Needle Exchange Programs
The United States has one of the lowest rates of needle exchange availability in the developed world. The use of federal funds for needle exchange programs has been banned since 1988, with a brief period of reversal between 2009 and 2011. Although federal funding is not available, 16 states and the District of Columbia have provisions explicitly authorizing needle exchange programs.1 These exchanges generally have been located in inner cities, which historically have contained the highest concentration of injection drug users.
In addition to the 16 states with laws explicitly authorizing needle exchange programs, there are a number of states with laws that either decrease barriers to the distribution of clean needles or altogether remove syringes from the list of drug paraphernalia.2 In some of these jurisdictions, local governments or nonprofits operate independent exchange programs. According to amfAR, the Foundation for AIDS Research, more than 203 exchange programs operate in 34 states.3
A recent HIV outbreak in the small town of Austin, Ind., has led some rural states to consider creating or expanding existing needle exchange programs. The outbreak has spread at an alarming rate due to the prevalence of needle sharing among abusers of oxymorphone, a prescription painkiller several times more potent than morphine. As of May 29, 2015, 163 people had been confirmed HIV-positive in the town of 4,300.4
The scale of this outbreak and continued attention to drug abuse in Appalachian counties led to the implementation of legislation in Indiana and Kentucky enabling local governments to implement needle exchange programs.
The Indiana statute makes the declaration of a public health emergency a prerequisitefor the creation of needle exchange programs,5 but the Kentucky law contains no such provision. Connecticut Gov. Dannel P. Malloy has called for a repeal of the ban on federal funding for needle exchange programs, citing “the recent outbreak of HIV and hepatitis in the Midwest.”6
Needle exchange programs allow addicts to confidentially exchange dirty needles and syringes for clean needles, allowing the contaminated materials to be sent away for proper disposal. These programs have been shown to reduce the incidence of HIV and hepatitis C among addicts due to needle sharing and also prevent accidental needle piercings from inappropriately discarded syringes. Current academic literature suggests “there is evidence to support the effectiveness of [needle exchange programs] in reducing the transmission of HIV among [people who inject drugs], although it is likely that other harm reduction interventions have contributed to the observed reduction in HIV risk.”7
Critics of needle exchange programs often claim that needle exchange programs facilitate addiction and, by association, the spread of communicable diseases. However, according to the World Health Organization, “there is no convincing evidence of major unintended consequences of programs providing sterile injecting equipment to injecting drug users, such as initiation of injecting among people who have not injected previously, or an increase in the duration or frequency of illicit drug use or drug injection.”8
Don Des Jarlais of the Baron Edmond de Rothschild Chemical Dependency Institute at Beth Israel Medical Center in New York describes needle exchange programs as “one of the most effective interventions of reducing HIV transmission that we have.”9
As recommended by the World Health Organization’s HIV/AIDS Program, needle exchange programs are most effective when bundled with other services targeted at injection drug users, including HIV testing and counseling, prevention and treatment of sexually trans- mitted infections, prevention and vaccination programs for hepatitis B and hepatitis C, antiretroviral therapy for HIV-positive patients, and other interventions designed to mitigate the risks associated with injection drug use. These programs often include incentives designed to ensure interventions requiring multiple treatments are completed.10
Most of the larger and better-documented needle exchange programs have been located outside the United States because the lack of federal funding has slowed adoption. In particular, the needle exchange program located in the city of Vancouver, Canada, was a key component of the response to a major HIV outbreak among that city’s injection drug users in the late 1990s.
Created in 1988 and run by the Downtown Eastside Youth Activities Society, Vancouver’s needle exchange program was distributing more than 1 million needles a year by 1993.11 Despite the relatively large scale of the program, it was unable to keep up with the additional demand caused by the shift from heroin to cocaine, which is injected more frequently. During this period, demand for syringes skyrocketed, with the program exchanging more than 3.5 million syringes in 2000.
Despite the increase, the number of syringes provided fell well short of the 5-10 million experts estimated were needed. The literature suggests that under-provisioning due to an unforeseen increase in demand for syringes contributed to the Vancouver program’s inability to effectively combat the HIV/AIDS epidemic.12
Rhode Island’s ENCORE is a textbook example of a similar program in the United States. ENCORE (Education, Needle Exchange, Counseling, Outreach and Referral), headquartered in Providence, runs the only needle exchange in the state. It provides services in five cities, operating a combination of fixed sites and mobile/street based exchange units.
