In 2010, approximately 8% of new HIV infections were among injection drug users, according to the CDC. Despite the overwhelming evidence that needle exchange programs significantly reduce the transmission of disease in this population, they still have a certain stigma that has banned them from receiving federal funding.
In 2009, the longstanding ban on federal funding for needle exchange programs (NEPs) was overturned by Congress and signed into law by President Barack Obama. In the 2010 election, however, the political power shifted in the House of Representatives and the ban on funding for NEPs was reinstated.
NEPs are not illegal. According to amfAR, The Foundation for AIDS Research, there were 214 NEPs operating in 30 states, the District of Columbia, Puerto Rico and the Indian Nations in 2013. In conjunction with other HIV prevention strategies, NEPs have led to a significant reduction in HIV incidence among injection drug users (IDUs).
The argument for NEPs is straightforward, according to Don Des Jarlais, PhD, director of research for the Edmond de Rothschild Chemical Dependency Institute of Beth Israel Medical Center.
Don Des Jarlais, PhD, director
of research for the Edmond de
Rothschild Chemical Dependency
Institute of Beth Israel Medical
Center, said needle exchange
Photo courtesy of Des Jarlais D
“They do not have any harmful effects,” Des Jarlais told Infectious Disease News. “They do not increase drug use and they do not lead non-drug users to start using drugs. They do reduce the transmission of HIV. They also help IDUs get into drug treatment and provide a wide variety of other health services, ranging from overdose prevention services to vaccinations and screening for diseases.”
NEPs that have been implemented on a large scale have led to reductions in HIV transmission, Des Jarlais said. Infectious Disease News spoke in depth with Des Jarlais and other advocates of NEPs to discuss their success, despite the underlying stigma that keeps them from receiving federal funding, and how much more successful they could be with federal support.
When HIV was first discovered among IDUs in the early 1980s, there was an ongoing crack epidemic in the United States that generated a lot of antipathy toward drug users because of the violence associated with the distribution of crack, Des Jarlais said. Because of this, there was a negative attitude toward anything that might help drug users. Des Jarlais said this attitude was particularly strong in the black community.
During a 7- to 9-year period, however, more evidence on the effectiveness of NEPs came to light, the violence associated with the crack epidemic waned, and there was a shift in the black community from opposition to NEPs to support. However, at the federal level, there was still a stigmatization of drug users and anything that might appear to “encourage” or “condone” drug use, Des Jarlais said.
The evidence is abundant that NEPs have a definite positive effect. Regardless, there is still a stigma attached to NEPs that is driven from the supposed argument that these programs condone illegal behavior.
“Those people who believe that NEPs are a bad thing are the same people who believe that providing any services to people with drug addiction is bad because they believe drug addiction is a moral problem,” Kimberly Page, PhD, MPH, professor in residence of the department of epidemiology and biostatistics at the University of California, San Francisco School of Medicine, told Infectious Disease News. “It’s not a moral problem; it’s a medical problem and a social problem. We need medical solutions and social solutions. We will never make people who don’t believe that feel any differently by presenting more evidence.”
According to Page, scientific data from many years ago suggested that those who went to NEPs had high rates of infection, causing others to say that NEPs actually made the problem worse. However, when the data were explored more carefully, researchers realized that the NEPs are actually attracting the high-risk people.
In other words, Page said, they are successfully attracting the population that they are meant to attract.
NEPs have a long history of success, first operating in the United States in an illicit manner as an underground movement. The first official, organized program was established in Tacoma, Wash., in 1988, which was followed quickly by programs in San Francisco and New York. They were not necessarily legal, but tolerated.
One of the first studies to measure the success of NEPs on reducing incidence of HIV was conducted by Edward H. Kaplan, PhD, now the William N. and Marie A. Beach professor of management sciences and professor of public health at Yale University. He evaluated the NEP of New Haven, Conn., which was established in November 1990. Rather than relying on self-reports from IDUs about their needle sharing, the needles provided by the program were coded and date-stamped.
