Needle exchange programs



A hypodermic needle-exchange program is a sometimes controversial social policy, based on the philosophy of harm reduction where injection drug users can obtain hypodermic needles and associated injection equipment at little or no cost. These programs are called "exchanges" because many require exchanging used needles for an equal number of new needles. In practice, some programs vary in their stringency; in the Canadian capital Ottawa, for example, participating clinics do not demand used needles before giving out new ones.

In addition to sterile needles, syringe exchange programs (SEPs) typically offer other services such as: HIV and Hepatitis C testing; alcohol swabs; bleach and sterile water; aluminum "cookers"; containers for needles and many other items. 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 counseling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads, and male and female condoms.

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. Supporters of SEPs estimated that with the aid of SEPs, the number of HIV infections could be prevented from 4000-10000 between 1987-2000. According to the analysis of New York State-approved SEPs, during one year period, SEPs contribute directly that 87 HIV infectors can be averted. Dozens of studies have shown needle exchanges to be effective at preventing the spread of HIV and Hepatitis C. Needle exchange programs are supported by the Center for Disease Control and the National Institute of Health. The National Institute of Health 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. The presence of needle exchange programs has been attributed to a reduction of high-risk injection behavior by up to 74%.

Needle-exchange programs 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 program was motivated by concerns regarding an outbreak of hepatitis A, the AIDS pandemic motivated the rapid adoption of these programs around the world. This reflects the pragmatic response to the pandemic undertaken by some governments, and encapsulated in the harm reduction / minimization philosophy.

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 UK, as the keystone prevention method, SEPs make the HIV spread among IDU dramatically avoided. As a developed country, especially for medical care, UK becomes pioneer to apply SEPs.In Australia, these programs are credited with maintaining a very low rate of HIV infections among injecting drug users. These benefits have led to an expansion of these programs 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.

Another advantages of these programs 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 neighbors. If people among IDU did not attend SEP or share injection equipment with program 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 benefits of these programs include being a first point of contact for drug treatment, access to health and counseling 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 behavior and/or drug use patterns.

These services can take on a wide range of configurations:
 * Primary needle and syringe program ("stand alone" service)
 * Secondary needle and syringe program (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 programs exist include: Australia, Brazil, Canada, The Netherlands, New Zealand, Portugal, Spain, Switzerland, United Kingdom, Ireland, Iran, and the United States; however in the United States such programs may not receive federal funding.

The provision of needle-exchange programs is opposed by different groups on a wide range of grounds. These can include:


 * That the programs represents a weakening of the "War on Drugs" (or equivalent) policy;
 * That the programs encourage drug use;
 * The services attract crime to an area;
 * That the permanent location of such services may lower surrounding property values;
 * There will be an increase in discarded injecting equipment around the service; and/or
 * The services build and/or strengthen social networks of injectors and undermine treatment or diversion.
 * Health centres for drug dependent, without distribution of needles, can offer condoms, dental service, HIV-test, medical service's, contact with drug treatment etc without the risks connected to needle distribution.

Each of these concerns have varying degrees of validity, though a number of meta-analysis of studies from around the world give mixed results. The methodology of such studies is under debate. European studies have found the provision of needles does not cause a rise in drug use. A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection These findings have been endorsed by, among others, former United States Surgeon General Dr. Davis Satcher, former Director of the National Institutes of Health Dr. Harold Varmus, and former Secretary of the Department of Health and Human Services, Donna Shalala.

In the United States, Federally funded reports conducted by the National Commission on AIDS, the General Accounting Office , the Centers for Disease Control and Prevention (CDC) , the National Institute of Medicine's National Research Council , and the Office of Technology Assessment have all concluded that needle exchanges reduce the transmission of HIV while not increasing drug use.

Regardless of this evidence, the use of federal funds for needle-exchange programs was banned in the United States of America in 1988. Most U.S. states criminalize the possession of needles without a prescription, even going so far as to arrest people as they leave private needle-exchange facilities. Nonetheless, every state in the United States has a program that supports needle exchange in some form or the purchase of new needles without a prescription at pharmacies.

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.