The USF Health Tampa Bay Street Medicine, Hillsborough County and Pioneer Foundation Needle Exchange Program is ready to hit the road as Florida’s second needle exchange or syringe service program (SSP). In conjunction with Tampa General Hospital, the Health, Equality and Linkage Project (HELP) Medical Van will offer to persons who inject drugs (PWID), a safe place to turn in used syringes for clean ones to avoid sharing blood-borne diseases like HIV and Hepatitis C, get anonymously tested for those diseases and be linked to free primary care, wound care, or drug treatment programs among other social services. Targeted locations in Hillsborough County will be those with the highest rates of HIV and opioid overdoses such as around the University Square Mall and downtown Tampa.

Representatives for the USF Health Tampa Bay Street Medicine, Hillsborough County and Pioneer Foundation Needle Exchange Program during a mock run through outside the University Square Mall.

Formed in 2014, Tampa Bay Street Medicine (TBSM) is a USF Health Morsani College of Medicine (MCOM) student-run service organization supervised by faculty that provides medical care to underserved populations. It was initially started to meet the needs of Tampa’s homeless community but continues to evolve as student leaders recognize opportunities to help elsewhere. TBSM students conduct biweekly street runs in unsheltered settings near the I-275 bypass, operate continuity clinics at First Presbyterian Church, and staff a medical van at a variety of clinic sites in partnership with Pioneer Medical Foundation.

USF Health Tampa Bay Street Medicine students talk with a homeless man during a night of biweekly street runs in unsheltered settings near the I-275 bypass. Pre-COVID photo.

“We’re going to the same locations where we’ve built that relationship, where they know that we have providers for primary care and they can trust us already,” said Asa Oxner, MD, FACP, faculty advisor for the USF Health TBSM and vice chair of the USF Health MCOM Department of Internal Medicine. “We have around 800 reoccurring customers in these locations, so we can first start by serving the people we already know well and work on marketing and growth.”

At a PWID’s first visit to the program, they can receive up to 10 clean hypodermic needles and every visit after that, it’s a 1:1 exchange. SSP volunteers will also distribute condoms, alcohol swabs, portable sharps containers and Naloxone (or Narcan), an emergency treatment for narcotic overdose. Pioneer also staffs the Lily Pharmacy free medical clinic inside the University Square Mall, adding another layer of resources along with the other community agencies partnering to offer downstream care for clients who engage in the SSP’s services. Enrollees in the program are tracked with a nickname and an ID number associated with a laminated card they’re asked to carry that identifies them as part of the SSP. If the card holder is arrested for drug paraphernalia, USF providers are working with the local police authorities to have our clients placed in drug rehabilitation instead of jail. At the same time, when PWID carry clean needles and a portable sharps container, it protects the law enforcement and first responders in return.

From inside of the medical van, Jerren Creak, MPH, patient care services research associate for Tampa General Hospital, explains the disease testing options to a mock patient, a member of the community in remission from a substance use disorder, during a mock run through of the needle exchange program.

“In communities where drug users are invited to swap out used needles without retribution, hospitals have reported major declines in the spread of blood-borne infections like hepatitis C and HIV, increased enrollment in drug treatment programs and fewer opioid-related overdose deaths,” said Khary Rigg, PhD, associate professor at the University of South Florida’s Department of Mental Health Law & Policy, in a report from the Tampa Bay Times. “As for the cost, research has shown that every $1 spent on needle exchange programs yields an average $7 savings in avoided costs for HIV-related medical treatment.”

According to the Centers for Disease Control and Prevention, more than 140 Americans die from drug overdoses every day. The U.S. Opioid Epidemic was declared a public health emergency by the United States Department of Health and Human Services (HHS) in 2017. SSPs are a key part of harm reduction strategy, meeting people who use drugs “where they’re at,” and addressing conditions of use along with the use itself. SSPs have been legal in many other states for decades, but it was not legal in Florida until recently. Thanks to the relentless fight for legislative approval and the resulting success of the University of Miami’s IDEA Exchange, a pilot program that was approved in a 2016 exception policy, Governor Ron DeSantis signed into law the Infectious Disease Elimination Act (IDEA) on June 27, 2019.  IDEA allows county commissions to authorize sterile needle and syringe exchange programs for PWID. The law states that disease prevention must be the goal of every exchange program, they cannot use state, county or municipal funds to operate, and they are required to be funded through grants and donations from private resources and funds.

