Needle exchange programme

Contents of a needle-exchange kit

A needle and syringe programme (NSP), syringe-exchange programme (SEP), or needle exchange program (NEP) is a social service that allows injecting drug users (IDUs) to obtain hypodermic needles and associated paraphernalia at little or no cost. It is based on the philosophy of harm reduction that attempts to reduce the risk factors for diseases such as HIV/AIDS and hepatitis. While NSPs provide most or all equipment free of charge, exchange programmes require service users to return used syringes to receive an equal number of new syringes.[1]

A comprehensive 2004 study by the World Health Organization (WHO) found 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] 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]

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. The idea is likely to have been rediscovered in multiple locations. The first government-approved initiative (Netherlands) was undertaken in the early to mid-1980s, followed closely by other initiatives. While the initial programme was motivated by an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programmes around the world.[5]

Harm reduction

Harm reduction begins with the assumption that it is not reasonable to assume that individuals make healthy decisions. Advocates hold that those trapped in dangerous behaviors are often unable and/or unwilling to break free of them, and should at least be enabled to continue these behaviors in a less harmful manner.[6] A tendency in the medical profession has been to treat drug dependency as a chronic illness like diabetes, hypertension and asthma, to be treated, evaluated and even insured in like manner.[7][8] Treating drug dependency as an illness absolves drug users of responsibility for their condition.[9]

NEPs typically support the health and well-being of people who use drugs through awareness, education, and empowerment; for example, programs in Australia use the community development (CD) discipline as a basis for their work.[10][11] NEPs treat recreational drug use as a health issue and neither condemn nor condone the practice.[10] Some US states ordinarily require a prescription to buy needles and syringes, as they are considered drug paraphernalia rather than medical equipment. NEPs provide access in such areas.[12]

National District Attorneys Association (NDAA)'s view is that denial of human agency offends common sense as well as criminal statutes, in that adults are responsible for their actions. Where individual decisions impact public health and welfare, criminal sanctions are appropriate and necessary.[13] Catholic Church doctrine asserts that harm reduction protocols treat persons as objects not in control of their own actions and gives the impression that certain types of irresponsible behavior have no moral content.[14] Former US President George W. Bush wrote: "Drug use in America, especially among children, increased dramatically under the Clinton-Gore Administration, and needle exchange programs signal nothing but abdication, that these dangers are here to stay. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life."[15]

HIV costs

It is estimated that the average annual cost of HIV care per person in the United States is US$15,745. Those with advanced HIV had an annual estimated cost of US$40,678.[16] Depending on when infection is detected and when the treatment process begins, it is estimated that, as of November 2006, the total lifetime healthcare costs of HIV care are between US$303,000 and $619,000.[17]

Operation

In addition to sterile needles, syringe-exchange programmes typically offer services such as HIV and Hepatitis C testing; alcohol swabs; bleach water and normal saline (often as eye drops); aluminium "cookers"; citric acid powder (an imperative agent that enables heroin to dissolve in water); containers for needles and many other items.[19] A survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, among 126 surveyed SEPs that 77% provided 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), around 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use.[20]

Needle-exchange programmes are supported by the CDC and the National Institute of Health.[20][21] 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.[21]

Proponents of harm reduction argue that the provision of a needle exchange provides a social benefit in reducing health costs and also provides a safe means to dispose of used syringes. For example, in the United Kingdom, proponents of SEPs assert that, along with other programs, they have reduced the spread of HIV among intravenous drug users.[22] These supposed benefits have led to an expansion of these programmes in most jurisdictions that have introduced them, increasing geographical coverage and operating hours. Vending machines that automatically dispense injecting equipment "packs"[23] have been successfully introduced.[24][25][26]

Another advantage cited by program supporters is that SEPs protect both users and their support network such as attenders, sexual partners, children or neighbours. SEPs can also have an indirect influence to control transmission risks. Nurses are important for spreading knowledge about HIV among users. These programmes provide physical protection from HIV and facilitate education by teaching users about blood-borne pathogens as well as how to protect themselves and others.

