Needle-exchange programme

Contents of a needle-exchange kit

A needle & syringe programme (NSP) or syringe-exchange programme (SEP) is a social policy based on the philosophy of harm reduction where injecting drug users (IDUs) can obtain hypodermic needles and associated injection equipment at little or no cost. Many programmes are called "exchanges" because some require exchanging used needles for an equal number of new needles. Other programmes do not have this requirement.^[1] The aim of these services is to reduce the damage associated with using unsterile or contaminated injecting equipment.

A comprensive study by the World Health Organization (WHO) in 2004 stated that there is a "compelling case that NSPs substantially and cost effectively reduce the spread of HIV among IDUs and do so without evidence of exacerbating injecting drug use at either the individual or societal level."^[2] The WHO's findings have also been supported by the American Medical Association (AMA), which in 2000 adopted a position strongly supporting NSPs when combined with addiction counseling.^[3][4] A 2010 review of reviews led by Norah Palmateer which examined systematic reviews and meta-analyses on the topic concluded that there is insufficient evidence that NSP prevents transmission of the Hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour.^[5]

History and development

"Sharps" container (for safe disposal of hypodermic needles)

Needle-exchange programmes can be traced back to informal activities undertaken during the 1970s, however the idea is likely to have been discovered a number of times in different locations. The first government-approved initiative was undertaken in the early to mid 1980s, with other initiatives following closely. While the initial Dutch programme was motivated by concerns regarding an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programmes around the world.^[6] This reflects the pragmatic response to the pandemic undertaken by some governments, and encapsulated in the harm reduction / minimization philosophy.

Operation

In addition to sterile needles, syringe-exchange programmes typically offer other services such as: HIV and Hepatitis C testing; alcohol swabs; bleach water and normal saline (often as rinse eye drops); aluminium "cookers"; citric acid powder (an imperative agent: enables heroin to dissolve in water); containers for needles and many other items.^[7] There was a survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, which showed among the 126 SEPs surveyed, 77% provided to material abuse therapy, 72% provided voluntary counselling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads, and male and female condoms.

According to the Centers for Disease Control (CDC), in the United States around 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use.^[8]

Needle-exchange programmes are supported by the CDC and the National Institute of Health.^[8][9] The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.^[9]

Proponents of harm reduction argue that the provision of a needle exchange therefore provides a social benefit in reducing health costs and also provides a means to dispose of used needles in a safe manner. For example, in the United Kingdom, as the keystone prevention method, proponents of SEPs assert that, along with other programs, they have reduced the spread of HIV among intravenous drug users. The most extensive review of research into their effectiveness backs this claim.^[10] As a developed country, especially for medical care, the UK has been seen as a pioneer in establishing SEPs. These supposed benefits have led to an expansion of these programmes in most jurisdictions that have introduced them, aiming to increase geographical coverage, but also the availability of these services out of hours. Vending machines which automatically dispense injecting equipment "pack" have been successfully introduced in a number of locations.^[11][12][13]

Another advantage cited by supporters of these programmes are that SEPs can not only protect attenders themselves, but also provide a safe environment for their social network such as sexual partners, children or neighbours. If people among injecting drug users (IDU) did not attend SEP or share injection equipment with programme attenders, SEPs can also have an indirect influence to control transmission risks. In fact, in those SEPs, nurses are very important in terms of spreading the knowledge about HIV among IDUs. Under this situation, people not only get physical protection from HIV, they also can learn a lot more information about HIV which can help them know well about this disease, and then learn how to protect by themselves and other people.

Other promoted benefits of these programmes include being a first point of contact for drug treatment,^[14] access to health and counselling service referrals, the provision of up-to-date information about safe injecting practices, access to condoms, and as a means for data collection from injecting drug users about their behaviour and/or drug use patterns. SEP outlets in some settings offer basic primary health care. These are known as 'targeted primary health care outlet'- as these outlets primarily target people who inect drugs and/or 'low-threshold health care outlet'- as these reduce common barriers clients often face when they try to access health care from the conventional health care outlets ^[15], ^[16]. For accessing sterile injecting eqipment clients frequently visit SEP outlets, and these frequent visit are used opportunistically to offer much needed health care ^[17][18].

A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection ^[19] These findings were endorsed by then United States Surgeon General Davis Satcher, then Director of the National Institutes of Health Harold Varmus, and then Secretary of the Department of Health and Human Services, Donna Shalala.^[20][21]

These services can take on a wide range of configurations:

• Primary needle and syringe programme ("stand alone" service)
• Secondary needle and syringe programme (such as incorporated within a pharmacy or health service)
• Mobile or on-call Service
• Dispensing machine distribution ("vending machine")
• Peer service: distribution networks
• Peer service: "flooding" or mass distribution
• Peer service: underground
• Prison-based facilities
• Distribution of bleach or other cleaning equipment (rather than needles and syringes)
• Ad hoc or informal distribution

Countries where these programmes exist include: Australia, Brazil, Canada, the Czech Republic, Netherlands, New Zealand, Norway, Portugal, Spain, Switzerland, United Kingdom, Ireland, Iran and the United States; however in the United States such programmes may not receive federal funding.