According to Kaplan, this allowed the researchers to know whether the person returning the needle was the same person who received it, if the distribution and return locations were similar, and how long the needles were in circulation. A subset of needles also was tested for HIV proviral DNA.
“We developed this approach to let the needles do the talking,” Kaplan told Infectious Disease News. “What we found was that over time, the level of infection measured in the needles fell about 33%, from roughly 60% measured pre-program, to less than 40% months later. Since the chance a drug user would become infected depends upon the likelihood of injecting with an infectious needle, this indicates that HIV incidence among IDUs must have also declined.”
The benefit of NEPs also was clear in New York, where the incidence of HIV among IDUs has decreased 80% since the implementation of NEPs, Des Jarlais said. Another NEP success story is in Amsterdam, where the incidence of HIV among IDUs has declined to nearly zero, according to study findings presented at the AIDS 2012 international conference. In Australia, Des Jarlais said an NEP was established before there was an HIV epidemic among IDUs, enabling them to prevent an HIV epidemic among this population.
More than a needle exchange
Exchanging needles is the primary component of NEPs, but programs across the country provide many other services.
In San Francisco, the NEP provides connections to a variety of services depending on the need, according to Tracey Packer, MPH, director of community health equity and promotion, population health division, San Francisco Department of Public Health. Some services include referrals to housing and linkage into drug treatment.
“This is an essential and integral part of our needle exchange service,” Packer told Infectious Disease News. “There is evidence that people who exchange needles are more likely to get into treatment. In addition, it allows IDUs the opportunity to dispose of their needles safely, which is something they have told us that they want. This prevents syringes from being found in public places, thus improving the neighborhood.”
In Baltimore, most HIV cases early in the HIV epidemic were related to IDUs, and the city council passed an ordinance in 1994 establishing an NEP, according to Patrick Chaulk, MD, MPH, Baltimore City Health Department acting deputy commissioner of the division of disease control. Since then, there have been numerous expansions to the program.
For example, every Thursday night, one NEP van visits “the block,” a location where there are known commercial sex worker clubs. They do needle exchanges, STD and HIV testing, reproductive health work, and immunizations. There also is a program called Staying Alive, in which people, including the drug users, are trained to administer naloxone to those who overdose on opioids.
“Approximately 1,200 to 1,300 people have undergone the training, and we estimate that about 250 people have had an overdose reversal because of the people who have been trained,” Chaulk told Infectious Disease News.
Baltimore also recently expanded service to include wound care. A physician visits two sites a week to evaluate and treat wounds. This service is volunteered by a physician.
For a cost of approximately $750,000 a year — most of which is city funds — Baltimore distributes about 500,000 needles a year to about 3,500 clients, Chaulk said. With a budget of $1.2 million a year — funded entirely by the city — San Francisco provides about 2.6 million needles a year, Packer said.
The lifetime cost of care for a person with HIV ranges from $385,200 to $618,900, according to an amfAR brief. Many IDUs with HIV are uninsured or rely on public programs like Medicaid or the Ryan White Program for their care, meaning that taxpayers bear this cost burden. NEPs significantly reduce this burden by reducing the number of HIV infections in IDUs. In Baltimore, Chaulk said, 62% of new HIV infections in 2001 were among IDUs. In 2010, that declined to 20%.
“We attribute that decline to our program,” Chaulk said. “We talk a lot with other cities with programs, and everyone is seeing the same results. It’s a real testament to the fact that this is a very useful strategy for this particular population.”
They also make neighborhoods safer, as Packer said, by allowing IDUs to dispose their syringes safely. In doing so, needles remain off the street and do not pose risk for others in a neighborhood, including law enforcement, sanitation workers and the general public.
“These programs improve the health of IDUs, but they also improve the community’s health,” Packer said.
Despite the health and financial benefits, and despite the social and safety benefits, none of the NEPs in the country can operate to their full potential. According to amfAR, NEPs are only able to provide sterile needles for less than 3% of the injections that are estimated to occur each year.
