Needle And Syringe Exchanges And Hiv/Aids

The first syringe exchange (SE) program was begun in 1984 in Amsterdam, the NETHERLANDS, out of concern for the spread of hepatitis B among INJECTING DRUG USERS (IDUs). While the hepatitis B virus, hepatitis C virus, and human T cell lymphotropic virus can all cause fatal illness and are all spread through multiperson use ("sharing") of drug-injection equipment, the threat of human immunodeficiency virus (HIV) has clearly become the dominant force in implementing needle- and syringe-exchange programs throughout the world.

HIV is the causative agent for ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS). As of 1995, HIV infection is eventually fatal; there is no permanently effective treatment for HIV infection. Large-scale vaccination studies began in the late 1980s, and have continued through the 1990s, focusing on some 27 different vaccines (Henderson, 1999). HIV has now been reported among IDUs in sixty countries, from all continents except Antarctica, and from both industrialized and developing nations.

A disturbing facet of HIV infection among injecting drug users is the potential for the rapid spread of the virus through a local population of IDUs. In Edinburgh, Scotland, HIV spread, after the introduction of the virus, into the local population to infect over 40 percent of the local IDUs within two years (Robertson, 1990). In Bangkok, Thailand, the percentage of HIV-infected IDUs (HIV seroprevalence) increased from 2 percent to over 40 percent in less than one year (Vanichseni et al., 1992). In the state of Manipur, India, over 50 percent of the local population of IDUs were infected with HIV within one year after the introduction of the virus into the group. The rapid spread of HIV among IDUs results from a lack of awareness of HIV/AIDS as a local threat and from mechanisms, such as shooting galleries (places where addicts "shoot up" together) and dealers' works, that allow large numbers of the population to be exposed to the virus through infected needles and syringes (Des Jarlais et al., 1992). In the United States, injection drug use accounts for 36 percent of AIDS cases overall. In 1998 alone, 31 percent of the 48,269 AIDS cases reported were IDU-related.

Once HIV becomes well established within a population of IDUs, their homosexual and heterosexual partners and transmission to developing fetuses (perinatal) become additional significant problems. In most developed countries, IDUs are the predominant source for both heterosexual and perinatal transmission of HIV. Since AIDS was identified as an epidemic in the United States, 31 percent of all AIDS cases among men have been attributed to injection drug use as compared to the 59 percent of all cases among women (CDC, 1999).

The need to reduce HIV transmission among and from injecting drug users has led to a variety of prevention programs; as a result, there are approximately 113 exchange programs active in 80 U.S. cities in 30 states (Bowdy, 1999). The programs have had differing degrees of effectiveness, although there is evidence that "education-only" programs (i.e., those that do not provide the physical means for behavior change) are the least effective. In almost all industrialized and in some developing countries, increasing legal access to sterile (or uncontaminated) injection equipment has become the most common HIV/AIDS prevention strategy for IDUs. This strategy has included both increased over-the-counter sales of sterile injection equipment and syringe-exchange programs, in which IDUs can turn in used injection equipment for sterile equipment at no cost. A study of a Canadian program in the province of Quebec showed that simple equipment exchanges were not enough. To succeed in reducing the total number of IDUs, transitional and basic support services needed to be part of the program (Belanger, et al., 2000).

Increasing legal access to sterile injection equipment has been politically controversial in several industrialized countries, notably the United States and Sweden, and in many developing countries. Concerns have been raised as to whether increased legal access would lead to increased injection of illicit drugs and whether increased legal access would appear to "condone" illicit drug use or "send the wrong message" about illicit drug use (Martinez, 1992). The decision to support needle exchange programs (NEPs), often lies at the state level. Perhaps the more controversial issue is legalization—or criminalization—of syringe possession. As of 2000, in an effort to reduce the spread of HIV through injection drug use, many states changed laws making it illegal to purchase, sell, or possess syringes without prescriptions. Other states (e.g., New Hampshire) renewed their NEPs. Unfortunately, in most states it is more a political, rather than a public health issue (AIDS Alert, 2000).

The empirical data on these questions will be reviewed below, but first it is important to address operational issues involved in needle-exchange programs—to specify how needle exchanges actually work before addressing evaluations of their outcomes.

