Needle-exchange programs are slowly finding greater acceptance

Needle prescriptions are new possibility

Despite continued federal resistance to needle-exchange funding, these programs are growing across the nation, and some states have also moved toward legislation that permits addicts to buy needles over the counter. Improving access to clean needles still is a long way from solving the problem of HIV transmission among the nation’s injection drug users (IDUs), who inject drugs an estimated 920 million to 1.7 billion times per year.1

The problem is evident: Among AIDS cases reported through June 2001, 25% were among injection drug users, and another 6% were men who have sex with men (MSM) and inject drugs. Among those who reported transmission through heterosexual contact with a person who had a known transmission risk, the vast majority (30,607 total) were women and men who had sex with an IDU, according to data from the Centers for Disease Control and Prevention in Atlanta.2

"Give us the resources, and we’ll stop the pandemic among injection drug users," says Dave Purchase, director of Point Defiance AIDS Project, which is funded to operate the North American Syringe Exchange Network (NASEN) of Tacoma, WA.

Efforts made by NASEN and others committed to HIV prevention among IDUs are starting to show some positive outcomes. There were 154 needle-exchange programs in the U.S. in 2000, and now there are about 180 programs, showing that there is a growth rate of about 10% to 15% per year, says Don Des Jarlais, PhD, director of research for Baron Edmond de Rothschild Chemical Dependency Institute of Beth Israel Medical Center in New York City. "About half of them receive either state or local funding, so that even though the federal government has been remiss in supporting HIV prevention, the city and state governments are increasingly involved," Des Jarlais says.

Des Jarlais’ research, based on surveys of 127 needle-exchange programs nationwide, estimates that the number of syringes exchanged increased significantly between 1994 and 2000, from close to 10 million to more than 22 million. The mean budget of a needle-exchange program currently is $100,648.

Also, needle-exchange programs are most common in the West and least common in the South. Most of those that are provided offer HIV counseling and testing in addition to exchanges. Some also provide hepatitis C counseling and testing, screening for sexually transmitted diseases, hepatitis B counseling and testing, hepatitis B vaccine, medical care, and hepatitis A counseling and testing.

On-site social services are provided by some needle-exchange programs, including food, case management, and transportation, and most of these needle-exchange programs provide free drug-related items, such as alcohol pads, cotton, cookers, water bottles, bleach, antibiotic ointment, ties, and hygiene kits. Most programs also provide participants with condoms, lubricant, female condoms, and dental dams.

Des Jarlais has conducted research on the impact of needle-exchange programs on communities and is familiar with the many studies that address the subject. "There is no evidence of harmful effects in terms of increased drug use, increased drug-related crime, or any other hypothesized ill effects," he concludes.

Studies repeatedly show that needle-exchange programs do not encourage drug use, increase community crime, or result in improperly discarded syringes, at least in communities where needle exchanges are legal and syringe disposal options are available.3-7 On the contrary, needle-exchange programs appear to do precisely what they are intended to do, which is to reduce the transmission of HIV among injection drug users, and by extension, to their sexual partners.8-11

"To stop the transmission of HIV among IDUs and from IDUs to heterosexuals, you need to prevent IDUs from becoming infected," Des Jarlais says. He presented some of his needle-exchange research at the 12th North American Syringe Exchange Convention, held April 24-27 in Albuquerque, NM.

Needle-exchange programs are one of the most effective ways of doing this. Des Jarlais points to New York’s strong needle-exchange focus as an example of success. "Here in New York, where we arguably have the best data, we are actually seeing dramatic reductions in HIV among drug injectors," Des Jarlais says. "Ten years ago, roughly 50% of drug injectors in New York City were infected with HIV, and now that’s down to under 20%"

With the HIV epidemic firmly entrenched in the United States, it will never be enough to rely solely on needle-exchange programs, because they are not available everywhere and are not available as often as addicts may need needles, some argue.

Politics govern needle-exchange policy

Plus, needle-exchange policy is subject to the whims of state and local governing officials, and this policy can change with the political tide. For instance, California has only in recent years permitted syringe exchanges in areas where local governments declare a public health emergency, Des Jarlais says. "Prior to that, they were doing it on an ambiguous basis," Des Jarlais adds. "Oakland had done it, and the county prosecutor fought them and shut the needle exchange down, and then a new governor and state legislature passed a law that made it fully legal to operate exchanges if the local health department declares a public health emergency."

So there is a second concerted effort among HIV prevention advocates aimed at making syringes and needles easier to purchase from pharmacies, hospitals, and clinics.

"Since the beginning of the epidemic, 10 states have taken some action to deregulate the sale or possession of some number of syringes, and in the last four years that trend has been accelerated," says Scott Burris, JD, professor at Temple University Beasley School of Law in Philadelphia. Burris also is the senior associate of the Johns Hopkins University School of Hygiene and Public Health and is associate director of the Center for Law & the Public’s Health at the CDC Collaborating Center Promoting Public Health Through Law.

