Needle exchanges and harm reduction

Needle exchanges

Needle exchange programmes (NEPs) are one of the principal harm reduction measures that aim to curb the spread of blood-borne viruses such as HIV and Hepatitis C among injecting drug users (IDUs). They provide access to sterile syringes to reduce the risk that IDUs come into contact with other users’ infected blood.

How they operate

A mobile needle exchange in Berkeley, California

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. Some needle exchanges 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 NEPs 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.¹

As well as providing clean needles, such services 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, NEPs will not control HIV infection among injecting drug users.²

Where they exist

Only 77 countries have needle exchange programmes and, particularly in developing nations, these are often poorly funded and have low coverage rates.³

Western Europe and Australia have the most developed programmes. Almost 25,000 NEPs exist across all Western European countries except Iceland and Turkey, the majority (18,000) being in French pharmacies. 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.⁴

Symbol used by UK pharmacies and other organisations to indicate needle exchange services

UK needle exchange services symbol

As of late 2007, 185 needle exchange programs existed in 36 US states, plus DC and Puerto Rico.⁵ The federal government, however, provides no funding for such services and also refuses to fund needle exchanges in other countries. A recent bill introduced by Congressman José Serrano (D-NY), and supported by Barack Obama, would lift the ban on states using federal funding for NEPs.⁶

Needle exchanges operate in just five countries in Latin America, with Brazil and Argentina accounting for the majority – 93 and 25, respectively, out of 122.⁷

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.⁸

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 NEPs 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 they are still at fairly low levels, estimated at just 120 and 24, respectively.⁹

Evidence

There is clear evidence that needle exchange programmes (NEPs) have reduced HIV transmission rates among IDUs in areas where they have been established. One of the most definitive studies of NEPs 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 NEPs, and decreased by 5.8% per year in the 29 cities that did provide NEPs.¹⁰

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 NEPs.¹¹

According to an Australian government study, investment in needle exchange programs from 1991 to 2000 had averted 25,000 HIV infections and 21,000 hepatitis C infections.¹²

The World Health Organisation (WHO) released a report in 2004 that reviewed the effectiveness of NEPs in many countries, and whether they promoted or prolonged illicit drug use; the results produced convincing evidence that NEPs significantly reduce HIV infection, and no evidence that they encourage drug use.¹³

Harm reduction

What is harm reduction?

Needle exchange programs are part of a wider approach towards dealing with drug taking known as harm reduction. Harm reduction focuses solely on minimising harm caused through drug use and preventing the spread of HIV, without condoning or prohibiting continued drug use. It defines policies, programmes, services and actions that work to reduce drug-related health, social and economic harms to individuals, communities and society that are associated with the use of drugs.¹⁴

“Harm reduction recognises that containment and reduction of drug-related harms is a more feasible option than efforts to eliminate drug use entirely… [it] does not focus on abstinence: although harm reduction supports those who seek to moderate or reduce their drug use, it neither excludes nor presumes a treatment goal of abstinence.” - UK Harm Reduction Alliance.¹⁵

Some of the guiding principles and aims of harm reduction include:¹⁶ ¹⁷

A belief that drug use in society has and will always exist
Approaches that are based on science, compassion, health and human rights
Criteria of success that are based on changes in death rates, disease, crime and suffering, rather than arrests, seizures, convictions or necessarily a reduction in overall drug use
Addressing harms that drugs can cause through education, prevention and treatment
Reducing the harm that law enforcement policies inflict on communities and individuals, in the name of combating drug use
Calling for a non-judgemental, non-coercive provision of services for drug users
Maximising any potential benefits that drugs may have, such as medicinal use

The controversy of harm reduction

Harm reduction has been surrounded by controversy since the mid 1980s when needle exchanges and substitution treatments were first introduced in Western Europe. Social and political attitudes on how to tackle drug use differ greatly. All governments enact supply and demand reduction techniques. However some countries do not agree with some elements of harm reduction believing that providing clean equipment or substitution therapy does not deter drug abuse.

The arguments against harm reduction range from moderate to extreme. Some believe that needle exchange services are a waste of money and only promote injecting drug use, when the message should be abstinence from drugs. Substitution drug treatment is a difficult concept for many to accept; critics argue that this prolongs drug addiction or provides users with drugs to sell on the street to fund further drug use. Although outreach work is the most accepted form of harm reduction, some believe it makes life easier for drug users by teaching them safer methods of injecting, and is overall a waste of resources. There is also strong opposition to safe injection rooms and heroin prescription for problem IDUs, which are the most contentious forms of harm reduction.

Needle exchange supplies in Washington state, USA

In 2004, Republican Congressman, Mark Souder, then chairman of the Subcommittee on Criminal Justice, Drug Policy and Human Resources, wrote to the director of the National Institutes of Health, Elias A Zerhouni, railing against harm reduction measures and calling for a summary of available studies on drug abuse and its effects. An excerpt is below:

“As you know, ‘harm reduction’ is an ideological position that assumes individuals cannot or will not make healthy decisions. Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles - or become trapped in them - should be enabled to continue these behaviors in a less harmful manner. Often, however, these lifestyles are the result of addiction, mental illness of other conditions that should and can be treated rather than accepted as normative, healthy behaviors. Sadly, harm reduction largely ignores these realities and programs driven by this ideological position have not been adequately reviewed with unbiased, scientific rigor.” ¹⁸

In response, Dr Alex Wodak, president of the International Harm Reduction Association, also wrote to Dr Zerhouni:

“Congressman Souder quotes studies concluding that needle syringe programmes may increase HIV infection. He does not quote some later studies by the same authors questioning or revising their own findings in earlier papers. The overwhelming majority of papers evaluating needle syringe programmes have found that these programmes reduce HIV infection among injecting drug users. There is no convincing evidence that needle syringe programmes increase HIV…

“This debate divides participants into those who their base judgments on data from those who base their judgments on other considerations than data. I have confined my response to evidence supporting needle syringe programmes but could just as well have covered the evidence supported methadone treatment programmes.