Other promoted benefits of these programmes include providing a first point of contact for formal drug treatment,[27] access to health and counselling service referrals, the provision of up-to-date information about safe injecting practices, access to contraception and sexual health services and providing a means for data collection from 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 outlets', because they primarily target people who inject drugs and/or 'low-threshold health care outlets', because they reduce common barriers to health care from the conventional health care outlets,.[28][29] Clients frequently visit SEP outlets for help accessing sterile injecting equipment. These visits are used opportunistically to offer other health care services.[30][31]

A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection [32] 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.[33][34]

These services can take on a wide range of configurations:

International experience

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. In the United States such programmes may not receive federal funding, but this ban was briefly lifted in 2009 before being re-instated in 2010.[35]

Australia

The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated. The Burnet Institute research organisation completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. Between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the surrounding City of Yarra, an average of 1,550 syringes per month were collected from public syringe disposal bins in 2012. Paul Dietze stated, "We have tried different measures and the problem persists, so it's time to change our approach".[36]

On 28 May 2013, the Burnet Institute stated that it recommended 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continued to grow after more than ten years of intense law enforcement efforts. The Institute's research concluded that public injecting behaviour is frequent in the area and injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken into syringe disposal bins to reuse discarded equipment.[37]

United Kingdom

The British public body, the National Institute for Health and Care Excellence (NICE), introduced a recommendation in April 2014 due to an increase in the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services were not advised for people under 18, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for “rapidly increasing numbers of steroid users”, and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.[38]

United States

General characteristics

As of 2011, at least 221 programs operated in the US.[39] Most (91%) were legally authorized to operate; 38.2% were managed by their local health authorities.[39][40]

More than 36 million syringes were distributed annually, mostly through large urban programs operating a stationary site.[39] More generally, US NEPs distribute syringes through a variety of methods including mobile vans, delivery services and backpack/pedestrian routes[40] that include secondary (peer-to-peer) exchange. "Estimates of the annual number of syringes required to meet the single-use standard run in the range of 1 billion."[41]

Funding

The use of federal funds for needle-exchange programs was banned in 1988, but this ban was overturned in 2009.[42] In the time before the federal funding ban was re-instated in 2011, at least three programs were able to obtain federal funds and two thirds reported planning to pursue such funding.[39] US NEPs continue to be funded through a mixture of state and local government funds, supplemented by private donations.[40] The funding ban was effectively lifted for every aspect of the exchanges except the needles themselves in the omnibus spending bill passed in December 2015 and signed by President Obama. This change was first suggested by Kentucky Republicans Hal Rogers and Mitch McConnell, according to their spokespeople.[43]

Legal aspects

Many states criminalized needle possession without a prescription, arresting people as they left private needle exchange facilities.[44] In jurisdictions where syringe-prescription status presented a legal barrier, physician-based prescription programs showed promise.[45] Epidemiological research demonstrating that syringe access programs are both effective and cost-effective helped to change state and local NEP-operation laws, as well as the status of syringe possession more broadly.[46] As of 2006, 48 states authorized needle exchange in some form or allowed the purchase of sterile syringes without a prescription at pharmacies.[47]

By 2012, legal syringe exchange programs existed in at least 35 states.[39] In some settings, syringe possession and purchase is decriminalized, while in others, authorized NEP clients are exempt from certain drug paraphernalia laws.[48] However, despite the legal changes, gaps between the formal law and environment mean that many programs continue to face law enforcement interference[49] and covert programs continue to exist within the U.S.[50]

Colorado allows covert syringe exchange programs to operate. Current Colorado laws leave room for interpretation over the requirement of a prescription to purchase syringes. Based on such laws, the majority of pharmacies do not sell syringes without a prescription and police arrest people who possess syringes without a prescription.[51] Volunteer-run groups such as The Works (Boulder) and The Underground Syringe Exchange of Denver (the USED) operate covertly to avoid prosecution and are entirely funded by donations. Due to the illegal nature of the organization, the USED website specifies that new clients must be referred in order to exchange syringes. According to The Works website, between January 2012 and March 2012, the group received over 45,000 dirty needles and distributed around 45,200 sterile syringes.[52]

