U.S. Department of Health and Human Services
Washington, DC

March 17, 2000

Contents

1. Needle Exchange in the U.S. - National Surveys

Paone D, Clark J, Shi Q, Purchase D, Des Jarlais DC. Syringe exchange in the United States, 1996: A national profile. Am J Public Health 1999 Jan; 89(l):43-6.

ABSTRACT Objectives: This paper provides 1996 information on the status of US syringe exchange programs and compares these findings with data from our 1994 survey. Methods: In November 1996, questionnaires were mailed to 101 syringe exchange programs. Program directors were contacted to conduct telephone interviews based on the mailed questionnaires. Data collected included number of syringes exchanged, syringe exchange program operations, legal status, and services offered. Results: Eighty-seven programs participated in the survey. A total of 46 (53%) were legal, 20 (23%) were illegal but tolerated, and 21 (24%) were illegal underground. Since 1994, there has been a 54% increase in the number of cities and a 38% increase in the number of states with syringe exchange programs. Eighty-four programs reported exchanging approximately 14 million syringes, a 75% increase from 1994. Syringe exchange programs also provided a variety of other services and supplies, and legal programs were more likely than illegal ones to provide these services. Conclusion: Despite continued lack of federal funding, syringe exchange programs expanded in terms of the number of syringes exchanged, the geographic distribution of programs, and the range of services offered.

COMMENT Many syringe exchange programs provide a range of preventive health services and health care, directly and through referrals. Of those programs surveyed, 97% provided referral to substance abuse treatment, 80% provided education to reduce risks of STDs, while many others provided HIV counseling and testing, primary health care, and tuberculosis screening in addition to exchanging sterile syringes for contaminated ones. The finding that legal programs are more likely to provide health services may reflect their ability to establish more regular hours and locations and to more formally refer clients to existing health, mental health and substance abuse treatment services. It has recently been estimated (Des Jarlais, 1999) that only 10% of injection drug users have access to needle exchange programs and their associated ancillary services, despite evidence that these programs are effective in reaching populations at very high risk for HIV and in need of substance abuse treatment services.

Centers for Disease Control and Prevention. Update: Syringe Exchange Programs -United States, 1997. Morbidity and Mortality Weekly Report, August 14, 1998, Vol 47 (31); 652655.

(NO PUBLISHED ABSTRACT)

COMMENT This report provides an updated survey of the number and characteristics of syringe exchange programs (SEPs) in operation in the United States. The findings indicate continued expansion in the number, geographic coverage, and activity of SEPs in the United States. Of 113 SEPS contacted, 100 (89%) participated in the survey. These 100 SEPs reported operating in 80 cities in 30 States, the District of Columbia, and Puerto Rico. In 1997, 96 of the SEPs provided information about the number of syringes and reported exchanging approximately 17.5 million syringes (median; 57,343 syringes per SEP). The 10 largest volume SEPs (i.e. those that exchanged greater than or equal to 500,000 syringes) exchanged approximately 10.3 million (59%) of all syringes exchanged. Most of the 100 SEPs provided other public health and social services: 99% offered instruction to prevent sexual transmission of HIV and other sexually transmitted diseases; 96% provided IDUs with information about safer injection techniques and/or use of bleach to disinfect equipment; and 94% referred clients for substance abuse treatment programs. Health care services offered on site included HIV counseling and testing (64%), tuberculosis skin testing (20%), STD screening (20%), and primary health care (19%). The 100 SEPs operated in various settings, with 69% operating in multiple settings. SEPs reported receiving financial support from various sources including foundations, individuals, and state and local governments.

2. Risks Associated with Re-use of Syringes: A Laboratory study

Abdala N, Stephens PC, Griffith BP, Heimer R. (1999). Survival of HIV-1 in Syringes. J Acquir Immune Defic Syndr Hum Retrovirol 1999 Jan 1;20(1):73-80

ABSTRACT Summary: We performed a study to determine the duration of survival of HIV-1 in syringes typically used by injectors of illicit drugs (IDUs). We describe the effectiveness of a microculture assay in detecting viable virus in volumes of blood typical of those commonly found inside used syringes. Using this assay and modeling the worse-case situation for syringe sharing, we have recovered viable, proliferating HIV-1 from syringes that have been maintained at room temperature for periods in excess of 4 weeks. The percentage of syringes with viable virus varied with the volume of residual blood and the titer of HIV- I in the blood. These experiments provide a scientific basis for needle exchange schemes, harm reduction, and other interventions among IDUs that support the nonsharing and removal of used syringes from circulation.