“Congressman Souder's comments on harm reduction should be rejected comprehensively.” ¹⁹

Other harm reduction measures

Maintenance therapy. Methadone or buprenorphine maintenance therapy, or substitution treatment, provides legal drugs, in pill or liquid form, to heroin addicts who are unable to quit in order to reduce the harms of injecting. The approach aims to curb needle sharing, the use of contaminated street drugs, overdoses and crimes associated with funding heroin addiction. Methadone or buprenorphine substitution therapy exists in just over 60 countries worldwide.²⁰

Drug substitution treatment has proven effective in rehabilitating and stabilising IDUs, and in reducing HIV infection rates.²¹ For example, researchers from the University of Philadelphia monitored 152 injecting users receiving methadone maintenance treatment and 103 injecting users on no treatment over a period of 18 months, all of whom were HIV negative at the beginning of the study. The results showed that over the 18 months, only 3.5% of those on treatment became infected with HIV, as opposed to 22% not on treatment.²²

Former injecting drug user takes methadone treatment

Another study in Amsterdam followed a group of 582 IDUs on methadone maintenance treatment for an average of three years. The HIV infection rate was 6.0 per 100 person-years among those who continued injecting throughout the treatment, and 0.2 per 100 person-years in those who stopped injecting while on treatment. These results indicate that oral methadone treatment is critical in stopping drug users injecting, though a small minority will later revert to high-risk behaviour.²³

A report by the WHO in March 2005 reviewed many global studies and concluded that substitution treatment is a ‘critical component’ of HIV prevention policy, significantly reducing opioid dependency and HIV infection rates.²⁴ In addition, studies have also found a decline in crime rates and commercial sex work when IDUs no longer have to find ways to fund their expensive addictions.²⁵ ²⁶ ²⁷

Safer injection facilities (SIFs). These provide an environment where IDUs can inject in a safer manner and under medical supervision. Like needle exchange programmes they may offer drug education and referral for treatment. They also aim to reduce public disorder issues and risks associated with injection drug use such as large congregations of injectors in public places and litter, particularly syringes. Such facilities exist in only a few countries including Germany, Switzerland, the Netherlands, Spain, Australia and Canada.

After Frankfurt introduced SIFs in the early 1990s cases of HIV among IDUs declined, as did overdose cases in the city which dropped dramatically from 147 in 1991 to 22 in 1997.²⁸ ²⁹ This decline can be attributed to the city’s overall harm reduction approach, though overdose cases dropped steeply in the year following the introduction of SIFs.³⁰ Furthermore, IDUs who overdose in safer injection facilities are 10 times less likely to require hospitalisation.³¹ A study in Vancouver, the site of North America’s first SIF, found there was no association between the facility and the rate of drug trafficking or other crimes linked to drug use.³²

Safer crack smoking resources. Like needle exchange programs they distribute clean crack-smoking implements in order to curb the risks associated with sharing of equipment

These have not been implemented on as wide a scale as NEPs but have shown to be effective in cutting behaviours associated with HIV transmission. An Ottowan needle exchange that also began providing sterile crack-smoking equipment, such as glass stems and rubber mouthpieces, found the proportion of participants sharing implements decrease from 85% six months prior to implementation, to 77% 12 months after. Of those who still shared just 12% did so every time, compared with 37% previously.³³

Pharmacy sale of syringes. Non-prescription over the counter sale of syringes is another way to allow drug users access to sterile needles. In the US, some states have amended drug paraphernalia laws to exclude syringes.

An examination of the 96 largest metropolitan areas in the United States found both the proportion of IDUs living with, and becoming infected with, HIV, was lower in the 60 areas that permitted the purchase of syringes without prescription compared to the 36 metropolitan areas that did not allow this.³⁴

Safe needle disposal. Various disposal methods exist so contaminated needles are unable to injure another person. These include drop-off points located in buildings such as police departments, clinics, community organizations or medical waste facilities; mail-back programs where users send their used needles in a special container to a collection site; residential pick-up services; and in-home disposal services that safely destroy the needle.³⁵

Disposing of a needle in a sharps box

Community-based outreach programmes. These work with IDUs to distribute clean equipment, promote condom use and provide information about prevention and rehabilitation. Injecting communities are often secretive and distrustful of authorities. Outreach programmes focus on accessing these hidden groups, opening an important route to providing support. In some cases, former IDUs are recruited and trained as peer-outreach workers. Some IDUs are likely to be involved in the commercial sex-trade to fund their expensive addiction, so sexual health information and condom promotion are key factors in preventing HIV transmission through other routes.

A report from the WHO reviewed data from over 40 studies on outreach prevention methods and concluded that these significantly reduce high-risk behaviour in IDUs and are successful in directing them to rehabilitation services.³⁶

In 2006, UNAIDS published a report that reviewed several ‘high coverage’ prevention programmes (50% of local IDU population accessing more than one prevention initiative) in transitional and developing countries. The inclusion of harm reduction measures was one of the key factors in achieving high coverage.³⁷

Conclusion

While the evidence for the effectiveness of harm reduction is overwhelming the future of HIV prevention for injecting drug users in many countries remains uncertain. Although some countries have increased harm reduction access it is often insufficient, and in many parts of the world authorities refuse to implement or sufficiently support such programmes for political or moralistic reasons. While this situation remains, it seems inevitable that the spread of HIV among drug users will continue to outpace attempts to control it.