In Baltimore, Chaulk said the program has not yet had to cut any services, but it has sustained some general funding cuts. The effect is that the program has not been able to venture into other areas of the city or provide new services. With federal funding, Chaulk said services such as housing and referral to drug treatment could be expanded.
“The services that we provide alongside our needle exchanges, such as reproductive health services and STD screening, are the services that suffer with funding cuts,” Chaulk said. “These are a cornerstone of our program, and with expanded funding, we could do a lot more.”
In San Francisco, the health department was planning to expand access to needles through all HIV prevention programs, not just the NEP. However, this plan was halted when federal funding was banned, Packer said, because most of those programs received federal funds.
“We have a lot of prevention programs that reach people in their communities, and it would make so much sense for people to access their needles in that way since they are already receiving services,” Packer said. “But we can’t do that because of the ban.”
Drug addiction is poorly understood, and some fear that access to needles means an increase in drug use, Packer said. But all of the scientific data have demonstrated the opposite is true.
According to amfAR, there have been many studies that demonstrated this fact. In addition, many organizations, governmental and other, including WHO, CDC, Infectious Diseases Society of America, American Medical Association, the Office of National AIDS Policy and the Office of the US Surgeon General, have stated that evidence of the success and benefits of NEPs is there.
Page said in places that have no NEPs, such as St. Petersburg, Russia, there is an explosive epidemic of HIV. In contrast, rates of HIV and hepatitis C in the United States have decreased among IDUs in the past 20 years because of the availability of prevention, including needle exchange.
“We have this mosaic of services in order to capture as much as we can,” Page said. “Drug addiction is a medical problem, and there is a solution to the problem. Needle exchange can help people stay healthy until they find their way out of it. It serves as an important gateway to a variety of services that are the solution.”
On the addiction spectrum, injection drug use has been considered a “second-class citizen” in terms of health and mental health issues, Chaulk said. This population often has many other issues, including homelessness and unemployment, and as a result, they are ostracized.
And this viewpoint has continued to persist, despite the evidence.
“That attitude was very resistant to factual information and was based on personal beliefs,” Des Jarlais said. “Unfortunately, that attitude has prevailed at the federal level in Congress.” – by Emily Shafer
amfAR. Fact Sheet: Public safety, law enforcement and syringe exchange. March 2013. Available at: www.amfar.org/uploadedFiles/_amfarorg/Articles/On_The_Hill/2013/fact%20sheet%20Syringe%20Exchange%20031413.pdf.
amfAR. Issue Brief: Federal funding for syringe services programs: Saving money, promoting public safety and improving public health. March 2013. Available at: www.amfar.org/uploadedFiles/_amfarorg/Articles/On_The_Hill/2013/IB%20SSPs%20031413.pdf.
Grady BPX. #MOAC0401. Presented at: AIDS 2012; July 22-27, 2012; Washington, D.C.
Health Resources and Services Administration. Ryan White HIV/AIDS Program. Available at: http://hab.hrsa.gov/abouthab/aboutprogram.html. Accessed Nov. 27, 2013.
For more information:
Patrick Chaulk, MD, MPH, can be reached at: Patrick.firstname.lastname@example.org.
Don Des Jarlais, PhD, can be reached at: email@example.com.
Edward H. Kaplan, PhD, can be reached at: Yale School of Management, Box 208200, New Haven, Connecticut 06520-8200.
Tracey Packer, MPH, can be reached at: firstname.lastname@example.org.
Kimberly Page, PhD, MPH, can be reached at: 50 Beale Street, Suite 1200, San Francisco, CA 94105; email: email@example.com.
Disclosure: Chaulk, Des Jarlais, Kaplan, Packer and Page report no relevant financial disclosures.
Are supervised injection sites the next step beyond NEPs to prevent disease transmission among IDUs?
The services provided by the sites go beyond HIV prevention.
