Response from the Board of Supervisors

The staff does a good job with order and cleanliness considering the age of facility and size constraints. Medical offices appear cramped. Storage areas for inmate property are crowded. Cell areas are very crowded. Response: Agree. Due to the age of the facility some of the areas are at capacity. The County agrees that the staff at the Stanislaus County Men’s Jail are dedicated to their jobs and keep the jail in order and clean despite the age of the facility and space constraints.

There were wet floors, with standing water, in the outside isles of the second and third floors. Response: Agree, in part. Due to the age of the facility, building leaks may occur. The staff is dedicated to keeping the facility clean and free from standing water.

Low-voltage cables from outlets to the portable telephone carts were draped over the floors in a manner to constitute a tripping hazard. In addition, there were severed cables on the floor. Further, these cables appeared to be vulnerable to inmate access for use as weapons. Response: Disagree, in part. Inmates have the right to use the telephone and due to a variety of safety issues, inmates are not removed from their cells in order to use a stationary phone. Therefore, the Sheriff's Department utilizes a Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program portable rolling cart to transport the telephone to the inmate; this practice is consistent within most California jails. However, cables from outlets are not draped in a manner that constitutes a safety hazard.

Some staff duty stations appeared physically cramped- not allowing sufficient space for staff to conduct work tasks. Response: Agree. Due to the age of the facility some of the areas are at capacity.

Additional staffing is needed. Response: Agree, in part. According to the Jail Needs Assessment, June 26, 2007 page G.2 additional facility escort staff and correctional officers for Central Control would enhance the current operations of the Men’s Jail.

There are critical staffing shortages that put the safety of staff as well as inmates and wards in jeopardy. The Jail Needs Assessment, June 2007, details staffing

Staffing shortages impede professional development programs, which, in turn, negatively affect staff promotion and retention. Response: Disagree. County employees are able to participate in a variety of professional development programs. The County encourages employees to promote to positions within his/her determined career path.

All four facilities appeared reasonably clean and trash-free. Response: Agree. General good housekeeping will continue.

According to the HIV Prevention Bulletin issued by the US Department of Health and Human Services, Centers for Disease Control, Health Resources and Services Administration (HRSA), National Institute on Drug Abuse, (NIDA), Substance Abuse and Mental Health Services Administration (SAMHSA), and the Morbidity and Mortality Weekly Report of the Center for Disease Control, November 9, 2007, persons who inject drugs should use sterile syringes to prevent the transmission of HIV. Response: Agree.

Syringes and equipment are shared for many reasons, but primarily because legal barriers have limited the access to sterile syringes. Removing legal sanctions against syringe possession would encourage proper disposal of dirty syringes through a legal syringe exchange program. Response: Agree. Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program

In a syringe exchange program, a used syringe is required in exchange for a new syringe, thereby enabling the proper disposal of dirty syringes and not increasing the number of syringes circulating in the county. Response: Agree.

Harm reduction strategies, such as allowing legal syringe exchange programs, reduce the spread of Hepatitis C and other blood-borne pathogens to law enforcement officials, health care providers, family members, newborn infants, and uninfected injection drug users. Response: Agree.

Outreach projects associated with syringe exchange programs provide introductions to early medical treatment for other problems affecting injection drug users. Services offered include risk reduction behavior counseling, housing programs, recovery programs, job placement, and referrals to related services. Response: Agree.

Safe community disposal of used syringes is a significant public health issue. A legal syringe exchange program would reduce the spread of Hepatitis C and HIV/AIDS among people, their sexual partners, their children, law enforcement officials, health care providers, sanitation workers and others exposed to discarded syringes in Stanislaus County. Response: Agree. Cost factors and related budget savings

HIV/AIDS patients are among the most expensive patients in the public health system. The direct lifetime medical cost for an HIV/AIDS patient from the time of diagnosis until death is estimated to be between $144,000 and $600,000. Response: Agree. One reported study from Boston and Baltimore documented the average cost at $618,000. Drs. Schackman & Freedberg at the Partners AIDS Research Center/Massachusetts General Hospital collaborated on the study with Drs. Gebo and Moore from the Johns Hopkins University School of Medicine. Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program

The direct lifetime medical cost of a Hepatitis C patient is estimated to be $100,000. If a liver transplant is needed the additional cost would be at least $300,000. Response: Agree. The Stanislaus County Health Services Agency established a Hepatitis C clinic in 2006. Since that time, 119 Stanislaus County residents have been served. 41% of the patients were covered by the Indigent Health Care Program, 46% had Medi-Cal coverage, and 13% were covered by other payers.

