Needle exchange and HIV
Advocates of harm reduction argue that HIV transmission through blood can be effectively averted through needle exchanges as they empower IDUs to protect themselves and others from HIV.3 Studies have found that through offering an accessible alternative to needle sharing, HIV transmission within IDU communities can be brought under control.4 5 However, this form of harm reduction can be controversial and the scale of implementation varies between countries.How does a needle exchange operate?
Needle exchange schemes provide access to sterile syringes and other injecting equipment such as swabs and sterile water to reduce the risk of IDUs coming into contact with other users’ infected blood. Needle exchange programmes that offer safe syringe access may be run by NGOs, hospitals or medical facilities, and local or national governments. Needles may be provided at drop-in centres, outreach points or from vans that service different points within a city or area. In some places, vending machines are used to distribute needles, functioning as a 24-hour service when other sites are shut.
A video about a harm reduction facility in America.
Sometimes a needle exchange may only distribute the same number of syringes that they receive from a user, whereas others may require a lower return rate or not require any return at all. Some needle exchange programmes may provide a high number of sterile syringes to a single user so they in turn can distribute them among IDU populations not accessing such programmes.6
As well as providing clean needles, a needle exchange scheme can also act as a gateway through which users learn about safe injection practices and equipment disposal, safer sex education, access to other prevention services such as substitution therapy, and referral to treatment. The World Health Organisation says that without such complementary measures, needle exchange programmes will not control HIV infection among injecting drug users.7
The UK’s medical advisory body recommends that needles are provided in different sizes, and are distributed in a quantity that meets need rather than being limited arbitrarily.8
Where do needle exchanges exist?
Only 77 countries have needle exchange programmes and, particularly in developing nations, these are often poorly funded and have low coverage rates.9
Western Europe and Australia have the most developed programmes. Almost 25,000 needle exchange programmes exist across all Western European countries except Iceland and Turkey, the majority (18,000) being in French pharmacies.10 In England, a 2005 survey counted over 1,300 needle exchange services among the 74% of Drug Action Teams that responded to the questionnaire.11 There are believed to be over 3,000 needle exchanges in New Zealand and Australia. The latter country is sometimes regarded as the world leader in needle exchange provision, and around 200 syringes are distributed to each injector, on average, per year, one of the highest levels in the world.12
As of late 2007, 185 needle exchange programmes existed in 36 US states, plus DC and Puerto Rico.13 For over two decades, the government forbade funding for such services, but in 2009 the federal funding ban was lifted. This should lead to needle exchange services becoming far more widespread throughout the United States.
Only 122 needle exchanges exist across five countries in Latin America with Brazil and Argentina accounting for the majority – 93 and 25, respectively.14
All countries in Eastern Europe and Central Asia, apart from Kosovo and Turkmenistan, have needle exchanges. For its sizeable IDU population just 69 facilities exist in Russia, and there are 362 needle exchanges in Ukraine.15
A study focusing on 14 European countries, including Estonia, Slovakia and Belgium, found a 33 percent increase in the number of syringes distributed by needle and syringe programmes between 2003 and 2007.16
Some countries that have traditionally opposed harm reduction have begun to significantly increase the number of needle exchange programmes. In China, for example, just 92 needle exchange programmes existed in early 2006, rising to 775 across 17 provinces by the following year. The number of syringe exchanges in India and Myanmar is also increasing, though still at a fairly low level, estimated at 120 and 24, respectively.17
Evidence of the effectiveness of needle exchanges
There is clear evidence that needle exchange programmes have reduced HIV transmission rates among injecting drug users (IDUs) in areas where they have been established. One of the most definitive studies of needle exchange programmes was carried out in 1997, focusing on 81 cities worldwide. It found that HIV infection rates increased by 5.9% per year in the 52 cities without needle exchange programmes, and decreased by 5.8% per year in the 29 cities that did provide them.18
“While NSPs (needle and syringe programmes) can help reduce the harm caused to people who inject drugs, the consequent reduction in the prevalence of blood-borne viruses benefits wider society.”19
England and Wales National Institute for Health and Clinical Excellence
A study of HIV among IDUs in New York, between 1990 and 2001, found that HIV prevalence fell from 54% to 13% following the introduction of needle exchange programmes.20
According to an Australian government study, investment in needle exchange programmes from 1991 to 2000 had averted 25,000 HIV infections and 21,000 hepatitis C infections.21 A later Australian study examining the impact of needle exchanges in the following decade revealed they had prevented 32,000 HIV infections and almost 100,000 hepatitis C infections. Furthermore, it is believed the needle exchanges led to healthcare cost savings of over AU$1 billon, equating to a five-fold return on investment for every dollar spent.22
The effectiveness of needle exchanges in preventing needle reuse and the potential transmission of HIV has been reflected in a Canadian report.23 The study found that between 2008 and 2009, needle sharing increased from 10 to 23 percent following the closure of Victoria's only fixed needle exchange. On the other hand needle sharing among those studied in Vancouver, which has a number of needle exchanges, remained at less than 11 percent.24
The World Health Organization (WHO) released a report in 2004 that reviewed the effectiveness of needle exchange programmes in many countries, and examined whether they promoted or prolonged illicit drug use. The results produced convincing evidence that needle exchange programmes significantly reduce HIV infection, and no evidence that they encourage drug use.25
A case study: Needle exchanges in the United States
There has been a long-standing opposition to needle exchanges in the United States, with a ban on federal funding for them being in place for more than twenty years. This funding ban was overturned in 2009 but while in place denied needle exchanges a crucial source of funding. Needle exchange coverage is therefore very poor compared to many other countries of similar economic development.
When the ban was lifted in December 2009, House Speaker Nancy Pelosi labelled it "a big victory for science and for public health."26 One needle exchange advocate claimed:
"Hundreds of thousands of Americans will not get HIV/AIDS or hepatitis C, thanks to Congress repealing the federal syringe funding ban."27
However, the repeal was not lifted without a fight, in an indication of how strong the opposition is to needle exchanges.
At one stage, the repeal contained a clause restricting federally-funded needle exchanges to locations at least 1,000 feet away from schools, parks, playgrounds, youth centres and similar areas where children congregate.28 This clause would have severely limited the areas where needle exchanges could operate, and underlined conservative opposition to them. Some needle exchange advocates used a map of Chicago to highlight the fact that the amendment would make nearly all parts of the city off limits, and that a city cemetery would be one of the few areas where a federally-funded needle exchange could operate.29
A similar restriction would have applied to all needle exchanges in the capital, Washington DC, whose spending is authorised separately from the rest of the country. The author of the DC amendment, Rep Jack Kingston, believed the mere presence of a needle exchange within proximity of a school would in some way encourage drug use:
“There’s a mixed signal when we're telling kids stay off drugs, but in some cases 200 feet away, we're allowing people to exchange needles.”30
In response to Rep Kingston's amendment, Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, said:
“It does not result in an increase in drug abuse, and it does decrease the incidence of HIV. The idea that kids are going to walk out of school and start using drugs because clean needles are available is ridiculous.”31
A Washington Post editorial was scathing of the Congressman's attempt to hamper needle exchange operations in the US capital:
"In a city that is in the grips of a harrowing AIDS epidemic, Mr. Kingston's move was unconscionable."32
Now the ban on federally-funded needle exchanges has been lifted, without unnecessarily strict restrictions on where they operate, the United States can perhaps make inroads into its HIV epidemic among injecting drug users.
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