We know that providing IDUs with sterile needles helps reduce disease transmission that happens as a result of sharing injection equipment. The more people with sterile needles, the more we are able to disrupt transmission of HIV. We also know that even in a city like San Francisco, where there are good NEPs, we’ve been very effective at reducing HIV transmission rates, but have not had the same success with reducing hepatitis C rates. We still have very high rates of hepatitis C among IDUs. Supervised injection programs ensure that people have fully sterile equipment and that they are not sharing their drugs, so we’re able to really disrupt some of the practices that may be continuing to transmit hepatitis C, even if they’re not transmitting HIV. But in addition to disease transmission, it allows IDUs to have a place where it is legal and safe to inject drugs and they’re treated with compassion and respect. The only legally supervised injection site in North America is Insite, a program in Vancouver, British Columbia. These people have access to other services, including counseling and detox programs. They’re surrounded by people who provide them with better harm reduction and health information and, as a result, they are generally able to take better control of their health and well-being.
There has been a lot of negativity surrounding supervised injection sites that is directly analogous to community and neighborhood concerns about NEPs and the misplaced fears that they encourage drug use and attract the wrong sort of people to a neighborhood. Science has shown us that is not what happens with NEPs, and often they are the link between IDUs and addiction services. Insite in Vancouver is a very contentious political issue, and although it remains open and is deemed legal by the Supreme Court of Canada, it faces a huge amount of political pressure.
I think it is inevitable that we will have supervised injection services in the United States. The evidence is going to mount and people will be increasingly convinced by it and understand the value that it adds to NEPs. What concerns me is that there’s a cost, in human lives, to a slow learning curve. If you ask a lot of people who support NEPs now but didn’t at the beginning, they would say they wish they had changed their minds earlier. The sooner we can get to the point where we’re opening and funding supervised injection sites in the United States, the better and the fewer lives we’re going to lose along the way. The cost of our delay in starting to provide these services is human lives and diseases transmitted. It’s a public health cost as well as an individual and community cost.
Laura Thomas, MPH, MPP, is Deputy State Director, San Francisco, Drug Policy Alliance. Disclosure: Thomas reports no relevant financial disclosures.
They will always be much more controversial than NEPs and many people have a problem with that.
Supervised injection sites have been around in Europe since the 1980s, but they have never been rigorously evaluated until they were established in Australia and Canada. We found that people using Insite frequently were 70% less likely to share syringes than those who used Insite infrequently or never. We also found a 30% increase in the rate of entry into addiction treatment programs among people using Insite. In those instances, people are abstaining from drug use and their risk of HIV infection becomes zero. Two additional studies have found that: a) Insite would prevent 1,191 HIV infections and 54 hepatitis C infections over 10 years; and b) if Insite closed, there would be an additional 83 HIV infections per year, resulting in about $17.6 million in lifetime medical costs for HIV disease alone.
You can’t really disentangle needle exchange from a safe injection site, but safe injection sites do offer more services. Even if you have clean needles from an NEP, you can still inject somewhere else, which carries with it another infectious disease risk, primarily bacterial infections related to unsafe injections. More importantly, when people come to NEPs, they are often only interested in acquiring the materials they need to get high. At supervised injection sites, once people have taken care of their withdrawal and addiction, they are in a much better place to talk about their health and social needs with the counselors and nurses. To that end, supervised injection sites have far greater capacity to engage this hard to reach population.
They are one more tool in the kit. There is no "silver bullet." In Vancouver, HIV infections among IDUs have declined by more than 90%. That’s a result of a combination of harm-reduction practices, including NEPs and supervised injection sites, as well as widespread access to addiction treatment under a universal health system. It has also been the widespread access to antiretroviral therapy among people who are living with HIV. Many studies have shown that controlling HIV infection among people with HIV typically coincides with a large decline in new infections. But ART and other services need to be accessible to people under some kind of universal health care system.
I don’t think a safe supervised injection site works best in every location. They tend to work best where there is high concentration of drug users, where there is public drug injection, or when people are injecting alone and there is a high rate of overdose. NEPs, however, are needed absolutely everywhere and on a large scale. I don’t think supervised injection sites will reach the same scale.
Thomas Kerr, PhD, is Director, Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS. Disclosure: Kerr reports no relevant financial disclosures.