ENCORE provides harm reduction tools, including “new syringes, alcohol swabs, antibiotic ointment, ascorbic acid, Band-Aids, bio-hazard sharps containers, cookers, cotton, rubber tip covers, sterile water, and tourniquets”13 in order to reduce harm and inhibit the spread of HIV and hepatitis C by contaminated paraphernalia. The program also provides disease testing and treatment, hygiene packs and counseling services. Although a variety of services were offered over a relatively wide area, “in 2008–2009, only 28 percent of a small sample of [people who inject drugs] seeking detoxification services in Rhode Island reported having accessed a needle exchange program in the last six months.”14
The literature suggests that in order to be effective needle exchange programs must have sufficient capacity to meet the needs of the community in which they are implemented and they must be easily accessed by their target populations. The World Health Organization claims that programs are most effective as part of a larger system of interventions designed to mitigate the risks associated with injection drug use.15
Some of the recommended services are available in certain states as part of other programs but, as in Rhode Island, there is often a low rate of contact with the target population. The ban on federal funding is a barrier to implementation in the United States. Experience has shown that, though some individual states have moved to implement these programs, their capacity for outreach is con- strained by inadequate funding.
1LawAtlas Policy Surveillance Portal (2015, April). Syringe Distribution Laws. Retrieved June 23, 2015, from http://lawatlas.org/files/upload/20150421_SyringeD_Report.pdf
4Daudelin, D. (2015, May 29). HIV Spread Slows in Southeastern Indiana, 163 Cases Reported. Retrieved June 17, 2015, from http://indianapublicmedia.org/news/state-reports-163-hiv-cases-southeast...
5Senate Enrolled Act No. 461 (2015). Retrieved June 23, 2015, from http://iga.in.gov/static-documents/d/1/a/6/d1a62251/SB0461.04.ENRS.pdf
6Hulse, C. (2015, May 19). Connecticut’s Governor, Dannel Malloy, Calls on Congress to Lift Needle-Exchange Ban. Retrieved June 17, 2015, from http://www.nytimes.com/politics/first-draft/2015/05/19/ connecticuts-governor-dannel-malloy-calls-on-congress-to-lift-needle-exchange-ban/
7Aspinall, E. et al. (2014). Are Needle and Syringe Programmes Associated with a Reduction in HIV Transmission Among People Who Inject Drugs: A Systematic Review and Meta-Analysis. International Journal of Epidemiology, 43(1), 235-248. Page 235. doi:10.1093/ije/dyt243
8Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users. (2004, July 13). Page 2.Retrieved June 17, 2015, from http://whqlibdoc.who.int/hq/2004/WHO_HIV_2004.03.pdf?ua=1
9Brownstein, J. (2014, April 18). Opposition to clean needles for addicts: Symbolism over science? Retrieved June 17, 2015, from http://america.aljazeera.com/articles/2014/4/18/needle-exchange-programs...
10WHO, UNAIDS Technical Guide for Countries to set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. (2013). Retrieved June 17, 2015, from http://www.who.int/hiv/pub/idu/targets_universal_access/en/
11Hyshka, E. et al. (2012). Needle exchange and the HIV epidemic in Vancouver: Lessons learned from 15 years of research. International Journal of Drug Policy, 23(4), 261-270. Page 264. doi:10.1016/j.drugpo.2012.03.006
12Ibid, p. 265.
13Joseph, R. et al. (2014). Hepatitis C Prevention and Needle Exchange Programs in Rhode Island: ENCORE. Rhode Island Medical Journal, 97(7), 31-34. Page 32. Retrieved June 17, 2015, from http://www.rimed.org/rimedicaljournal-2014-07.asp
14Ibid, p. 34.
15WHO, UNAIDS Technical Guide for Countries to set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. (2013). Page 10. Retrieved June 17, 2015, from http://www.who.int/hiv/pub/idu/ targets_universal_access/en/
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