The estimated costs of treatment of Hepatitis C and HIV do not include the social implications of lost wages, disability benefits, unemployment or the fiscal impact of lost tax revenue and Social Security contributions. Response: Unable to respond. County Public Health staff is unable to verify all the sources of this finding.

A clean syringe costs pennies compared to the lifetime medical and social costs of caring for chronically ill patients. Response: Disagree, in part. It is correct that the cost benefit is significant for clean syringes; however, there is the controversial issue of providing equipment for the illegal use of drugs. Most, but not all, patients will become chronically ill. “In a New York study, seven SEP’s exchanged 1,667,682 syringes in a year, with an annual cost of $1,822,426. The study determines that over the course of the year, the SEP’s prevented 87 infections, saving $7.6 million in HIV treatment costs.” This quote was taken from F.N. Laufer’s article titled Cost-Effectiveness of Syringe Exchange as an HIV Prevention Strategy (2001). Journal of Acquired Immune Deficiency Syndromes. 15 (3-4), 88-94.

The 2007 budget for the Fresno syringe exchange program, a private enterprise, was $47,000. None of its budget was subsidized by Fresno County. It was funded by grants and donations. Response: Agree, in part. However, the syringe exchange program in Fresno has not received approval from the Fresno County Board of Supervisors nor has AB547 been enacted there. Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program The budget for Fresno’s needle exchange program for Fiscal Year 2007-2008 was $35,000. The majority of the budget was provided by a grant for $30,000 from the Comer Foundation. The Comer foundation has funded the program for the last 14 years. The remainder of the program is funded through donations from clients and fundraisers. The Fresno syringe exchange is operated by all volunteer staff. The Tides Foundation also provided a $5,000 technical assistance grant, which helps to support travel and fund development skills. The program also receives donations of supplies from other thriving larger Syringe exchange programs. Both the San Francisco and Illinois syringe exchange programs have donated supplies in support of the Fresno program.

A study titled Science-based literature on Syringe Exchange Programs (SEPs) 1996-2007, dated October 2007, by Joanna Berton Martinez, reveals the following information: SEPs reduce HIV transmission SEPs do increase enrollment in drug treatment programs SEPs do reduce risky behaviors and injection drug use SEPs do not promote substance abuse. Response: Disagree, in part. The document cited is from the Harm Reduction Coalition and includes the information listed above. However, it is unclear whether the author included a comprehensive world literature to definitively document the conclusions. Including a more comprehensive review may have modified the conclusions contained in the study.

Syringe exchange programs do not encourage the use of injection drugs and do not increase criminal activity. Response: Disagree, in part. This is controversial, and there are a limited number of studies to support this conclusion. ‘Enabling Legislation

Assembly Bill 547, Berg, was signed by Governor Schwarzenegger and went into effect January 1, 2006. The bill amends previous legislation (AB 136, Mazzoni) to allow counties and cities to authorize syringe exchange programs in their jurisdictions without the necessity to declare a state of local emergency. The purpose of AB 547 is to simplify the procedure for syringe exchange program authorization in order to encourage the integration of syringe exchanges into Hepatitis C and HIV prevention efforts throughout the State of California. Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program Response: Agree. There have been several pieces of legislation regarding syringe exchange programs (SEPs) in California: AB136 (Mazzoni). Became effective January 1, 2000. This law focused on HIV prevention and would allow SEPs if the local Public Health Officer declared a local public health emergency. If approved, the emergency declaration would require Board of Supervisor approval every two weeks. Since 2000, Stanislaus County has not invoked the provisions of AB 136. $B1159 (Vasconsellos). Became effective January 1, 2005. This legislation established a five-year demonstration project to assess the effectiveness of SEPs. It would allow sale of syringes without a prescription by participating pharmacies. During 2006 the Public Health Officer reviewed the legislation and took an OPPOSED position. He surveyed key stakeholders regarding this legislation, including the Law Enforcement Executives, the BOS Health Executive Committee, and Advisory Board on Substance Abuse Prevention (ABSAP). All three agreed with the opposed position; however, the vote on APSAP was close. AB547 (Berg-Richman). Became effective January 1, 2005. The law would allow syringe exchange programs (SEPs). Seventeen County Boards of Supervisors and four City Councils have approved the law in their jurisdictions. There are now more than 40 SEPs operating in California. Most of the SEPs are along the coast. There are several in the Sacramento Valley. There are currently no approved SEPs in the San Joaquin Valley. AB136 (Berg). Became effective January 1, 2007. The law would allow local HIV/AIDS funds to be used for the purchase of syringes for a SEP. This has not been done in Stanislaus County.

