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Needle Exchange & HIV Prevention
Needle exchange programmes are one of the main harm reduction measures that aim to curb the spread of blood-borne viruses such as HIV and Hepatitis C among people who inject drugs (PWID). With an estimated 1 in 5 people who inject drugs worldwide infected with HIV and 30 percent of HIV infections outside sub-Saharan Africa resulting from injecting drugs, such programmes are key to bringing the global epidemic under control. 1 2
Needle exchange and HIV
Advocates of harm reduction argue that HIV transmission through blood can be effectively averted through needle exchanges as they empower PWID to protect themselves and others from HIV. 3 Studies have found that through offering an accessible alternative to needle sharing, HIV transmission within PWID 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 PWID coming into contact with other users' 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.
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 PWID 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 people who inject drugs. 7
The UK’s medical advisory body (NICE) recommends that needles are provided in different sizes, and are distributed in a quantity that meets need rather than being limited arbitrarily. 8 In 2014, NICE published guidelines for good practice in the implementation of NSPs, which you can read here.
Where do needle exchanges exist?
Many countries that report HIV among their injecting populations do not have needle/syringe exchanges. 9 Globally, only 82 countries have needle exchange programmes. 10 Moreover, it is evident that although countries report having NSP sites, people who inject drugs are still not accessing enough needles/syringes. For example, in Germany there are 250 needle/syringe exchanges, yet people who inject drugs only receive an average of 2 needles/syringes each, per year. It is recommended that in order for needle exchanges to prevent HIV transmission and to make an impact on the HIV epidemic a distribution rate of 200 needle/syringes per PWID, per year is needed. 11 12 So far this target has only been met by three low- and middle-income countries - Bangladesh, India and Slovakia. 13
Low numbers of NSP sites and low distribution rates can be due to a variety of reasons; for example, the lack of resources, public and/or political opposition to harm reduction, as well as laws which criminalise harm reduction. 14
Overall, Western European countries and Australia are the leaders in harm reduction, and some of the highest distribution levels in the world are among these countries. In 2009, Australia distributed an average of 213 needles/syringes per PWID, per year. 15 However, many countries are failing to deliver an adequate harm reduction service.
As of March 2009, only 184 needle exchange programmes existed in 36 US states, plus Washington DC and Puerto Rico. 16 For over two decades, the US 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 of America. Currently, the needle/syringe rate is 22 per PWID, per year - far below the recommended rate and one of the lowest in the world. 17
Throughout Eastern Europe and Central Asia, a promising scale up of harm reduction services has occurred in recent years in many countries, notably Ukraine (which increased the number of NSPs by nearly a thousand to 1,323 between 2008 and 2010). 18 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. 19 However, distribution levels remain low across this region.
Despite an average of one in six PWID in Asia living with HIV, 20 most Asian countries have a long way to go before the needle exchange services which exist make an impact on their HIV epidemics. Whilst some countries have many NSPs, in several cases they are only reaching a very low percentage of the country’s injecting population, who receive very few clean needles/syringes per year. 21 Despite increasing the number of NSPs from 92 in 2006 to 901 in 2010, syringe distribution in China remains very low, at an average of 32 needles/ syringes per PWID, per year. 22 23
Apart from a few notable exceptions needle exchanges across Latin America and the Caribbean, Africa and the Middle East are largely non-existent or where they exist inadequate. Brazil, Mauritius and Iran are some of the countries which have the most advanced NSPs throughout these regions, although the number of syringes they distribute is low. 24
Evidence of the effectiveness of needle exchanges
There is clear evidence that needle exchange programmes have reduced HIV transmission rates among people who inject drugs 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 percent per year in the 52 cities without needle exchange programmes, and decreased by 5.8 percent per year in the 29 cities that did provide them. 25
“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.” 26
England and Wales National Institute for Health and Clinical Excellence
A study of HIV among PWID in New York between 1990 and 2001, found that HIV prevalence fell from 54 percent to 13 percent following the introduction of needle exchange programmes. 27
According to an Australian government study, investment in needle exchange programmes from 1991 to 2000 averted 25,000 HIV infections and 21,000 hepatitis C infections. 28 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. 29
The effectiveness of needle exchanges in preventing needle reuse and the potential transmission of HIV has been reflected in a Canadian report. 30 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.
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. 31
A case study: Needle exchanges in the United States of America
There has been a long-standing opposition to needle exchanges in the United States of America, 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. Unfortunately, the lifting of the ban was short lived, and in 2012, a ban on federal-funding for needle exchanges was reinstated. 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." 32 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." 33
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. 34 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. 35
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.” 36
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.” 37
A Washington Post editorial was scathing of the Congressman's attempt to hamper needle exchange operations in the USA capital:
"In a city that is in the grips of a harrowing AIDS epidemic, Mr. Kingston's move was unconscionable." 38
As USA specific research shows, needle and syringe exchanges are key to addressing HIV and AIDS sustainably in the United States of America. A USA-based study found that expanding syringe exchange programmes (SEPs) in the United States of America would avert hundreds of infections and save three times the amount of investment needed to implement the programmes. For example, 5 percent SEP coverage would require US$19 million in investment, but would save US$66 million in treatment costs, and prevent 169 infections. 39 In light of such evidence, the failure of the United States of America government to invest in needle and syringe exchanges remains inconceivable.
The future of needle exchanges and harm reduction
It is also argued that countries must significantly scale up harm reduction services for PWID if benefits are to be population-wide. 40 However, despite notable progress by some countries to improve their harm reduction services, barriers remain, and the future of HIV prevention for people who inject drugs in many countries remains uncertain.
