Increase Access to Needle Exchanges

Return to Opioid Top-Level Strategy Map or Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)

 

Background

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C.

Many Organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others.

The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C. As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well.

Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.

Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:

• 194 HIV infections averted in one year 
• And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent 

Do Needle Exchanges Increase Drug Injection Rates?

A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). 

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. 

Different Models for Syringe Exchanges

There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:

Primary and Secondary Needle and Syringe Programs:

• They are fixed sites that are typically located in areas with high levels of injecting drug use.
• They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.
• Those who attend will be able to receive clean paraphernalia, and dispose safely of used paraphernalia. Also typically At fixed sites, additional services are offered such as healthcare alongside testing and or counselling for HIV and other blood-borne viruses 

Mobile or On-Call Service

• Mobile programs operate from a van or bus with clean needles that are distributed.

Larger mobile programs typically proved testing and other healthcare services.

• These will typically operate along regular routes at fixed times, often at night at times when increased use occurs.

Mobile services can also be smaller and choose to target specific populations.

Typically, Mobile programs are more accessible to injection drug users and face less opposition from a community. 

</ul>

Dispensing Machine Distribution

• A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.
• Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.
• Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.
• A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.

Peer Service: Distribution Networks

• Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.
• These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.
• This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. 

Prison-Based Facilities

• Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.
• High need because prison populations have higher cases of Hepatitis C and HIV than the average population. 

Hepatitis C is more than three time more prevalent among people who inject drugs than HIV. In most countries, more than half the people who inject drugs are living with Hepatitis C. In addition, the number of undiagnosed cases is estimated to be very high: between 50 and 90 percent of people living with Hepatitis C may be unaware of their infection. In countries with repressive drug laws, Hep C testing rates among people who use drugs are often even lower largely due to stigmatisation in health care settings, fear of arrest, or the unavailability of treatment and testing.

  Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C transmission among people who inject drugs, provided they are accessible and delivered at the required scale.

  While chronic Hepatitis C is not a death sentence, it creates a slew of long term problems. About one in five people will develop more progressive liver damage with fibrosis (scarring of the liver). Hep C can also cause cirrhosis to the point where the scarring diminishes liver function. Aside from discomfort, this slow burn inflammation can exacerbate other conditions, and in up to five percent of people lead to the kind of full liver failure that requires an organ transplant.
 

  Prevention is a extraordinarily cost effective. In 2013 the FDA approved a new class of direct-acting antiviral drugs for Hep C, which can clear the body 90% of the time. However, a course of treatment for either of the most common medications, Viekira Pak or Harvoni, can cost $85,000 to $94,500. It would cost more than 10 percent of all the medical care in the country to treat the roughly 3.5 million Americans estimated to be infected with Hep C. Hep C treatment is costly to public programs as well. In 2015, Medicaid spent about $2.2 billion on just one Hep C medication, Harvoni, made by Gilead Sciences. This Hep C treatment cost more than any other individual medication.

  Sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). IN turn, IDUs often spread HIV to other, non-injecting populations through sexual relations. In addition, used syringes and needles are a potential biohazard throughout the geographic area within which IDUs primarily reside, and beyond it as well.

  Studies have found that needle exchange programs also reduce pollution.

 

 

Different Models for Syringe Exchanges

There are several different modesl for syringe exchanges that have different advantages and limitations.  The website for the North Carolina Harm Reduction Coalition (NCHRC) describes these in their website. The models include: 

• Fixed-site Exchanges
• Mobile/Street-based Exchanges or Vehicle-based Exchanges
• Home Delivery or Peer-based Exchanges
• Integrated Syringe Exchanges
   

Return Rates of Needle Exchanges

One prominent study sought to answer the question "is the number of needles distributed from NEPs proportionate to the number of needles returned to NEPs?"
  Overall, the global return rate for NEPs was 90% based on a total distribution of 11,971,584 needles (needles out) and 10,793,270 needles returned to the NEPs (needles in). The US return rate was over 90% (315,942 needles distributed, 282,897 needles returned).

  The evidence regarding return rates presented in this this study makes it clear that supplying IDUs (Injecting Drug Users) with clean needles does not lead to more "dirty" needles in any given community. While NEP critics argue that distribution of needles to IDUs does nothing more than increase the number of needles in circulation, the evidence presented here does not support that assertion.

 

 

Peer-Delivered Needle Exchanges

One option being used in King County, WA is to use peers to bring new syringes to people injecting drugs. (Find out more.)
[2]
[3]
  Research on the influence of peer-delivered syringe exchanges on mental health

 

 

Success Stories

Scott County, Indiana

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month.

 

Tools & Resources

TR - Increase Access to Needle Exchanges

Scorecard Building

Potential Objective Details
Potential Measures and Data Sources
Potential Actions and Partners

Resources to Investigate

More RTI on Increase Access to Needle Exchanges

PAGE MANAGER: [insert name here]
SUBJECT MATTER EXPERT: [fill out table below]

Reviewer	Date	Comments

Sources

---

1. [4]
2. [5]
3. [6]
4. [7]
5. [8]
6. [9]
7. [10]
8. [11]