A grant already pays for prescription medications for patients of existing programs operating through partnerships with the University of South Florida, Tampa General Hospital, the Drug Abuse Comprehensive Coordinating Office and Gracepoint, and the SPP will be allowed to use that money to buy the county’s first batch of hypodermic needles and syringes.

With this green light, TBSM and USF faculty began advocating for an SSP in Hillsborough County with the Hillsborough County Commissioner’s Office Opioid Task Force Behavioral Health subcommittee. They used the robust data from Miami’s IDEA Exchange and their program was approved. The needle exchange was supposed to kick off in April but was delayed due to COVID-19.

During a mock run through of the SSP, Heather Henderson, MA, CAS (second from left), USF Applied Medical Anthropology PhD Candidate and director of social medicine programs for Tampa General Hospital, hands a prop to mock patients, members of the community in remission from a substance use disorder, to represent the needle exchange.

In preparation for the official start of the program in December, the USF Health and Pioneer team met in the University Square Mall parking lot with two members of the community in remission from a substance use disorder serving on the SSP advisory board, to do a mock run through and receive their feedback. “This was really great,” said one of the mock patients. “You guys came across that you care and you’re nonjudgmental.”

TBSM will be joined at the needle exchange by USF Health College of Public Health and USF Applied Medical Anthropology students to create a true interprofessional effort to make life better for people in the community. “Preventing acquisition of HIV/HCV requires a complex understanding of the interconnection between biomedical and social dimensions of infectious disease,” said Bernice McCoy, MPH, USF PhD Candidate in Applied Anthropology. “These students will apply both epidemiological and ethnographic methods to contextually assess our SSP’s potential impact and further explore the drug-using habits of PWID. Through this assessment that we can and identify facilitators and barriers towards HIV/HCV risk-reduction within the Tampa Bay community.”

The Opioid Crisis in Florida          

According to the National Institute on Drug Abuse, nearly 68% of the 4,698 reported drug overdose deaths in Florida involved opioids in 2018—a total of 3,189 fatalities (Figure 1).

Figure 1. Number of drug and opioid-involved overdose deaths in Florida. Deaths may have involved more than one substance. Source: CDC WONDER

The increase in substance use has resulted in consequent increases in injection drug use across the country. This has caused not only large increases in overdose deaths, but also the transmission of blood-borne diseases. According to the CDC, the majority of new acute hepatitis C virus (HCV) infections are due to injection drug use and Florida is in the top 10 states with the highest rates of infection. According to the Florida Department of Health HIV/AIDS Surveillance Program, about 7% of the new diagnoses of HIV in Florida in 2018 were from injection drug use (IDU) (Figure 2) and 11% of persons living with an HIV diagnosis were persons who inject drugs (PWID) (Figure 3).

Figure 2. HIV modes of exposure in 2018. Source: National HIV Behavioral Surveillance System (NHBS).

Figure 3. The number of persons who inject drugs (PWID) living with an HIV diagnosis in Florida in 2018. Source: NHBS.

According to the CDC, the HIV burden in Florida is the highest in Broward, Duval, Hillsborough (Figure 4), Miami-Dade, Orange, Palm Beach, and Pinellas. It was announced in the February 2019 State of the Union Address that these counties are a part of 57 jurisdictions that are the focus of the Trump administration’s, “Ending the HIV Epidemic: A Plan for America” or EHE initiative, which aims to end the HIV epidemic in the United States by 2030.

Figure 4. Hillsborough County is one of Florida’s HIV hotspots. Source: NHBS.

