Needless exchange programs

The methodology was codified in a manual. Standardized training of the research staff was provided. In the 15 cities, 33 needle exchange sites were visited and a total of interviews with needle exchange directors and staff, public health officials, injection drug use researchers, community leaders, program participants 11 focus groups , and injection drug users not enrolled in programs 7 focus groups were completed.

Observation guidelines were pretested at two sites and the results were compared qualitatively for interrater reliability before adopting the final guidelines.

Of the nine outcomes and expectations for successful needle exchange programs listed in Table 7. That is, research findings concerning four of the five possible positive outcome domains were reviewed: reduction in drug-related and sexual risk behaviors, increase in referrals to drug abuse treatment, and reduction in HIV and other infection rates.

The report addressed all four possible negative outcomes: increases in 1 drug use by program participants; 2 new initiates to injection drug use; 3 drug use in the community in general; and 4 the number of contaminated needles discarded. The University of California report reviewed data on reported needle-sharing frequency in studies of needle exchange programs.

Of the 26 evaluations addressing behavior change associated with the use of needle exchange programs that were identified, 16 were deemed of acceptable quality rating 3 or higher. Of the 16 studies, 14 presented data on the frequency of needle sharing; 9 of these had comparison groups reported. As Table 7. Regarding sexual risk behavior change, the report concluded that the findings were neutral. That is, four studies reported beneficial effects of needle exchange programs relating to sexual risk associated with number of partners and two reported mixed or neutral effects.

When reviewing studies that addressed risk associated with partner choice, three showed beneficial effects and two reported mixed or neutral effects. Finally, beneficial effects of needle exchange programs relating to condom use were observed in one study, mixed or neutral results in another, and adverse effects in three studies. The University of California report noted that 17 of 18 U.

Of 33 U. The extent to which referrals enter treatment and are retained was described—the 6 programs that collect data on referrals reported 2,—but was not studied. The report noted Lurie et al. This affects the likelihood that a needle exchange program will refer and that a referral will link a client with treatment. The University of California report identified 21 studies that were relevant to the issue of whether needle exchange programs impact rates of HIV infection: 2 case studies, 7 serial community cross-sectional studies, 6 serial needle exchange program cross-sectional studies, 1 case-control study, and 3 prospective studies.

The quality of studies was rated on a 5-point scale ranging from a low of 1 not valid to a high of 5 excellent and a mid-point of 3 acceptable. Only two of the studies received a quality rating of 3 or higher, and two others were rated between 2 and 3. None of the studies showed increased prevalence or incidence of HIV infection among needle exchange participants. Given the quality rating of the studies, it is not surprising that the University of California report concluded that the studies available up to the time of the report Lurie et al.

However, needle exchange programs do not appear to be associated with increased rates of infection. It is intrinsically difficult to measure effects of intervention on the incidence of new infections of rare diseases, whose victims ordinarily do not show symptoms at the time of infection.

Although most of the early studies used prevalent infection as the outcome measure, the more appropriate measure is incident or new infection. However, a further complication is that incidence is low in most locations, thereby requiring larger study populations to demonstrate program effects. The University of California report noted Lurie et al.

Well-conducted, sufficiently large case-control studies offer the best combination of scientific rigor and feasibility for assessing the effect of needle exchange programs on HIV rates. The University of California report noted that eight "acceptable" studies were identified that presented data on the issue of reported injection frequency. This last study also found reduced needle sharing reported among needle exchange participants. This study noted that the apparent increase in injection could be attributed to several other factors, including the differential dropout of low-level injectors.

The report also reviewed the methodological limitations of the studies, including the potential for socially acceptable responses by injection drug users. On balance, because of methodological problems, the report drew no strong conclusions about levels of injection drug use.

The University of California report reviewed a variety of studies and used focus groups to understand whether needle exchange programs could encourage persons to initiate injection drug use. In reviewing the demographic data from the programs, the report noted that the median age of participants across programs ranged from 33 to 41, and the median duration of injection drug use from 7 to 20 years.

This suggests that most participants initiated injection drug use prior to using the needle exchange program. A review of serial cross-sectional studies of injection drug users in San Francisco noted an increase in the mean age of the samples over time from 34 in to 40 in , suggesting that there was not an increase in young new injectors over time. Researchers in Amsterdam used a capture-recapture method to estimate the number of injection drug users between and Despite initiation of a needle exchange program in , no change in the number of injection drug users was reported, and the average age of drug users increased over time.

