How to run a successful needle exchange program
How to run a successful needle exchange program
Report shows importance of range of services
As Congress faces growing pressure from both sides of the needle exchange issue, a recent case study of two successful programs underscores the need for widespread community support and a complement of services for injection drug users.
The case studies, conducted by the Association of State and Territorial Health Officials (ASTHO) in Washington and supported by the Centers for Disease Control and Prevention in Atlanta, describe the policies and programs for preventing HIV in injection drug users in the states of Massachusetts and Washington.
Syringe exchange programs were established in Massachusetts several years ago through legislation introduced by a lawmaker who had been a narcotics police officer. The law designates two dollars in substance abuse treatment funds for every dollar spent toward syringe exchange. Washington, on the other hand, has established syringe exchange programs through court cases, which found that the AIDS crisis called for health officials to offer the programs.
While needle exchange is an important component of these states’ prevention efforts, they also rely on numerous comprehensive strategies, including substance abuse treatment, outreach, public education, and coordination with police and corrections, the report notes.
More than one-quarter of all AIDS cases in the United States and half of all AIDS cases in women are attributable to injection drug use. In addition, an estimated 15% of hepatitis B virus and 38% of hepatitis C virus infections are associated with sharing dirty needles.
"To lock HIV out of a community, I look at it like notches on a key," says Rhoda Creamer, director of Boston’s Addict’s Health Opportunity Program and Exchange. "One of those notches is needle exchange. Another notch is substance abuse treatment. Another notch is education about sexual issues. Another notch is prevention with young kids. And you have to do all of them and figure out how they all come together to lock out HIV disease."
Recently, the notch of the key garnering the most attention is needle exchange. Although the concept of needle exchange as an effective HIV prevention method has received backing from numerous groups, including the American Medical Association and the American Public Health Association, it is strongly opposed by conservative political groups. In September, the House of Representatives passed a measure that would prevent President Clinton from approving funds for needle-exchange programs.
At the U.S. Conference on AIDS in Miami Beach in September, public health officials noted that state lawmakers have become frustrated at the federal government’s slow movement on the issue.
"States should not wait for the federal government to support needle exchange," Paul Loberti, chief administrator of the Rhode Island Department of Health Office of AIDS said at the conference. "States without needle-exchange programs should begin the step-by-step process of introducing the important public health significance of creating access to clean injecting equipment."
As federal legislation flounders in a political morass, several states have been successful in legalizing needle-exchange programs. Last year, Maine became the second state after Connecticut to modify state paraphernalia laws and allocate funds for needle-exchange programs. A politically conservative state, Maine was able to approve the programs after open debate among voters and community leaders, Geoff Beckett, MPH, the state’s assistant state epidemiologist said at the conference. "When issues are brought into the light of day, in an open discussion, many individuals who would not be expected to support these programs actually do," he said. He added that the state’s chief of police and the state pharmacist association support the program.
This year, the Minnesota legislature passed a proposal to legalize the sale of 10 or fewer syringes. New Mexico, where 80% to 90% of IDUs have hepatitis, also has begun a new eedle-exchange program. At the same time, however, similar legislation in Colorado and Illinois was defeated, says Patrick M. Flaherty, MPP, HIV/AIDS project coordinator for ASTHO.
"There has been movement on both sides," he tells AIDS Alert. "Many people are trying to look at this as a criminal justice issue, rather than a medical one, while others are trying to put the public health focus back on this problem."
ASTHO’s policy on HIV prevention for IDUs includes support of needle-exchange programs as one of several services constituting a comprehensive program. While substance abuse treatment should be the primary prevention measure, the association notes that individual states have determined that sterile syringes are also needed because not all IDUs can obtain treatment, and even those in treatment can experience relapses. ASTHO’s policy urges the U.S. Public Health Service to "provide in writing . . . clear advice to interested states on how to increase access to sterile needles and syringes and to deregulate possession of needles and syringes."
AIDS Action Council, the largest lobby for AIDS organizations, also has come out in support of needle-exchange programs, which now number more than 120 nationwide. "After 16 years of work as a physician on the front lines of the AIDS epidemic, I have learned that we must let science lead HIV policy. The science is clear as it relates to the effectiveness of syringe-exchange programs in reducing rates of HIV transmission," says AIDS Action Council board member Victoria Sharp, MD, director of the HIV/AIDS program at St. Luke-Roosevelt Hospital in New York. She notes that the majority of women and Latino and African-American patients in her clinic were infected through injection drug use.
As states grapple with the issue of needle-exchange programs, ASTHO encourages them to look at the experience of Massachusetts and Washington to achieve a multifaceted and complementary program with the following goals:
• Increase the availability of substance abuse treatments.
• Offer primary health care, mental health, support, and educational services.
• Provide HIV prevention programs and education for injection drug users through special outreach efforts.
• Provide outreach/treatment for specific populations in need, such as women, commercial sex workers, cultural and linguistic minorities, incarcerated people, and sexual minorities.
• Increase access to sterile syringes for drug injectors who continue to inject by establishing syringe-exchange programs and repealing or modifying laws restricting sale or possession of syringes.
• Work collaboratively with pharmacists and police to gain their support and address their concerns.
• Link HIV counseling and testing to syringe exchange and substance abuse treatment.
• Improve cooperation among those who treat substance abuse and HIV/AIDS, and policy makers.
• Work with the criminal justice system to provide programs for injection drug users in jail or prison, or on probation.
Changing public image of IDUs
One of the biggest barriers to implementing needle-exchange programs is the public perception of injection drug users, Flaherty says. Indeed, policy officials in Washington have considered hiring a public relations specialist to educate the public about the nature of substance abuse and the need for sterile needles. Flaherty quoted a prevention program official in Washington as saying that he spent as much time dealing with community leaders, politicians, and police as with program clients.
Although it is difficult to prove the programs have decreased HIV infection rates, Flaherty notes that substance abuse treatment admissions have increased in both states since the programs began. And in Massachusetts, the percentage of AIDS cases among IDUs is lower in Boston and Cambridge than in three cities that don’t have programs, he adds.
"They say, and we say, that needle exchange won’t solve the problem, but it has kind of kept it in check," he says.
Needle-exchange programs also provide a bridge between IDUs and health care providers that other services don’t, says Patricia Nolan, MD, MPH, the Rhode Island Commissioner of Health, and chairwoman of the ASTHO Infectious Disease Policy Committee. "Needle exchange is an important program, not only because it exchanges clean needles for dirty ones, but also because it provides an opportunity for injection drug users to interface with the public health system," she notes.
[Editor’s note: For a copy of the 72-page report or a 16-page executive summary, contact ASTHO at (202) 371-9090, or find it on the ASTHO web site at http://www.astho.org/HIVAIDS/hivaids.html.]
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