It’s not that most states had previously prohibited over-the-counter sales of syringes, but many had not addressed the issue directly, and this ambiguity impacted their accessibility, Burris says.

"There are pharmacy regulations that limit what pharmacists can do; there are paraphernalia laws, prescription laws, and, by and large — whatever the rules are — pharmacists usually don’t leave syringes sitting out on the counter," Burris says. "A bunch of states have pharmacy regulations that require the pharmacist to make sure the syringe will be used for legitimate legal purposes."

Now some states are trying to clarify their laws to make it easier for addicts to buy syringes. One way they’re doing this is by making certain that syringes are excluded from paraphernalia laws, meaning that people in possession of syringes would not automatically be lawbreakers. Without these legislative changes, IDUs could be and have been arrested for possession of syringes, and pharmacists would be reluctant to sell them to addicts.

Wanted: A clean and new needle each time

"From the health perspective, the reality is very simple," Burris says. "You have to make sure that anybody injecting illegal drugs uses a clean and new needle each time, and that prevents disease of all types."

That argument is winning converts within states. At present, only six states require people to have a prescription to purchase a syringe, says Glenn Backes, MSW, MPH, director of health policy at the Lindesmith Center Drug Policy Foundation in Sacramento, CA. "There seems to be greater and greater understanding among Republicans and Democrats to allow individuals to use their own money to protect the health of themselves and others," Backes says.

However, the six states where over-the-counter syringe sales are illegal pose a particular problem because most of these are states with major AIDS problems, Backes says. These states are California, Illinois, New Jersey, Delaware, Pennsylvania, and Massachusetts. "It’s almost stunning that Massachusetts is one of the last remaining states to have this counterintuitive law," Backes says. Every state should have a comprehensive HIV prevention policy that includes expanding drug treatment and needle exchange, as well as permitting people to walk into a pharmacy to buy syringes that will protect the public’s health, Backes adds.

The Lindesmith Center has chosen to lobby for state legislation that will give addicts easier access to clean needles through over-the-counter sales, which is less politically charged than needle-exchange programs, Backes says. However, the fight for more funding for needle-exchange programs has not been lost, despite opposition among both Republican and Democratic presidencies.

Needle-exchange proponents are optimistic that even New Jersey, the toughest nut among the states, will be cracked now that there is a new governor. Former Gov. Christine Todd Whitman was opposed to even privately funded needle-exchange programs and directed police to arrest needle-exchange volunteers. This was despite the state’s growing problem of HIV infection and transmission among IDUs and their sexual partners.

"The highest levels of IDU transmission rates are in New Jersey," Purchase says. "New Jersey’s [anti-needle exchange] laws still are in place, but it looks like the pendulum will swing in our direction," he says. "But the pendulum swings slowly." On the positive side, there have been no arrests of syringe exchange volunteers since Whitman left office to join President George W. Bush’s administration, Purchase says.

While Purchase agrees that easier needle access also is needed, he sees this as a less direct way to reduce HIV transmission among IDUs. "Over-the-counter sales are still at the discretion of the pharmacy," he explains. "As good as it is, it simply allows for commercial activity for syringes, and that does nothing to provide outreach to the injecting community." Needle-exchange programs were directly responsible for preventing the HIV epidemic among Australia’s IDU population because the country started the programs early enough and has kept them funded, Purchase adds.

Another strategy employed by industrialized nations has been to provide needle exchanges in prisons, where drug use is common and HIV infection can be high, and there is some evidence that these programs are successful.12 Spain and Germany, for example, have experimented with prison needle-exchange programs. But despite the need, this hasn’t been attempted in the United States, and it’s unlikely to happen any time soon, Purchase says.

"What you have in prison is the worst imaginable shooting gallery, and I don’t think there’s one of us who if we got the call today wouldn’t be there in an hour to do syringe exchange," Purchase says. "But the politics and restrictive legislation make that very hard to do, and there’s no such thing anywhere in the United States."

Another little-tried option for making needles more accessible involves encouraging physicians to prescribe needles to their drug-addicted patients, Burris says.

Syringe prescriptions reduce sharing

An HIV and infectious disease physician in Rhode Island started a research project a couple of years ago that involves prescribing syringes to IDUs, and so far the results are promising. "We recruited 350 very high-risk patients, and the majority had shared syringes at some time," says Josiah Rich, MD, MPH, an infectious disease physician at Miriam Hospital in Providence, RI. Rich also is an associate professor of medicine and community health at Brown University Medical School in Providence. "Half of these patients were homeless and had been doing drugs for a long time," Rich adds. "With the program, we had a dramatic decrease in syringe sharing and syringe reuse, and it seems quite promising from that standpoint alone."