Law enforcement

Extra-legal interference

Removal of legal barriers to the operation of NEPs and other syringe access initiatives has been identified as an important part of a comprehensive approach to reducing HIV transmission among IDUs.[46] Legal barriers include both "law on the books" and "law on the streets," i.e., the actual practices of law enforcement officers,[49][53] which may or may not reflect relevant law. Changes in syringe and drug control policy can be ineffective in reducing such barriers if police continue to treat syringe possession as a crime or participation in NEP as evidence of criminal activity.[54]

Although most US NEPs operate legally, many report some form of police interference.[48] In a 2009 national survey of 111 US NEP managers, 43% reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients’ syringes, 12% at least monthly client arrest en route to or from NEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of the program (operating legally vs illegally) and jurisdiction’s syringe regulation environment were not associated with frequency of police interference.[48] This finding confirms a substantial gap between law and law enforcement.

A detailed 2011 analysis of NEP client experiences in Los Angeles suggested that as many as 7% of clients report negative encounters with security officers in any given month. Given that syringes are not prohibited in the jurisdiction and their confiscation can only occur as part of an otherwise authorized arrest, almost 40% of those who reported syringe confiscation were not arrested. This raises concerns about extrajudicial confiscation of personal property. Approximately 25% of the encounters detailed by respondents involved private security personnel, rather than local police.[55]

Similar findings have emerged internationally. For example, despite instituting laws protecting syringe access and possession and adopting NEPs, IDUs and sex workers in Mexico’s Northern Border regions report frequent syringe confiscation by law enforcement personnel. In this region as well as elsewhere, reports of syringe confiscation are correlated with increases in risky behaviors, such as groin injecting, public injection and utilization of pharmacies.[56] These practices translate to risk for HIV and other blood-borne diseases.[56][57]

Racial gradient

NEPs serving predominantly IDUs of color may be almost 4 times more likely to report frequent client arrest en route to or from the program and almost 4 times more likely to report unauthorized syringe confiscation.[48] A 2005 study in Philadelphia found that African-Americans accessing the city's legally operated exchange decreased at more than twice the rate of white individuals after the initiation of a police anti-drug operation.[58] These and other findings illustrate a possible mechanism by which racial disparities in law enforcement can translate into disparities in HIV transmission.[55][59] Notably, the majority (56%) of respondents reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation. These findings suggest that systematic surveillance and interventions are needed to address police interference.[49]

Causes

Police interference with legal NEP operations may be partially explained by training defects. A study of police officers in an urban police department four years after the decriminalization of syringe purchase and possession in the US state of Rhode Island suggested that up to a third of police officers were not aware that the law had changed.[49] This knowledge gap parallels other areas of public health law, underscoring pervasive gaps in dissemination.[60]

Even police officers with accurate knowledge of the law, however, reported intention to confiscate syringes from drug users as a way to address problematic substance abuse.[49] Police also reported anxiety about accidental needle sticks and acquiring communicable diseases from IDUs, but were not trained or equipped to deal with this occupational risk; this anxiety was intertwined with negative attitudes towards syringe access initiatives.

Training and interventions to address law enforcement barriers

US NEPs have successfully trained police, especially when framed as addressing police occupational safety and human resources concerns.[35] Preliminary evidence also suggests that training can shift police knowledge and attitudes regarding NEPs specifically and public health-based approaches towards problematic drug use in general.[61]

According to a 2011 survey, 20% of US NEPs reported training police during the previous year. Covered topics included the public health rationale behind NEPs (71%), police occupational health (67%), needle stick injury (62%), NEPs’ legal status (57%), and harm reduction philosophy (67%). On average, training was seen as moderately effective, but only four programs reported conducting any formal evaluation. Assistance with training police was identified by 72% of respondents as the key to improving police relations.[62]

Advocacy

Organizations ranging from the NIH,[63] CDC,[64] the American Bar Association,[65] the American Medical Association,[66] the American Psychological Association,[67] the World Health Organization[68] and many others endorsed low-threshold programs including needle exchange.

Needle exchange programs have faced opposition on both political and moral grounds. Advocacy groups including the National District Attorneys Association (NDAA),[13] Drug Watch International,[69] the Heritage Foundation,[9] Drug Free Australia,[70] and so forth, religious organizations such as the Catholic Church,[14] and many individuals in important policy-making positions have united to oppose these programs.