Furthermore, the number of drug users under age 22 decreased from 14 percent in to 3 percent in The authors concluded that there was no increase in the number of new initiates into injection drug use. The report concluded, on the basis of evidence from surveys, that Lurie et al. Focus groups were consulted. Of 10 focus groups from needle exchange programs, comprising 65 injection drug users, 2 individuals thought needle exchange programs could encourage nonparenteral drug users to start injecting.

Among seven nonprogram focus groups comprising 47 injection drug users, 2 individuals thought needle exchange programs could encourage nonparenteral drug users to start injecting. The focus group data were viewed as corroborating evidence for the data available from surveys arguing against an effect of needle exchange programs on increasing the community levels of injection drug use. The University of California report addressed the potential for increased drug use in the community by reviewing the studies noted in the previous section.

Researchers searched for additional data by examining established data sets of drug abuse indicators and answers to additional questions asked of focus groups of injection drug users. The University of California researchers attempted to relate the presence or absence of needle exchange programs to ongoing statistical series like the Drug Abuse Warning Network DAWN , Drug Use Forecasting DUF , and Uniformed Crime Reports UCR , which might reflect altered patterns of drug-related events, such as drug cases in hospital emergency rooms, positive urine drug screens, and drug-related arrests, respectively.

The report noted wide variation in these drug-use indicators over time, which suggests inherent lack of precision and limits the manifestation of patterns—if any—relating to needle exchange. The University of California report also noted that, because needle exchange programs are relatively new, changes in drug use might yet appear with longer follow-up.

The report concluded that Lurie et al. The report also noted that the San Francisco and Amsterdam surveys described above provide Lurie et al. The University of California report noted that adverse community responses to needle exchange programs are likely to be centered on the issue of discarded needles and the risk to the public of accidental needlestick injury. However, the report noted that one-for-one exchange rules cannot, in theory, increase the total number of discarded needles, although programs could affect the geographic distribution of discarded syringes.

Data on a surveillance project with the Portland, Oregon, needle exchange program noted a decrease in the prevalence of discarded syringes near the program Lurie et al. Passive surveillance of health or police department reports over time indicated either declines or small increases in needlestick injuries, with the trends due to changes in reporting patterns. The University of California report concluded that needle exchange programs "have not increased the total number of discarded syringes" and, if structured as a one-for-one exchange with no starter needles, "they cannot increase the total number of discarded needles" Lurie et al.

Using multiple data sources, the University of California reviewed a number of questions about needle exchange programs.

As far as possible positive outcomes are concerned, the report concluded that the data available at the time of the report "do not … provide clear evidence that needle exchange programs decrease HIV infection rates," p. The report goes on to state that there is no evidence that drug use among program participants increased, and there is no evidence of change in overall community levels of noninjection or injection drug use Lurie et al.

This section is organized into topical areas that parallel the summaries of the GAO and University of California reports. Study findings are categorized according to the outcomes and expectations of program effects listed in Table 7. Since the University of California report was issued, a number of studies on the impact of needle exchange programs have been presented or published.

These studies utilize a variety of designs, including an ecological design; a comparison of prevalence rates between injection drug users who use and those who do not use needle exchange programs; HIV incidence rates among needle exchange program attenders; and, using data collected prospectively, a comparison of HIV incidence rates between injection drug users who attend and those who do not attend a needle exchange program.

Recent publications on needle exchange programs in San Francisco, New York City, and Portland, Oregon, have addressed the issue of the impact of the programs on HIV drug-use risk behaviors and sexual risk behaviors Watters et al. In an ecological study in San Francisco, Watters examined the trends in risk behaviors and HIV seroprevalence over a 6. Interviews 5, were conducted with injectors in street settings and drug detoxification clinics.

During that time period, multiple prevention efforts targeting injection drug users had been implemented including outreach, education, voluntary HIV testing and counseling, bleach and condom distribution, and needle exchange programs.

Among injection drug users who reported sharing needles, the proportion of those who reported ever using bleach increased from 3 percent in to 89 percent by and remained relatively constant at that level through fall Sexually active heterosexual male injectors also reported significant changes in condom use i. However, Lewis and Watters found that a substantial proportion of sexually active male drug injectors, including heterosexuals, bisexuals, and homosexuals, reported frequently engaging in unprotected sex i.