ORGANIZATIONAL CHARACTERISTICS OF PROGRAMS

At first glance (and regrettably, in much of the public debate about needle-exchange programs thus far), the operation of a program seems quite simple—one would merely select a location and provide staff who could trade new injection equipment for used. In practice, since the exchanges are service-delivery programs, the organization of the services is critical to their effectiveness. Some programs are heavily utilized—for example, the Amsterdam programs exchange approximately 6 million needles and syringes per year in a city with an estimated 3,000 injection drug users. In contrast, the first legal program in New York City traded fewer than 1,000 needles and syringes per year in a city with an estimated 200,000 injecting drug users.

As of 2000, there have been only two comparative studies of the organizational characteristics of the programs (Stimson et al., 1988; Lurie & Reingold, 1993). According to the Stimson study, the most important aspect of an exchange program is "user-friendliness"—which includes such practical considerations as convenient location and convenient hours of operation but also addresses some of the philosophical issues involved.

Perhaps the most vital element of user-friendliness is the nonjudgmental attitude of the staff toward the participants in the exchange. Participants in a user-friendly program are treated with dignity and respect. They are not stigmatized as morally and psychologically impaired simply because they inject psychoactive drugs. The participants are presumed to care about their health and to be capable of taking actions to preserve their health and the health of others.

User-friendliness also requires that exchanges offer multiple services. Other concerns need to be addressed beyond the provision of sterile injection equipment; the sexual transmission of HIV also needs to be prevented, which includes the distribution of condoms without cost. Moreover, the trusting relationships that gradually develop between staff and participants lead to the discovery of other health and social-service needs, especially the need for drug-abuse treatment. The exchange service should be able to respond positively to such needs, either through referral or through on-site provision of assistance. Failure to do so would undermine the trusting relationships between staff and participants.

There is as yet no consensus as to which additional services should be offered on site and which ones through referral—or even a set of available guidelines for how an individual exchange program should decide which additional services to offer on site and which to offer through referral. However, a broad range of additional services are presently being offered on site, with some programs offering conventional drug-abuse treatment, self-help recovery groups, women's support groups, tuberculosis screening and treatment, and Bible study groups.

The need to provide on-site (or link to other) services means that exchange programs should be considered a part of a system of services for preventing HIV infection among injecting drug users, rather than as self-sufficient HIV prevention programs.

THE EFFECTIVENESS OF THE EXCHANGES

Studying the effectiveness of an HIV prevention program that facilitates sustained risk reduction is extremely difficult. Research ethics require that comparison subjects be provided with some intervention to reduce their chances of HIV infection, and it is not easy to determine an appropriate comparison condition for a program. Should the comparison subjects be told/permitted to purchase sterile injection equipment from pharmacies? Should they be told to purchase sterile injection equipment through an illicit market? or find some method of disinfecting their own injection equipment?

The logical unit of analysis in an exchange evaluation would be the needs of the local population of injecting drug users rather than the needs of individual drug users. If HIV-infected drug users participate in exchanges—returning their needles and syringes to the exchange rather than passing them on to other injectors—those who do not participate in the exchange would then still be protected against HIV infection. Using communities as the unit of analysis in a clinical trial, however, would be extremely expensive, and it is doubtful that many communities would accept random assignment to experimental or control conditions.

No needle-exchange study as of 2000 has approached a randomized clinical trial. Most studies have measured HIV risk behavior prior to and after participation in an exchange, or have compared risk behavior among exchange participants with that of some other group of injecting drug users. Conclusions about the effectiveness of needle-ex-change programs must thus be drawn from the consistency of findings across many methodologically limited studies, rather than rely on a single or small group of methodologically rigorous tests of needle exchange. It should be noted, however, that a consensus panel of the National Institutes of Health in February 1997 concluded that needle exchange programs in general, "show reduction in risk behavior as high as 80 percent in [IDUs], with estimates of a 30 percent reduction of HIV" (Fuller, 1998). In addition, the Centers for Disease Control, the American Medical Association, and the American Public Health Association, have all in some measure acknowledged the amalgam of data pointing toward needle exchange programs as being successful in reducing the incidents of HIV (AIDS Alert, 2000).

Drug Injection.

