Needle Exchange Programs

A common practice among injecting drug users is the sharing of needles and other injection equipment. Sharing needles allows diseases to spread from one user to another. HIV, the virus that causes AIDS , has been reported among injecting drug users in sixty countries, from all continents except Antarctica, and from both industrialized and developing nations. The Centers for Disease Control and Prevention (CDC) estimates that injection drug use directly accounts for 25 percent of infections among men and women. This figure does not include cases of HIV infection with an indirect relation to injection drug use, such as those having sexual contact with people who acquired the virus through injection drug use.

Once HIV becomes well established in a population of injecting drug users, their sexual partners are at risk of contracting the virus. In addition, pregnant women can pass the virus on to developing fetuses. Injecting drug users are the main source for both heterosexual transmission of HIV and transmission of HIV to a fetus. According to the CDC, at least 36 percent and possibly as many as one-half of new HIV infections are caused by the sharing of needles and syringes, either directly due to injection drug use, through unprotected sex with someone who acquired HIV infection through injection drug use, or in the case of young children, through birth to a mother who acquired HIV infection through these means. A CDC report also estimates that three out of four AIDS cases among women are due to injection drug use or heterosexual contact with someone infected with HIV through injection drug use, and over 75 percent of new infections in children are the result of injection drug use in a parent.

The spread of HIV/AIDS has led many countries to develop needle exchange programs. In these programs, the drug user can turn in used injection equipment (needles and syringes) and receive sterile equipment in exchange. The sterile equipment is provided legally and at no cost. The hope is that providing sterile equipment can slow or stop the spread of disease among people who inject drugs.

Controversy

Needle exchange programs have been the subject of a great deal of controversy in the United States and many other countries. Some opponents of the programs are concerned that increasing legal access to injection equipment will lead to increasing use of illegal drugs. However, research studies show that needle exchange does not lead to an increase in drug use on either a community or an individual level. In fact, some studies show a slight decrease in the frequency of injection among participants in needle exchange programs.

Opponents also argue that increased legal access appears to condone illegal drug use and sends the wrong message about illegal drug use. Supporters of needle exchange programs disagree. They argue that the programs do not send the message that the injection of drugs like heroin and cocaine is acceptable. Instead, needle exchange programs send the message that previous policies on illegal drug use cannot cope with the urgent public-health crisis of HIV infection among injecting drug users, their sexual partners, and their children. Supporters argue that society's ability to treat drug users so that they will never take drugs again is clearly limited. In this view, letting drug injectors, their sexual partners, and their children die of HIV infection is inhumane, and providing needle exchanges is an essential way to prevent further disease and death.

Opponents have also expressed the concern that exchange programs could attract people who had not previously injected drugs. However, the majority of participants in needle exchanges have long histories of drug injection, usually from five to ten years or more. Studies show no evidence of new injectors participating in programs.

State governments are often responsible for decisions about supporting or opposing needle exchange programs. One of the most controversial issues facing states is whether to make possession of needles and syringes legal or criminal. As of 2000, in an effort to reduce the spread of HIV through injection drug use, many states made it illegal to purchase, sell, or possess syringes without prescriptions. In some of these states, syringe prescription laws have been repealed, and pharmacy regulations and practice guidelines restricting the sale of sterile syringes have been changed. Other states (such as New Hampshire) renewed their needle exchange programs.

Unfortunately, the debate over these programs is often a political issue rather than a public-health issue. Political leaders may want to avoid the appearance of approving of drug use by approving of needle exchange programs. As a result, they may concentrate more on the political angle of the issue rather than on determining the best policies for health.

How the Programs Work

Needle exchange programs have had varying degrees of success. Programs that offer sterile needles but do not offer support services to drug users have been ineffective. Simple equipment exchanges are not enough to prevent the spread of HIV. The organization of services offered by needle exchange programs is critical to their success. Programs must be located where drug users will find them, and they must have hours of operation geared toward the population they serve. Even more important is the attitude of the staff toward the participants in the exchange. Participants should be treated with dignity and respect. Staff members should not take a judgmental attitude toward the participants' morality or ability to manage their lives. The participants care enough about their health and the health of others to participate in the program.

Needle exchange programs can also offer other services, such as distribution of condoms without cost to prevent the sexual transmission of HIV. When participants develop trust in the staff members, the staff may be able to determine other health and social-service needs. Staff can then refer participants to drug treatment programs or other social services. Some programs offer a variety of programs on site, including drug treatment, self-help recovery groups, women's support groups, tuberculosis screening and treatment, and Bible study groups.

Effectiveness

The National Institutes of Health in February 1997 concluded that needle exchange programs in general have reduced behavior that poses the risk of spreading HIV by about 80 percent. Virtually every major scientific study since that time confirms the conclusion that needle exchange programs are effective and do not have the unwanted effects which cause concern among opponents. In addition, the CDC, the American Medical Association, the American Public Health Association, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have all concluded that enough data exist to suggest that needle exchange programs are successful at reducing the number of HIV cases.

Some opponents argue that needle exchange programs should not be funded with public money, such as federal, state, or city taxes. A recent study found that needle exchange programs are in fact cost- effective. Through needle exchange programs, one HIV infection can be prevented for one-third the cost of medical care for an infected person.

see also Complications from Injecting Drugs; Substance Abuse and AIDS.

IN THEIR OWN WORDS

People who need [drug abuse] treatment have got to get it. You don t have to be a humanitarian to believe addicts need treatment. The public is threatened every time a drug addict is told to come back next week.

Robert M. Hayes, Executive Director, Coalition for the Homeless. Quoted in the New York Times, October 9, 1988.