Even in countries that have increased access to sterile needles and other harm reduction methods, progress is often insufficient, and in many parts of the world authorities refuse to implement or sufficiently support such programmes for political or moralistic reasons. 41
In 2010 a report claimed that in low and middle income countries prevention of the HIV epidemic among people who inject drugs is failing due to funding shortfalls for HIV-related harm reduction programmes. 42 The report found spending in 2007 totalled $12.80 per injector, far less than the estimated average need of $256 per injector per year in 2010. 43
While this situation exists, it seems inevitable that the spread of HIV among drug users will continue to outpace attempts to control it. As Michel SidibÃ©, Executive Director of UNAIDS identified:
"The vicious cycle of secrecy, social exclusion, drug use, criminalization and HIV spread must be broken." 44
- 1. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 2. International Harm Reduction Association (2010, 26th April) ' Media Release - Global Report: 3 cents a day is not enough to prevent injecting drug use fuelling HIV/AIDS epidemics in Eastern Europe and Asia'
- 3. UNAIDS (2010, 10th March) 'Call for urgent action to improve coverage of HIV services for injecting drug users'
- 4. UNAIDS (2009, 20th April) 'International Harm Reduction conference opens in Bangkok'
- 5. WHO (2004, 13th July) 'Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among IDUs'
- 6. World Health Organisation (2004), ‘Policy Brief: Provision of Sterile Injecting Equipment to Reduce HIV Transmission’
- 7. World Health Organization (2004), ‘Policy Brief: Provision of Sterile Injecting Equipment to Reduce HIV Transmission’
- 8. National Institute for Health and Clinical Excellence (2009, February), ‘Needle and syringe programmes: providing people who inject drugs with injecting equipment’
- 9. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 10. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 11. WHO/UNAIDS/UNICEF (2011) ‚' Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 12. WHO/UNODC/UNAIDS (2008, January) ' Technical Guide For Countries To Set Targets For Universal Access To HIV Prevention, Treatment And Care For Injecting Drug Users (IDU's)'
- 13. WHO/UNAIDS/UNICEF (2011) ‚' Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 14. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 15. Mathers, B et al. (2010, 1st March) ' HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional, and national coverage' The Lancet 375
- 16. CDC (2010, 19th November) ' MMWR: Syringe Exchange Programs'
- 17. Mathers, B (2010) ‘ HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage' The Lancet 375
- 18. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 19. European Monitoring Centre for Drugs and Drug Addiction (2010) ' Trends in injecting drug use in Europe'
- 20. WHO/UNAIDS/UNICEF (2011) ‚' Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 21. Mathers, B et al. (2010, 1st March) ' HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional, and national coverage' The Lancet 375
- 22. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 23. Mathers, B et al. (2010, 1st March) ' HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional, and national coverage'
- 24. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 25. Hurley S.F., et al (1997, 21st June), ‘Effectiveness of needle-exchange programmes for prevention of HIV infection’, The Lancet; 349(9068)
- 26. National Institute for Health and Clinical Excellence (2009, February), ‘Needle and syringe programmes: Guidance'
- 27. Jarlais D., et al (2005, 19th October), ‘Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990 – 2001’, AIDS 2005 19(3)
- 28. Australian National Council on Drugs (2006, 13th November), ‘Australia commemorates 20 years of needle syringe programs’
- 29. Australian Government Department of Health and Ageing (2009), 'Return on investment 2: evaluating the cost-effectiveness of needle and syringe programs in Australia 2009'
- 30. Ivsins, A et al.' Drug Use Trends in Victoria and Vancouver, and changes in injection drug use after the closure of Victoria’s fixed site needle exchange' (CARBC Statistical Bulletin). Victoria, British Columbia: University of Victoria
- 31. World Health Organisation (2004), ‘Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users’
- 32. San Francisco Chronicle (2009, 18th December), 'U.S. repeals funding ban for needle exchanges'
- 33. San Francisco Chronicle (2009, 18th December), 'U.S. repeals funding ban for needle exchanges'
- 34. The Washington Post (2009, 25th July), ‘House Bill Lifts Ban On Needle Exchanges’
- 35. StoptheDrugWar.org (2009, 10th October), '1000 feet from everywhere'
- 36. NPR (2009, 10th October), ‘Needle exchanges face a fight in Congress’
- 37. Michael Gerson, Washington Post (2009, 5th August), ‘Helping America's Least Wanted’
- 38. The Washington Post (2009, 12th December), 'At Last, Power for D.C.'
- 39. Nguyen, TQ et. al (2012) ' Increasing investment in syringe exchange is cost-saving HIV prevention: modeling hypothetical syringe coverage levels in the United States' XIX International AIDS Conference July 22-27 Washington DC USA, Oral Abstract MOAE0204
- 40. The Lancet (2010, 20th March) ' HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage' )
- 41. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 42. International Harm Reduction Association (2010, 26th April) ' Global Report: 3 cents a day is not enough to prevent injecting drug use fuelling HIV/AIDS epidemics in Eastern Europe and Asia'
- 43. International Harm Reduction Association (2010, 26th April) ' Global Report: 3 cents a day is not enough to prevent injecting drug use fuelling HIV/AIDS epidemics in Eastern Europe and Asia'
- 44. UNAIDS (2010, 10th March) ' Pragmatism vs. Punishment: The case for harm reduction'