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 injecting drug users (IDUs). With 30% of HIV infections outside sub-Saharan Africa being caused by injecting drug use, such programmes are key to bringing the global epidemic under control. The provision of needle exchange and other harm reduction measures, however, is generally poor, and opposition to them is impairing the fight against HIV.

Needle exchange

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.

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.¹

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.²

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.³

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.⁴

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.⁵ In England, a 2005 survey counted over 1,300 needle exchange services among the 74% of Drug Action Teams that responded to the questionnaire.⁶ 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.⁷

As of late 2007, 185 needle exchange programmes existed in 36 US states, plus DC and Puerto Rico.⁸ For over two decades, the government forbade funding for such services, but in 2009 the federal funding ban was lifted. This should hopefully 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.⁹

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.¹⁰

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.¹¹

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.¹²

“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.”¹³

- 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.¹⁴

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.¹⁵ 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.¹⁶

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.¹⁷

Other harm reduction measures

Like needle exchanges, other harm reduction measures exist to minimise the harmful consequences associated with drug use.

Maintenance therapy. Maintenance therapy, or opioid substitution treatment, involves the provision of drugs such as methadone or buprenorphine, in pill or liquid form, to drug users as a way of minimising risks associated with injecting. These programmes aim to curb needle sharing, the use of contaminated street drugs, overdoses, and crimes associated with funding drug addiction. Methadone or buprenorphine substitution therapy exists in just over 60 countries worldwide.¹⁸

Drug substitution treatment has proven effective in rehabilitating and stabilising IDUs, and in reducing HIV infection rates.¹⁹ 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 receiving methadone became infected with HIV, in contrast to 22% not on treatment.²⁰

Another study in Amsterdam followed a group of 582 IDUs on methadone maintenance therapy for an average of three years. The HIV infection rate among those who continued injecting throughout the treatment was 30 times higher than in those who stopped injecting while on treatment. These results revealed that oral methadone treatment is critical in stopping drug users injecting, though a small minority will later revert to high-risk behaviour.²¹

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.²² 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.^{23 24}

Several studies have shown that prescribing injectable opiates – including heroin – can help heroin addicts who have failed on traditional maintenance therapy. The Randomised Injectable Opioid Treatment Trial (RIOTT), which took place in three UK cities, targeted the 5% of addicts who were not benefiting from existing treatments and were continuing to inject street heroin despite receiving oral methadone. Individuals in all three groups – those receiving injectable heroin, injectable methadone, or oral methadone – decreased their consumption of street heroin, with the biggest decrease among those receiving injectable heroin. Programmes such as these would be beneficial for HIV prevention among ‘problem’ drug users as reducing their use of street heroin also reduces the likelihood of using contaminated needles. This was in addition to a substantial reduction in crime.²⁵

Safer injection facilities (SIFs). These provide an environment where drug users 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.^{26 27} 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.²⁸ Furthermore, IDUs who overdose in safer injection facilities are 10 times less likely to require hospitalisation.²⁹ Research of Vancouver's Insite, 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.³⁰

The Insite facility had faced pressure by Canada’s Conservative government, and was threatened with closure under drug trafficking and possession laws. However, a 2008 ruling allowed it to remain open.³¹ In the judge’s opinion, Canada’s Controlled Drugs and Substances Act violated individuals' constitutional rights:

“It denies the addict access to a health care facility where the risk of morbidity associated with infectious disease is diminished, if not eliminated… While there is nothing to be said in favour of the injection of controlled substances that leads to addiction, there is much to be said against denying addicts health care services that will ameliorate the effects of their condition.”³²

Safer crack smoking resources. Like needle exchange programmes 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 needle exchange programmes 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. Pharmacies that provide clean injecting equipment may also offer similar secondary services as needle exchanges such as providing information and referrals. In Australia, pharmacy-based needle and syringe programmes account for 15% of all syringes used for injecting drugs.³⁴

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.³⁵

Supplying tin foil to deter injecting. One method of helping habitual drug users avoid the harms of injecting is supplying tin foil to encourage smoking of drugs instead. Heroin can be boiled on a piece of foil and then its vapours inhaled. Some countries such as Holland and Spain supply foil through their needle exchanges. In England, however, it is illegal to do so, though it is believed that around 100 of the known 1300 needle exchanges break the law and supply foil.³⁶ An Early Day Motion in the British Parliament aims to overturn section 9A of the Misuse of Drugs Act which restricts the supply of tin foil.³⁷

Again, while no one would claim that smoking heroin is a healthy activity, for people who are addicted to the drug and normally inject, smoking can be a preferable option:

"Smoking drugs is by no means safe, but is a great deal safer than injecting drugs – which is particularly associated with overdose, blood-borne viruses, drug-related litter, greater dependency, abscesses and vein damage." - Jamie Bridge, International Harm Reduction Association³⁸

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 organisations or medical waste facilities; mail-back programmes where used needles are sent in a special container to a collection site; residential pick-up services; and in-home disposal services that safely destroy the needle.³⁹ Programmes that offer safer syringe disposal may well be part of a general needle exchange service.

