Why do we need needle exchange?
More than a million people in the United States inject drugs, at a cost to society (in health care, lost productivity, accidents, and crime) of more than $50 billion a year.(1) People who inject drugs imperil their health. If they contract HIV, their needle sharing partners, sexual partners and offspring may also be endangered.
One-third of all AIDS cases are linked to injection drug use. For women, 64% o f all AIDS cases are due to injection drug use or sex with partners who inject drugs. Inject-ion drug use is the source of infection for more than half of all children born with HIV.(2)
Around the world and in more than sixty locations in the United States, needle exchange programs have sprung up to address drug injection risks. These programs not only distribute clean needles and safely dispose of used ones for injection drug users (IDUs), they generally offer a variety of related services, including referrals to drug treatment and HIV counseling and testing.(3)
Why do drug users share needles?
In part because there are not enough needles and syringes to go around. The overwhelming majority of IDUs are aware of the risk of the transmission of HIV and other diseases if they share contaminated equipment. However, sterile needles are not always available or affordable.
Most US states have paraphernalia laws that make it a crime to possess or distribute drug paraphernalia not for a "legitimate medical purpose," which subjects drug injectors to prosecution. In addition, ten states and the District of Columbia have laws that require a prescription to buy a needle and syringe. Even where over-the-counter sales of syringes are permitted by law, pharmacists are often unwilling to sell to IDUs.(4)
In July of 1992, the state of Connecticut passed a law permitting the purchase and possession of up to ten syringes without a prescription. After the new law went into effect, the sharing of needles among IDUs decreased, and there was a shift from street needle and syringe purchasing to pharmacy purchasing.(5)
How can injection risks be reduced?
Getting drug injectors into treatment and off drugs is the best answer. Unfortunately, not all drug injectors are ready to quit. Even those who are highly motivated may find few services available. Drug treatment centers frequently have long waiting lists and fewer than 15% of IDUs are in treatment at any given time.(6)
For those who cannot or will not stop injecting drugs, the best way to avoid spreading HIV is to use a sterile needle for each injection, or at least not to share needles. Users who share should disinfect their injection equipment thoroughly with bleach, although this is not as safe as always using a sterile needle and syringe.(7)
Does needle exchange encourage drug use?
There is no evidence that needle exchange programs increase the amount of drug use by needle exchange clients or in the wider community.(3) A study of a San Francisco needle exchange program that opened in 1988 found that from 1987 to 1992, frequency of injecting drugs among street-recruited IDUs declined from 1.9 to 0.7 injections per day. The mean age of IDUs increased from 36 to 42 years, and the percentage of new initiates into injection drug use dropped from 3% to 1%.(8) Drug abuse and the recruitment of new or younger users did not increase in the presence of the exchange; in fact, the exchange may have helped decrease the amount of drug abuse in the area.
Does needle exchange reduce the spread of HIV?
Yes, almost certainly. Needle exchange programs are based on a sound public health principle Ñeliminating the item that helps transmit infection from one person to another, just as reducing the number of mosquitoes helps prevent malaria.
In New Haven, CT, a study tested needles returned to the needle exchange, and developed a mathematical model that estimated a possible 33% reduction in the rate of new HIV infections among needle exchange program clients.(9) A review of the modeling literature by a CDC-sponsored research team suggested this estimate may even be low.(3)
In New York City, NY, a large comprehensive study of needle exchange programs found that the rate of new HIV infections for participants in the exchange was 2%. This rate is much lower than the estimated 4-7% HIV infection rate among IDUs not enrolled in the exchange.(10) The study also found that among clients, using rented syringes decreased 75%, using borrowed syringes decreased 62%, and using alcohol wipes before injecting went up 150%.
Needle exchange programs have also achieved reductions in the rate of hepatitis B infection, which can also be spread through sharing needles. In Tacoma, WA, clients of a needle exchange program were up to eight times less likely to contract hepatitis B and C than non-client IDUs.(11)
Needle exchange programs also have the potential to act as a bridge to drug treatment, and can provide referrals and, in some cases, actual services for HIV testing and counseling, primary medical care, tuberculosis and sexually transmitted disease screening. In Seattle, WA, the needle exchange program issued 181 vouchers for drug treatment, and 78% were successfully redeemed. Fifty-eight percent entered methadone maintenance, and 86% of those were still in treatment three months after intake.(12)
Is needle exchange cost-effective?
Yes. The median annual budget for running a program is $169,000, with a range of $31,000-$393,000. This translates to $.71 to $1.63 per syringe distributed.(3) In addition, mathematical models predict that over five years, needle exchanges could prevent many HIV infections among clients, their sex partners, and offspring, at a cost of about $9,400 per infection averted.(3) This is far below the $119,000 lifetime cost of treating an HIV-infected person.
What must be done?
Efforts to increase the availability of sterile needles must be a part of a broader strategy of drug treatment and prevention efforts. The currently available data provide sufficient evidence to repeal the ban on the use of federal funds for needle exchange services. States with prescription laws should repeal them; those with paraphernalia laws should revise them insofar as they restrict access to needles and syringes. Local governments and public health officials should work with community groups to develop comprehensive approaches to HIV prevention among IDUs and their sexual partners, including, but certainly not limited to, needle exchange programs.
Needle exchange programs have become a standard of public health practice around the world. Failure to support ready access to sterile needles has been described as tantamount to medical malpractice.(13)
References:
This fact sheet is drawn from two recent reports, single copies of which are
available free from the following sources:
"Dimensions of HIV Prevention: Needle Exchange" from the Kaiser Family
Foundation Publication Request Line at 800/656-4533.
Prepared by Peter Lurie and Pamela DeCarlo
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
"The Public Health Impact of Needle Exchange Programs in the United States
and Abroad" from the CDC National AIDS Clearinghouse, 800/458-5231.
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