Several trends in drug-use risk behaviors were reported. In , for example, 65 percent of injection drug users reported having used shooting galleries in the preceding 2 years; in the to survey, only 3 percent reported injecting in shooting galleries in the preceding 6 months. Substantial reductions in sharing behavior were also observed. Use of potentially contaminated needles declined from 51 to 7 percent of injections. Moreover, an increasing proportion of injection drug users entering the detoxification program reported using the needle exchange programs since they opened in For the to period, results also show that needle exchange participation was associated with a downward trend in the proportion of subjects reporting any injection with needles that had been used by someone else and a reduction in the percentage of study participants reporting having passed on used needles to others.

The extent to which the reductions in risk behaviors reported in the two surveys can be attributed to the needle exchange program itself is limited by the fact that the data are ecological trends.

Other prevention efforts were occurring in New York City between the two time intervals. Therefore, although the results are consistent with an inference of reduction in risk behaviors following the introduction of a needle exchange program, the study design does not exclude the possibility of contributing or alternate explanations. In the San Francisco needle exchange program evaluation, Watters compared frequent needle exchange participants with two comparison groups—injection drug users who used the exchange less frequently and a group who did not use it at all.

These researchers found a 47 percent decline from 66 to 35 percent in reported sharing behavior among injection drug user study participants between spring and spring More refined analyses revealed that frequent needle exchange participants i. In contrast, over the 3-year study period, no change in reported rates of sharing behavior was observed among those not using the program.

In New York City, Paone et al. Participants reported a two-thirds decline in the proportion of time they injected with previously used needles 12 percent before participating in the needle exchange program, compared with 4 percent in the last 30 days while participating in the program. Similar reductions in renting or buying used needles 73 percent decline were observed, and similar reductions in the number of participants who reported borrowing used needles were found 59 percent decline.

The number of participants who reported using alcohol pads increased from 30 percent before participating in the needle exchange program to 80 percent in the most recent 30 days in the exchange. Although the reduction in high-risk behaviors was based on self-reports of exchange users and no comparison of injection drug users not using the exchange was included in this report, this pattern of reduction in drug-use risk behaviors was found to be relatively stable in recent updates Des Jarlais et al.

These authors also note in their recent updates that minimal changes in sexual risk behaviors were reported. For example, always using a condom with a primary sexual partner increased from 36 percent in the 30 days prior to first using the needle exchange program to 37 percent for the last 30 days while using the program; whereas always using a condom with a casual sexual partner increased from 56 percent in the 30 days prior to first using the exchange program to 60 percent in the last 30 days while using the exchange.

However, due to design constraints, it cannot be stated what portion of the reduction in risk behaviors is due to the needle exchange program.

An evaluation of the Portland needle exchange program Oliver et al. When drug-use risk behaviors of frequent attenders attended four or more times were compared with risk behaviors of those who attended three or fewer times, frequent attenders reported greater risk reduction on borrowing and returning used needles to the program. Frequent needle exchange participants were found to be less likely to reuse needles without cleaning or to improperly dispose of used needles than were the NADR clients.

The two groups were not found to differ on other risk behaviors assessed. It is worth noting that there was little overlap between the two groups 11 percent. The two interventions apparently are recruiting different participants. In sum, from the earliest studies of needle exchanges, there has been a dominant trend in the data showing significant and meaningful associations between participation in needle exchange programs and lower levels of drug-use risk behaviors, and small or no change in sexual risk behaviors.

The most recent data continue to reflect this trend. Moreover, this pattern of findings has also been observed in foreign cities Davoli et al. Both reported a stabilization of HIV seroprevalence rates that coincided with reductions in high-risk behaviors and the implementation of various prevention programs including outreach, education, testing and counseling, bleach and condom distribution, and needle exchange programs. Although these ecological studies do not provide direct causal evidence of the effect of such programs, they nonetheless document a pattern in behavioral risk reduction that corresponds with stabilization of seroprevalence rates in distinct populations of injection drug users.

