen, Jessica LaRicci, Derrick Hunt, and Adam Bocek. Without them, these clinics would not have been possible. Finally, all authors acknowledge the people who access syringe services program services in Baltimore City, all of whom have enriched their lives and deserve the same dignity and respect from public health and health care systems as everyone else. It is a pleasure to serve you all. Cargill and Farley are co–senior authors. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. To access the authors’ disclosures, click on the Details tab of the article online.

NOTES

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