Community-based outreach programmes. These work with injecting drug users (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 sex work to fund their expensive addiction, so provision of sexual health information and condom promotion play key roles 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.⁴⁰

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.⁴¹

The controversy of needle exchanges and harm reduction

Harm reduction measures are supported and implemented by NGOs, health authorities, governments and multilateral organisations worldwide. However, such methods for dealing with the harms of drugs have been surrounded by controversy since the mid 1980s when needle exchanges and substitution treatments were first introduced in Western Europe. Drugs policy is often discussed in a very moralistic way, with many politicians adopting stances that do not take into account scientific evidence. Because of the impact of drug abuse on society, and perhaps the mind-altering nature of drugs, legislators want to show they are "tough on drugs", even if their policies contribute to the damage they claim to be against.

Advocates of needle exchanges and other harm reduction measures point to the evidence that such programmes reduce the incidence of HIV infection and do not encourage drug use. Furthermore, they say having abstinence as the only goal worth pursuing is unrealistic, and as long as people continue to take drugs, they should be encouraged to do so in the least harmful way possible.

"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.⁴²

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. Opioid substitution 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 its activities, such as teaching safer injecting methods, is a waste of resources. There is also strong opposition to safe injection rooms and heroin prescription for problem IDUs, often the most contentious forms of harm reduction.

In 2004, Republican Congressman, Mark Souder, then chairman of the US Subcommittee on Criminal Justice, Drug Policy and Human Resources, criticised harm reduction supporters:

"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." - ⁴³

In response the president of the International Harm Reduction Association summarised the debate over needle exchange programmes and other harm reduction measures as one which “divides participants into those who base their judgements on data from those who base their judgements on other considerations than data”.⁴⁴

The controversy surrounding harm reduction exists at the highest levels of global decision making. Harm reduction is supported by many United Nations bodies including the General Assembly, UNAIDS, the UN Office on Drugs and Crime, and the World Health Organization. However, the 2009 Political Declaration of the UN Commission on Narcotics Drugs, which outlines international cooperation on drug strategy for the next ten years, does not refer to it at all.⁴⁵ This omission was encouraged by several states including the United States and Russia (see more about their approach to needle exchange and harm reduction below) as well as Sweden, Italy and Japan. Even the Vatican weighed into the debate, criticising harm reduction, to which one group in favour responded:

“By making a statement against harm reduction, the Vatican has indicated that its moral objection to drug use is more important than its commitment to the sanctity of life.”⁴⁶

Needle exchange in the United States

There has been a longstanding 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."⁴⁷ 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."⁴⁸

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.⁴⁹ 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.⁵⁰

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.”⁵¹

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.”⁵²

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."⁵³

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.

Harm reduction in Russia

Given that the Russian AIDS epidemic is being driven by injecting drug use, harm reduction measures like needle exchanges and substitution therapy are crucial. However, HIV prevention for drug users is out of reach with opioid substitution therapy being illegal and needle exchange coverage hugely inadequate. It is estimated that in 2005 just 5% of Russian injecting drug users were accessing needle exchanges.⁵⁴ This is reflected across the wider Eastern Europe and Central Asia region, which Russia dominates, and it is no coincidence that this is the only large part of the world where HIV prevalence is increasing.

Russia’s leading figures in psychiatry and addiction have rejected opioid substitution as an effective way of dealing with the harms of drug use. In an official memorandum they wrote:

“The effective way to solve the problem of drug addiction treatment is an intensive search for and introduction of new methods and means that focus on complete cessation of drugs use by patients with addiction, their socialization into a new life style free from drugs, but not on exchanging from one drug to another.”⁵⁵

In 2009, Global Fund prevention programmes were almost cut after the organisation, under its strict guidelines, deemed the country too wealthy to continue to receive funding. The Russian government chose not to step in, instead saying it would focus on broader health promotion. Given Russia's stance, the Global Fund felt it had no option but to extend funding for prevention efforts directed at vulnerable groups until 2011.⁵⁶ An editorial in The Lancet outlined the difficulties of providing prevention services for drug users and stressed the need for harm reduction initiatives in the country:

“In Russia, the opposition to harm reduction programmes has meant that needle exchange is mostly run by non-governmental organizations (NGOs). The government has repeatedly refused to allow methadone substitution to be offered to people who inject drug, despite many international calls to support this evidence-based intervention…We urge the Russian Government to continue to fund effective and science-driven harm reduction programmes, in addition to its general health promotion efforts.”⁵⁷

Read more about drug use and HIV prevention in Russia.

The future of needle exchanges and harm reduction

While the evidence for the effectiveness of needle exchanges and other harm reduction measures is overwhelming, the future of HIV prevention for injecting drug users 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. While this situation exists, it seems inevitable that the spread of HIV among drug users will continue to outpace attempts to control it.

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