Hagan and colleagues b reported seroprevalence rates of needle exchange participants and nonparticipants. Because the outcome measured in this study was prevalent infection, temporal associations cannot be established with certainty, and the possibility that the results might reflect that the needle exchange program attracts lower-risk injection drug users cannot be dismissed out of hand. However, the results are consistent with the inference that needle exchange programs are associated with a lower risk of infection.

On the basis of recent updates from the International Conference on AIDS, Des Jarlais ; in press provided descriptive information on HIV incidence among injection drug users who participate in needle exchange programs across 14 different cities Table 7. Some of these incidence rates were measured directly by testing cohorts of needle exchange participants; others were based on self-reports of prior serological tests; still others were derived from statistical modeling techniques e.

These findings are consistent with the premise that an AIDS prevention program e. Although the prevalence is moderate and has remained stable, the observed incidence is high among the needle exchange cohort being studied.

The program is located in an area of the city noted for prostitution, and the program operates in the middle of the night, which makes it prone to recruiting high-risk users. That is, although the risk of seroconversion was found to be higher among needle exchange participants when compared to nonparticipants, injection drug users who used the needle exchange program as their exclusive source of sterile needles were found to be at substantially lower risk than those who used diverse sources of sterile needles.

Furthermore, the needle exchange program limit of 15 needles per visit may not be sufficient to properly address drug-use risk behaviors of individuals who inject large amounts of cocaine. There is also a high level of male prostitution among the needle exchange participants. Specific ethnographic studies are needed to better understand the primary routes of transmission implicated and their dynamics e.

This would allow the program to better tailor its services e. The potential ability of needle exchanges to attract injection drug users that are at high risk of seroconversion was also recently reported in the United States by a San Francisco research team Hahn et al.

Although the disparities in observed seroincidence rates between needle exchange participants and nonparticipants could not be attributed to having been exposed to the needle exchange program, the program appeared to serve a relatively high-risk subset of injection drug users. The authors concluded that the San Francisco program provides a unique setting for intervention because it provides direct access to a population that is at high risk. Other cities with needle exchange programs that have high seroprevalence data e.

These data are consistent with the premise that AIDS prevention programs e. Obviously, these results are descriptive in nature there are no comparison groups and, as a consequence, cannot in themselves provide evidence of the direct causal effect of needle exchange programs on HIV incidence rates. Nonetheless, they do provide valuable insight into HIV incidence rates among needle exchange participants in cities with varying levels of HIV seroprevalence among the local populations of injection drug users.

The HIV seroconversion rate among high-frequency drug injectors not using the needle exchange programs ranged from 4 to 7 per person years at risk, compared with needle exchange participant groups with seroconversion rates ranging from 1 to 2 per person years at risk. These findings suggest that the use of needle exchange programs has a substantial protective effect for preventing new HIV infections.

However, the results need to be interpreted with care. That is, nonequivalence across groups being compared needle exchange users versus nonusers precludes making strong causal inferences about the direct effect of the needle exchange on HIV incidence rates.

Nonetheless, these data do reflect a significant association between needle exchange participation and HIV infection Des Jarlais et al. The most recent studies that have examined drug-use behaviors among needle exchange participants show either stable levels of reported drug injection frequency or even slight declines over time among injection drug users who continue to participate in needle exchange programs Watters et al.

In the recent New York City study, Paone et al. The only exception to this reported trend comes from an unpublished research manuscript from Chicago researchers O'Brien et al. As noted in the Preface, as the panel was concluding its deliberations, the Assistant Secretary for Health made public statements that a number of unpublished needle exchange evaluation reports had raised doubts in his mind about the effectiveness of these programs. The panel deemed these statements to be significant in the public debate, therefore necessitating appropriate consideration in order for the panel to be fully responsive to its charge.

The panel therefore reviewed the unpublished studies, one of which was the aforementioned O'Brien et al. As unpublished findings, this research lacks the authority provided by the peer review and publication process.

For this reason, the panel gave special attention to scrutinizing and describing in detail results reported by the researchers, as well as appraising their probative value see Appendix A. The investigators infer from their findings that those who participate in needle exchange programs spend more money and inject more frequently than nonparticipants as a result of their participation in the program.

Their assertion is based on data that, according to these authors, support the contention that program participation is economically driven i. The panel's review raised serious concerns about the tenability of their inferences. For instance, a clearly insufficient theoretical and empirical development of the underlying models is used.