Rich became interested in the idea of prescribing syringes because, until recently, half of Rhode Island’s HIV population were IDUs. The problem was that the state made syringe possession a felony punishable by five years in prison until September 1998, when it was changed to a misdemeanor charge. Then, again with lobbying by the HIV prevention community, the state finally legalized syringe possession and permitted needles to be sold over the counter at pharmacies, Rich says.

Since fellow New England states Delaware and Massachusetts still haven’t permitted syringes to be sold over the counter, those would be ideal places for HIV clinics and physicians to prescribe syringes to addicts, Rich says. "In reality, most physicians are not going to be interested in doing this, but you don’t need a lot of them to prescribe syringes to make a big change," Rich adds. "And from a physician’s standpoint, I find it very satisfying because it provides much better patient-physician interaction and relationships."

Lawyers who have examined the issue have found that there’s little legal risk to physicians who do so, although the fear of repercussions prevents them from being proactive in this way, Burris says. "The problem that physicians worry about is that they may somehow be charged with a crime and have their license revoked, which is their death penalty, even if the charge is a misdemeanor," Burris explains. "So it’s not an insubstantial thing to worry about."

However, most state laws clearly permit physicians to prescribe needles legally to drug-using populations. Even in New Jersey, this can be done, and it wouldn’t take very many physicians writing the prescriptions to have a big impact on reducing HIV transmission among IDUs, Burris says. "What you need are physicians committed to the population and who are willing to do it in an area where there are no other means of getting syringes, and New Jersey certainly is that place," he says.

Doubt about the legality of prescribing needles to IDUs could be resolved by medical advisory boards or state legislation that clarifies the issue.

Program might get started in hospital

There is some talk now about starting a needle-exchange program in a hospital in New Jersey, which is a way to make needle exchange less threatening, at least to the not-in-my-backyard folks, Burris says. "Doing it in hospitals is a problem for everyone involved, and it’s not going to be popular, but it’s a first step," Burris adds. "Even under Whitman, I was a proponent of the idea that some brave hospital should set up a hospital exchange program as the most legally defensible way of improving needle access under New Jersey law."

While there remains strong opposition from some corners to needle-exchange programs, the fact remains that there is no scientific evidence to suggest that needle-exchange programs create any problems, Purchase says. "So what that tells you is the opponents, no matter how they talk, are not talking about the science of preventing deaths," Purchase says. "They have other reasons to resist."

Advocates for the prevention of HIV transmission among IDUs will continue to push for changes to state laws and expansion of needle-exchange programs for as long as it’s necessary, Burris says. "We’re having a victory of a thousand cuts; we’re winning, but winning slowly," he says. "More and more states each year are getting with the program and seeing the light, but it’s taking too long, and literally thousands of people are becoming infected every year because the law makes it impossible for them not to, given that they’re going to use drugs, and that’s shameful."

References

1. Lurie P, Jones ST, Foley J. A sterile syringe for every drug user injection: How many injections take place annually, and how might pharmacists contribute to syringe distribution? J AIDS Hum Retrovirology 1998; 18:S45-S51.

2. U.S. HIV and AIDS cases reported through June 2001; Midyear Edition. Centers for Disease Control and Prevention Surveillance Report 2002; 13:Table 5: AIDS cases by age group, exposure category, and sex, reported through June 2001, United States.

3. Marx MA, et al. Attitudes of adolescents about illegal drug use and needle exchange programs — final analysis. Annual Meeting of the American Public Health Association. Chicago; Nov. 8-12, 1999.

4. Macalino G, Springer KW, Rahman ZS, et al. Community-based programs for safe disposal of used needles and syringes. J AIDS Hum Retrovirol 1998; 18(Supp)1: S111-S119.

5. Oliver KJ, Friedman SR, Maynard H, et al. Impact of a needle exchange program on potentially infectious syringes in public places [letter]. J AIDS Hum Retrovirol 1992; 5:534-535.

6. Doherty MC, Junge B, Rathouz P, et al. The effect of a needle exchange program on numbers of discarded needles: A 2-year follow-up. Am J Publ Health 2000; 90:936-939.

7. Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Publ Health 2000; 90:1933-1936.

8. Lurie P, Reingold AL, eds. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Atlanta; Centers for Disease Control and Prevention, 1993.

9. Bluthenthal RN, Kral AH, Gee L, et al. The effect of syringe exchange use on high-risk injection drug users: A cohort study. AIDS 2000; 14:605-611.

10. Hagan H, McGough JP, Thiede H, et al. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat 2000; 19:247-252.

11. Des Jarlais D. Prevention. Needle-exchange programs effective in New York City. AIDS Policy Law News 2001; 16:6.

12. Stover H. Evaluation of needle exchange pilot projects shows positive results. Can HIV AIDS Policy Law News 2000; 5:60-64, 65-69.