Five years ago, AB 136 was signed into law, creating Health and Safety Code Section 11364.7(a). The law reads, in part: “No public entity, its agents, or employees shall be subject to criminal prosecution for distribution of hypodermic needles or syringes to participants in clean needle and syringe exchange projects authorized by the public entity pursuant to a declaration of a local emergency due to the existence of a critical local public health crisis.” Health and Safety Code Section 11364.7(a) protected local government organizations, their employees, and authorized subcontractors in local health jurisdictions that declared a local health emergency from criminal prosecution for distribution of syringes. Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program The requirement to declare a local emergency has been rescinded by AB 547. Response: Agree. The following a list of authorized Syringe Exchange Programs in California: Alameda, City of Berkeley City of Los Angeles City of Sacramento City of San Diego Contra Costa Humboldt Los Angeles Marin Mendocino Monterey San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sonoma Ventura Yolo California SEPs operate with modest budgets and provide a wide range of services, including HIV testing and risk reduction counseling, provision of sterile injection equipment, and referrals to drug treatment, housing, and mental health services. Support for Syringe Exchange Program

The Stanislaus County Civil Grand Jury finds that there is considerable support for syringe exchange and for AB 547. National organizations in support of syringe exchange programs include the following: American Bar Association American Medical Association American Academy of Pediatrics American Nurses Association American Public Health Association American Pharmaceutical Association Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program American Psychological Association American Red Cross Council of State and Territorial Epidemiologists National Black Caucus of State Legislators National Black Police Officers Association National Alliance of State and Territorial AIDS Directors National Association of State Alcohol and Drug Abuse Directors U.S. Conference of Mayors U.S. Government Accounting Office Health & Human Services National Institute on Drug Abuse Response: Agree.

California supporters of AB 547 and syringe exchange programs include: Health Officers Association of California California Chapter, National Association of Social Workers California Narcotic Officers’ Association California Medical Association California Peace Officer's Association California State Association of Counties County Alcohol and Drug Program Administrators Association of California County Health Executives Association of California Response: Disagree, in part. Two organizations listed as supporting the bill actually opposed it. Both the California Narcotic Officers’ Association, and California Peace Officers Association opposed AB 547. On August 7, 2008 the Stanislaus County Public Health Officer consulted the Stanislaus County Law Enforcement Executives (LEX). The group opposed a SEP in Stanislaus County.

Stanislaus County supporters of AB 547 and a syringe exchange program include: Advisory Board of Substance Abuse Programs of Stanislaus County Hepatitis C Coalition of Stanislaus County Local Implementation Group of Stanislaus County Response: Agree. Comments: Approval of Response to the 2007-2008 Stanislaus County Civil Grand Jury Final Reports Regarding: 1) Correctional Facilities Inspections, and 2) Containing the Emerging Threat of Hepatitis C through a Syringe Exchange Program The Advisory Board for Substance Abuse Prevention (ABSAP) voted in favor of a SEP in Stanislaus County at its July, 2007 meeting. The Hepatitis C Taskforce did include SEP in its strategic plan of December 2006. Syringe exchange programs were included as a primary prevention strategy in the state strategic plan published in 2001. The Local Implementation Group (LIG) is an Advisory Group to the HIV/AIDS Program within Public Health. It is composed of Public Health staff and community members.