The IDEA Exchange

On July 1, 2016, after years of struggling to win legislative approval, Miami-Dade became the first county in Florida with a legal hypodermic needle exchange program and on December 1, 2016, World AIDS Day, the IDEA Exchange opened its doors as a pilot program. The IDEA Exchange in Miami was started by Hansel Tookes, MD, MPH, an assistant professor at the University of Miami’s Miller School of Medicine and principle director of its harm reduction research group. NBC Miami reported in June 2019 that the Miami program has disposed of more than 317,000 used needles since it received temporary authorization from lawmakers in 2016. The program also distributes naloxone and Tookes told the Miami Herald in November 2019 that since March 2017, “the IDEA Exchange has handed out 2,871 boxes of the drug and those who have taken naloxone from the clinic to carry with them have reported 1,529 overdose reversals in that time.” Miami is the only place in Florida seeing a decrease in opioid-related mortality while death tolls spike across the state.

Video by Torie Doll, USF Health Communications & Marketing, with interview footage assistance provided by Ian Vancattenburch, Movie Magic Productions.

USF graduate students and community professionals will gain stronger research skills for addressing drug abuse and other behavioral health problems in children and adolescents with the help of a $1.72 million grant from the National Institute on Drug Abuse.

The 5-year grant supports a project called the Institute for Translational Research Education in Adolescent Drug Abuse and focuses on translational research methods, policies and perspectives, and the practical skills of participatory research, said Julie Baldwin, PhD, principal investigator, and professor in the Department of Community and Family Health in the USF College of Public Health. Co-investigators are Bruce Lubotsky Levin, DrPH, associate professor and curriculum director, Tom Massey, PhD, associate professor and evaluation director, and Donna Burton, Ed.M., research assistant professor and project director, all of whom are faculty in the USF College of Behavioral and Community Sciences. Drs. Levin and Massey are also joint faculty in the Department of Community and Family Health, and Ms. Burton is a doctoral candidate in the department.

From left, Dr. Tom Massey, Dr. Julie Baldwin, Dr. Bruce Lubotsky Levin, and Donna Burton.

This grant will use a unique cross-disciplinary approach between public health and behavioral health and relies on a model of graduate education that includes graduate web-based and face-to-face training, service learning in the community, and a community based capstone project.  Trainees will earn graduate college credit (15 hours) fully paid by the grant, culminating with the awarding of a graduate certificate.  Further, this NIDA grant and the graduate certificate program serves as an additional research component of the Graduate Studies in Behavioral Health Program, a collaborative teaching and research initiative between the USF College of Public Health and the USF College of Behavioral and Community Sciences.

Central to the project is its community-based team mentoring approach, which includes community, service-based mentors, academic mentors, and national mentors, Dr. Baldwin said.

“This group of mentors will guide trainees in the latest science of alcohol, tobacco, other drug (ATOD) prevention, intervention and sustainability with an added emphasis on translational issues of evidence based practices (EBPs),” Dr. Massey said. 

Training sites will include agencies in the community for whom child and adolescent behavioral health is of interest.  Training will include an annual conference bringing together experts in the etiology and epidemiology of adolescent behavioral health (including ATOD and other emotional and behavioral disorders of childhood), and experts in translational science and implementation of EBPs. 

“For all program participants, the core curricula will include a Capstone Project, conceptualized during the first semester of the graduate certificate program, based upon course presentations of problems, issues, and trends in epidemiology of child and adolescent drug use and mental disorders, and guided by each mentoring team,” Dr. Levin said.

“Program participants will have four full semesters to conceptualize, plan, and complete their Capstone Projects, resulting in graduate level research initiatives that represent meaningful and cutting-edge applied research and academic development in the content areas selected,” Ms. Burton said. “When complete, students will present their Capstone Projects at the annual conference.”

Examples of applicable projects might include: evaluation of existing implementation projects within community programs; development of a grant proposal that addresses implementation of an evidence-based practice in a clinical setting; or the design of a research project that would enhance community-based clinical programming.

The ultimate goal of this grant is to develop, cultivate, and disseminate an innovative model of research education that addresses best practices for translational research in the field of child and adolescent drug use and co-occurring disorders.

“By fostering collaboration, team-building, and cross-disciplinary approaches, researchers’ knowledge of EBPs and skills in delivering EBPs in community settings are enhanced, which ensures that interventions are more effective and accessible,” Dr. Baldwin said. “Furthermore, we will strive to create greater awareness among researchers and educators regarding the impact of practice on the evidence base.”

Story by Sarah A. Worth, photos by Eric Younghans, USF Health Office of Communications