A common concern expressed by opponents to exchange is that the programs would increase the frequency of illicit drug injection. However, research studies have consistently found that such exchange is not associated with any detectable increase in drug use on either a community or an individual level (Des Jarlais & Friedman, 1992). The most recent review emphasized that "there is no evidence that needle exchange programs increase the amount of drug use by needle exchange clients or change overall community levels of noninjection or injection drug use" (Lurie & Reingold, 1993). Of the eight relevant studies analyzed in this review, three found reductions in injection associated with needle exchange, four found mixed or no effect, and one found an increase in injection compared with the controls. Data from the New York City exchange evaluation (which were not available at the time of Lurie & Reingold's 1993 review) indicate a modest decrease in the frequency of injection among participants using needle exchange (Paone et al., 1995).

Moreover, although opponents have often expressed an additional concern—that exchange programs would attract new injectors—the overwhelming number of IDUs participating in exchanges have long histories of drug injection. The mean length of time usually ranges from five to ten years or more. Typically only 1 to 2 percent of exchange participants initiated drug injecting within the previous year. If providing sterile injection equipment had induced large numbers of people to begin injecting drugs, then the numerous studies to date should have observed substantial numbers of new injectors participating in programs.

HIV Injection Risk Behavior.

Consistent findings across studies indicate declines in self-re-ported frequencies of injection with potentially HIV-contaminated needles (Paone et al., 1993). The magnitude of the reduction is difficult to estimate, because studies have used different metrics for risk behavior; some studies have used differences in pre- and post-exchange measurements, while other studies have compared participants with various other groups of drug injectors. Nonetheless, the trend observed from participants in a program has been a reduction in risk behavior, through injection of contaminated equipment, ranging from 50 percent to 80 percent. No studies, however, have shown anything approaching complete elimination of risk behavior among needle-exchange participants.

Exchange programs probably attract drug injectors who are relatively concerned about their health, and it is possible that, even in the absence of exchange programs, these injectors would seek alternative ways of reducing HIV injection risk, such as purchasing sterile injection equipment from pharmacies or on the illicit market. Thus the present data do not permit a conclusion that exchange programs are necessary to reduce risk behavior leading to HIV infection. However, the possibility of alternative methods for reducing injection risk behavior does not imply that an exchange program is not effective in reducing such behavior.

Nevertheless, the fact that very few new injectors participate in exchange programs may be considered a limitation on their current effectiveness. Since IDUs are typically exposed to hepatitis B and C within the first few years of injecting drugs (Hagan et al., 1993), new injectors may already be infected with these blood-borne viruses before they start to obtain sterile injection equipment from an exchange program. Moreover, in cities with high HIV-seroprevalence, even new injectors may be at high risk for HIV infection. In New York City, the estimated seroconversion rate among new injectors is 6.6 per 100 person-years at risk (Des Jarlais et al., 1994). The new injectors may become infected with HIV before they even begin to participate in an exchange program.

Sexual Risk Behavior.

While all exchange programs address sexual transmission of HIV to some extent, fewer studies have examined the effect that the program has had on sexual-risk reduction among participants. Moreover, the findings from these few studies are ambiguous. Very few HIV prevention programs for injecting drug users have had consistent success in changing the sexual behavior of IDUs, particularly those with "regular" sexual partners (Friedman et al., 1994). The one exception might be programs that provide HIV counseling and testing, since drug injectors who know they are infected with HIV are more likely to change their behavior to reduce the chances of transmitting HIV to others (Vanichseni et al., 1993).

Effects on HIV and Hepatitis B Transmission.

Research data on exchange programs has produced a body of consistent findings with regard to reduced risk behavior through drug injection. Studies within the programs of HIV seroprevalence and HIV seroincidence tend to validate the self-reported risk reduction. Seroprevalence rates have usually stabilized after a program has been implemented, and the rates of new infections among participants have ranged from zero to less than 1 per 100 person-years at risk to a moderate 4 per 100 person-years at risk in Amsterdam. While there is as yet no definite evidence that participation in a needle exchange reduces the chances of HIV infection, the available HIV seroprevalence and seroincidence data are largely consistent with this hypothesis.

The same behaviors that transmit HIV infection (multiperson use of injection equipment and unprotected sexual behavior) also transmit hepatitis B. The epidemiology of these viruses is similar in most countries, and injecting drug users are at high risk for infection with both viruses.

Studies on the effects of exchange-program participation and new hepatitis B infection among drug users in several cities have shown actual declines (Hagan et al., 1991), further validating self-reported risk reduction and indicating that exchange programs do have a large-scale effect on AIDS risk behavior among injecting drug users.

Discarded Syringes.