That is, there are numerous other plausible models that could explain their data. From an economic standpoint, it would seem that individual socioeconomic status may be causally related to both drug abuse and use of the needle exchange program, rather than to the explanation that needle exchange programs cause drug use.

Nonetheless, the authors do not test any alternative plausible models to assess the relative fit of their models compared with other viable competing models. Moreover, a weak theoretical justification is provided of their postulated model e.

The empirical information provided on key variables is inadequate. Properties of the distributions of key variables are absent and aggregate summary statistics are used in various models without attention to the possible adverse effect of outliers. The presence of such outliers can severely distort the results and challenges the viability of the inferences drawn by these investigators.

Substantial inconsistencies between data on key variables self-report presented in the manuscript and information extracted from the needle exchange program records raised serious concerns among panel members. Moreover, as discussed in some detail in Appendix A , the panel had serious reservations about the appropriateness of the modeling techniques as implemented by these researchers. Although this particular study suffers from serious limitations, the conclusions reached by the authors raise interesting questions and hypotheses that should be subjected to sound empirical testing.

These issues should be further studied with adequate designs, measures, and analytical methods. In the meantime, in the panel's opinion, these difficulties are serious enough to preclude making causal inferences about the effect of needle exchange programs. The concern that having the opportunity to use a needle exchange may lead persons who are not currently injecting to begin injecting demands attention, and some information about this is available. If the opportunity to participate in needle exchange programs were to lead to an increase in the number of new injection drug users, one would expect to see relatively large numbers of young newer injectors at the needle exchange programs.

This has not been observed in any of the earlier studies e. Investigators in Amsterdam have recently published data that permit examination of the hypothesis that "mixing" of injecting and noninjecting drug users at needle exchanges will lead noninjectors to begin injecting behavior van Ameijden et al. Many of the Amsterdam needle exchanges are operated out of the "low-threshold" methadone programs.

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We use our own as well as third party cookies to improve your site experience and the services we make available. You can learn more about our use of cookies in our Privacy Policy. What Are Needle Exchange Programs? Although the services they provide may vary, SSPs are community-based programs that provide access to sterile needles and syringes, facilitate safe disposal of used syringes, and provide and link to other important services and programs such as.

Some states have passed laws specifically legalizing SSPs because of their life-saving potential. SSPs may also be legal in states where possession and distribution of syringes without a prescription are legal. Decisions about use of SSPs as part of prevention programs are made at the state and local levels.

The Federal Consolidated Appropriations Act of includes language that gives states and local communities meeting certain criteria the opportunity to use federal funds provided through the Department of Health and Human Services to support certain components of SSPs, with the exception of provision of needles, syringes, or other equipment used solely for the purposes of illicit drug use.

People who inject drugs and who have used an SSP regularly are nearly three times as likely to report a reduction in injection frequency as those who have never used an SSP. Nonsterile injections can lead to transmission of HIV, viral hepatitis, bacterial, and fungal infections and other complications. By providing access to sterile syringes and other injection equipment, SSPs help people prevent transmitting bloodborne and other infections when they inject drugs.

In addition to being at risk for HIV, viral hepatitis, and other blood-borne and sexually transmitted diseases, people who inject drugs can get other serious, life-threatening, and costly health problems, such as infections of the heart valves endocarditis , serious skin infections, and deep tissue abscesses.

Access to sterile injection equipment can help prevent these infections, and health care provided at SSPs can catch these problems early and provide easy-to-access treatment to a population that may be reluctant to go to a hospital or seek other medical care. Studies show that SSPs protect the public and first responders by providing safe needle disposal and reducing the presence of needles in the community. SSPs do not cause or increase illegal drug use.

They do not cause or increase crime. SSPs reduce health care costs by preventing HIV, viral hepatitis, and other infections, including endocarditis, a life-threatening heart valve infection. SSPs help people overcome substance use disorders. If people who inject drugs use an SSP, they are more likely to enter treatment for substance use disorder and reduce or stop injecting. Skip directly to site content Skip directly to page options Skip directly to A-Z link.

Dziko Colin Arthur Non-Cost Services Available Free needles, cookers, filters, ties, etc. Do a test shot. Inject slowly. Avoid using alone. This can put you at a higher risk of overdosing because no one is there to help you. Keep your tolerance in mind. Use a smaller amount. No clean equipment?