US NEP programs have proliferated, despite lack of public acceptance. Internationally, needle exchange is widely accepted.[71]

Needle exchanges have achieved acceptance by some churches and other religious groups, as the House of Bishops of the Episcopal Church, the Central Conference of American Rabbis, the Presbyterian Church and the Society of Christian Ethics.[72]

Research

Disease transmission

Two 2010 ‘reviews of reviews’ by a team originally led by Norah Palmateer that examined systematic reviews and meta-analyses on the topic found 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 risky injecting behaviour.[73] In a comment Palmateer warned politicians not to use her team's review of reviews as a justification to close existing programs or to hinder the introduction of new needle-exchange schemes. The weak evidence on the programs' disease prevention effectiveness is due to inherent design limitations of the reviewed primary studies and should not be interpreted as the programs lacking preventive effects.[74]

The second of the Palmateer team's 'review of reviews' scrutinised 10 previous formal reviews of needle exchange studies,[75] and after critical appraisal only four reviews were considered rigorous enough to meet the inclusion criteria. Those were done by the teams of Gibson (2001),[76] Wodak and Cooney (2004),[2] Tilson (2007)[22] and Käll (2007).[77] The Palmateer team judged that their conclusion in favour of NSP effectiveness was not consistent with the results from the HIV studies they reviewed.

The Wodak and Cooney review had, from 11 studies of what they determined as demonstrating acceptable rigour, found 6 that were positive regarding the effectiveness of NSPs in preventing HIV, 3 that were negative and 2 inconclusive.[2] However a review by Käll et al. disagreed with the Wodak and Cooney review, reclassifying the studies on NSP effectiveness to 3 positive, 3 negative and 5 inconclusive.[77] The US Institute of Medicine evaluated the conflicting evidence of both Drs Wodak[78] and Käll[79] in their Geneva session[80] and concluded that although multicomponent HIV prevention programs that include needle and syringe exchange reduced intermediate HIV risk behavior, evidence regarding the effect of needle and syringe exchange alone on HIV incidence was limited and inconclusive, given "myriad design and methodological issues noted in the majority of studies."[22] Four studies that associated needle exchange with reduced HIV prevalence failed to establish a causal link, because they were designed as population studies rather than assessing individuals.[22]
NEPs successfully serve as one component of HIV prevention strategies.[22] Multi-component HIV prevention programs that include NSE reduce drug-related HIV risk behaviors[22] and enhance the impact of harm reduction services.[81]

Tilson (2007) concluded that only comprehensive packages of services in multi-component prevention programs can be effective in reducing drug-related HIV risks. In such packages, it is unclear what the relative contribution of needle exchange may be to reductions in risk behavior and HIV incidence.[22]

Multiple examples can be cited showing the relative ineffectiveness of needle exchange programs alone in stopping the spread of blood-borne disease.[2][22][73][75] Many needle exchange programs do not make any serious effort to treat drug addiction. For example, David Noffs of the Life Education Center wrote, "I have visited sites around Chicago where people who request info on quitting their habit are given a single sheet on how to go cold turkey -- hardly effective treatment or counseling."[82]

A 2013 systematic review found support for the use of NEPs to prevent and treat HIV and HCV infection.[83] A 2014 systematic review and meta-analysis found evidence that NEPs were effective in reducing HIV transmission among injection drug users, but that other harm reduction programs have probably also contributed to the decrease in HIV incidence.[84]

Worker training

Lemon and Shah presented a 2013 paper at the International Congress of Psychiatrists that highlighted lack of training for needle exchange workers and also showed the workers performing a range of tasks beyond contractual obligations, for which they had little support or training. It also showed how needle exchange workers were a common first contact for distressed drug users. Perhaps the most concerning finding was that workers were not legally allowed to provide Naloxone should it be needed.[85]

Arguments for and against

Needle disposal

Treatment program enrollment

Cost effectiveness

As of 2011, CDC estimated that every HIV infection prevented through a needle exchange program saves an estimated US$178,000+. Separately it reported an overall 30 percent or more reduction in HIV cases among IDUs.[95]

Scope

Community issues

See also

Wikimedia Commons has media related to Needle exchange.

References

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