Exchange programs create an economic value for used needles and syringes—they can be traded for new injection equipment. Thus exchanges have the potential for reducing the amount of used and damaged equipment that is just discarded in the community. Indeed, the one study that systematically examined the amount of discarded injection equipment before and after implementation of an exchange program found a significant reduction in needles and syringes left on sidewalks and in the streets (Oliver et al., 1992)—where anyone might touch it and become a potential victim.

THE "MESSAGE" OF EXCHANGE PROGRAMS

Objections that exchange programs will lead to increased illicit drug use or that they will not lead to reductions in HIV risk behavior can be addressed through empirical studies. Such studies show consistent findings of no increase in illicit drug injection and consistent reductions in HIV risk behavior (although it has not yet been possible to translate the reductions in risk behavior into empirically grounded reductions in HIV transmission rates).

A common objection to the programs, however, is that they "condone" or "send the wrong message" about illicit drug use. The symbolism of a government providing the equipment needed for the injection of illicit drugs seems to contradict society's fundamental disapproval of illicit drug injection; and exchange participants do not misinterpret a need to prevent HIV infection as indicating a reversal of prevailing societal attitudes toward the injection of psychoactive drugs.

The important political message in the programs is not that the injection of drugs like HEROIN and COCAINE is a social good but that previous policies on illicit drug use cannot cope with a public-health catastrophe such as HIV infection among injecting drug users, their sexual partners (and theirs), and their children. The "war on drugs" or "ZERO TOLERANCE" approach focused on reducing the use of illicit drugs. It was clearly impractical, however. The ability to treat drug users so that they will never take drugs again is also clearly limited, and letting drug injectors, their sexual partners, and their children die of HIV infection is clearly inhumane—and they have potential for spreading HIV into the rest of society.

Needle-exchange programs suggest the possibility of greatly reducing the individual and social harm associated with drug use through means other than simply reducing drug use or the drug supply. Making the distinction between reducing drug-related harm and reducing drug use per se is the fundamental premise of a new approach to drug policy that has been termed "harm reduction" or "harm minimization." Harm-reduction practices existed before HIV/AIDS and exchange programs and extend well beyond HIV/AIDS issues, but they have come to be recognized as a prototype of the harm-reduction approach in general.

The harm-reduction perspective itself is in a period of rapid development, so it is not possible to state its fundamental principles definitively, but there are at least four common assumptions in descriptions of the approach:

  1. Pragmatism is valued over idealism. The nonmedical use of both licit and illicit psychoactive drugs is likely to continue indefinitely, so policies should be formulated on a realistic basis rather than on the basis of a utopian drug-free society.
  2. Reducing drug use, particularly very heavy (dependent, addictive) drug use, is the most desirable but not the only means of reducing the individual and social harms associated with psychoactive drug use. Exchange programs to prevent HIV infection are a clear example of reducing harm without necessarily reducing drug use. (Designated-driver programs are another example of harm reduction—reducing the harm associated with alcohol use without necessarily reducing alcohol use.)
  3. In general, drug-related harm is likely to be reduced through integrating drug users into society rather than stigmatizing them and treating them as social outcasts.
  4. While drug addiction clearly restricts an individual's ability to control his or her own behavior, drug users are still capable of making rational choices and should be offered choices among different ways of reducing the harm that drug misuse causes them and society.

The harm-reduction perspective is thus quite different from the war on drugs-zero tolerance perspective. Harm reduction is also distinct from the LEGALIZATION of all psychoactive drugs. The individual and social harms of drugs are not likely to be minimized by the mass marketing of drugs. NICOTINE/TOBACCO is a prime example of how large-scale harm has been created through uncontrolled merchandising of an addictive drug.

Rather than base policy on a utopian ideal of a drug-free society or the equally implausible ideal of a society that freely uses psychoactive drugs without problems, the harm-reduction perspective calls for basing policy on a flexible pragmatism. Specific harms associated with specific types of drug use can be identified, and concrete steps can be taken to reduce those specific harms. Exchange programs to reduce HIV infection among injecting drug users and their social contacts are a prototypical example of a concrete action for reducing drug-related harm. The message sent by exchange programs thus should not be read as "drug injecting is good" but rather that drug policies should be based on their pragmatic effects instead of on their symbolism.

(SEE ALSO: Alcohol and AIDS; ; Injecting Drug Users and HIV; Substance Abuse and AIDS)

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DON C. DES JARLAIS

DENISE PAONE

REVISED BY KIMBERLY A. MCGRATH