U.S. programs

The use of federal funds for needle-exchange programs was banned in the United States of America in 1988, but this ban was overturned in 2009.^[22] In the past, many U.S. states criminalized the possession of needles without a prescription, even going so far as to arrest people as they leave private needle-exchange facilities.^[23] Nonetheless, as of 2006, 48 states in the United States had a program that supported needle exchange in some form or the purchase of new needles without a prescription at pharmacies.^[24]

These programs were introduced during the Clinton Administration but were disbanded following negative public reactions to the initiatives. Covert programs still exist within the United States.^[25]

One such state operating with covert needle operations is Colorado. Current laws in Colorado leave room for interpretation on the requirement of a prescription to purchase syringes. Because of this law the majority of pharmacies will not sell needles without prescription, and police will arrest people in possession needles without prescription.^[26] Groups including The Works (Boulder) and The Underground Syringe Exchange of Denver (the USED) attempt to ease the burden this legislation places on IDUs in Colorado. Both exchanges operate covertly to avoid legal prosecution and are entirely funded by donations and operated by volunteers. Because of the illegal nature of the organization, the USED website specifies that new clients must be referred in order to exchange needles. Both organizations have been highly successful in supplying IDUs with an alternative to using dirty needles. According to The Works website this year they have received over 45,000 dirty needles, and distributed around 45,200.^[27]

Needle exchange programs were once again banned in December 2011, as part of the 2012 US budget.^[28]

Pro-Needle Exchange Arguments

• It is estimated that the average annual cost of HIV care per person in the United States is $15,745. Those with advanced HIV had an annual estimated cost of $40,678.^[29]
• Depending on when infection is detected and when the treatment process begins, it is estimated that total lifetime healthcare costs of HIV care to be between $303,000 and $619,000.^[30]
• The Center for Disease Control estimates that every HIV infection prevented through a needle exchange program saves an estimated $178,000+, as well as an overall estimate of 30 percent or more reduction in HIV cases in reported injection drug users.^[31]
• NEPs bring drug users into medical facilities and expose them to voluntary physical, psychological, and emotional treatment programs. ^[32]
• NEPs offer a commitment to supporting drug users to focus on their health and well-being through: raising awareness, education, and empowerment^[33]
• NEPs treat addictive drug use as a health issue, as opposed to a moral one^[34]
• An estimated 1.2 million people in the United States had HIV, and one in five people with the virus were not aware of their infection. It is also estimated that over 50,000 new cases of HIV are developed each year^[35]
• Of those 1.2 million people infected, 25 percent resulted from injection drug use which is the fastest growing population of HIV^[36]
• Many states require a prescription to buy needles and syringes because they are considered drug paraphernalia and not used for direct medical purposes^[37]
• It costs about $0.97 per needle at an exchange clinic (Center for Disease Control) as opposed to the estimated $36 it costs to pay for a day’s worth of Truvada, a pill sold as one of the numerous treatments necessary for HIV.^[38]

Anti-Needle Exchange Arguments

• Popularity of Needle Exchange programs has grown over time, more than quadrupling in six years from 1993-1999. ^[39]
  • Despite discussions for federal funding of Needle Exchange Programs since President Bill Clinton’s administration, the U.S. has yet to implement a permanent change in its federal policy.
• In 2011, there were up to 221 sterile NEP sites in the United States. An estimated annual budget was approximately $169,000 for just one site to operate. The estimated total for all sites in the United States was roughly $37.5 million. ^[40]
• Legally, police officers in the US cannot arrest an individual if they present a valid needle exchange program card. However, this makes one wonder as to how many people are illegally possessing hypodermic needles. ^[41]
  • Paraphernalia laws
    • Licensed physicians, dentists, nurses, veterinarians, pharmacists, private citizens with prescriptions or approved certifications can lawfully possess hypodermic needles.
    • Participants in approved needle exchange programs can legally possess hypodermic needles from a pilot program, as long as they possessed a valid needle exchange program card. These cards only have an identification number in order to obscure the holder’s identity.
• President Barack Obama repealed a 21 year long ban on federal funding for needle exchange program in 2009. The repeal will make federal grants available to local NEPs. ^[42]
• As part of a large spending bill passed to get the federal government through the 2012 fiscal year, federal funding for NEPs was banned again just two years after Obama repealed the original ban. ^[43]

Opposition

Discarded needles dangerous to the community

An Australian bi-partisan Federal Parliamentary inquiry which published recommendations in 2003 registered government concern about the lack of accountability of Australia’s needle exchanges, inadequate exchange and lack of a national register of resulting needle stick injuries.^[44] Community concern about discarded needles^[45] and needle stick injury led the Australian Federal Government to allocate $17.5 million in 2003/4 to investigating the provision of retractable technology for syringes.

See also

Wikimedia Commons has media related to: Needle exchange

• Arguments for and against drug prohibition
• Drug abuse
• Drug addiction
• Drug policy of the Soviet Union
• Drug possession
• Demand reduction
• Hard and soft drugs
• Moral panic
• Recreational drug use
• Safe injection site
• Taboo
• War on drugs

Footnotes

References