COMMENT Since the early years of the epidemic, researchers have documented that sharing of blood-contaminated equipment carries a substantial risk for transmission of HIV, and hepatitis B and C. These newly reported findings which document the long survival time of HIV- 1 in syringes have implications for needle exchange program, in that the study confirms that a substantial proportion of needles removed from circulation may have viable HIV and could transmit the infection. This data provides a scientific virologic rationale for the role syringe exchange programs play in reducing HIV transmission via used injection equipment, as these programs are organized to provide new, sterile injection equipment and remove from circulation potentially infectious needles and syringes.

3. Effectiveness of Needle Exchange Programs

Brooner R., Kidorf M, King V, Bielenson P, Svikis D, Vlahov D. A Drug Abuse Treatment Success among Needle Exchange Participants. Public Health Reports, 113; Supplement 1: pp. 130-139, June 1998.

ABSTRACT Objective: Although lowering incidence rates of human immunodeficiency virus (HIV) transmission is the primary goal of needle exchange programs (NEPs), other desirable outcomes are possible. Referring exchange participants to more comprehensive drug abuse treatment programs has the potential to reduce or eliminate the use of drugs. This possibility was evaluated by comparing the treatment responses of new admissions with an outpatient opioid agonist treatment program in Baltimore, Maryland. Methods: New admissions (1994-1997) to an opioid agonist treatment program were first grouped by referral source (needle exchange, n =82, vs. standard referrals, n = 243) and then compared on admission demographic and clinical variables and response to treatment during the first three months. Outcome measures included retention rates, self-reported drug use and injecting frequencies, self-reported illegal activities for profit, and results from weekly urinalysis testing for opioids and cocaine. Results: Patients from the NEP were significantly older and more likely to be male, African American, and unemployed than standard referral patients. Needle exchange patients also had a greater baseline severity of drug use than patients in the standard referral group. Despite these baseline differences, both groups achieved comparably good short-term treatment outcomes (including reduced drug use and criminal activity for profit); treatment retention was also good, although slightly better in the standard referral group (88% vs. 76%). Conclusion: These data demonstrate the feasibility and merits of creating strong linkages between NEPs and more comprehensive drug abuse treatment clinics.

COMMENT Two significant findings of this study are the ability of a NEP to successfully refer NEP clients to a substance abuse treatment program (51 % of referrals were admitted to treatment) and the relatively high treatment retention rates for NEP-referred clients, despite greater severity of baseline drug use among this population compared to clients from standard referral sources. Establishing linkages between syringe/needle exchange programs and substance abuse treatment programs may lead to meaningful reductions in, or the elimination of, drug use among NEP clients in addition to the primary goal of reducing the risk of bloodborne infectious diseases in this population.

Hagan H, McGough JP et al. Reduced Injection Frequency and Increased Entry and Retention in Drug Treatment Associated with Needle Exchange Participation in Seattle Drug Injectors. In Press, Journal of Substance Abuse Treatment

ABSTRACT Objectives: The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Methods: Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. Results: IDUs who had formerly been exchange users were more likely than never exchangers to report a substantial (> 75%) reduction in injection (ARR=2.85, 95% CL 1.47-5.51, to stop injecting altogether (ARR=3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. Conclusions: Reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.

COMMENT The frequency of drug injection among active IDUs using a needle exchange program decreased during the time of this study. Both current users and new users of the needle exchange program were more likely to enter methadone treatment programs than IDUs who did not use the needle exchange program. Retention in methadone treatment at 12-month follow-up was 68% for former users of the NEP, 60% of current users of the exchange, and 45% of new users of the NEP. These findings support the role NEPs can play as a conduit into sustainable substance abuse treatment among heroin injectors.

Strathdee S, Celentano D et al. Needle Exchange Attendance and Health Care Utilization Promote Entry into Detoxification. In Press, Journal of Urban Health

ABSTRACT This study was undertaken to identify factors associated with entry into detoxification among injection drug users (IDUs), and to assess the role of needle exchange programs (NEPs) as a bridge to treatment. IDUs undergoing semi-annual human immunodeficiency virus (HIV) tests and interviews were prospectively studied between 1994 and 1998, during which time a NEP was introduced in Baltimore. Logistic regression was used to identify independent predictors of entry into detoxification, stratifying by HIV serostatus. Of 1490 IDUs, similar proportions of HIV-infected and uninfected IDUs entered detoxification (25% vs. 23%, respectively). After accounting for recent drug use, hospital admission was associated with four-fold increased odds of entering detoxification for HIV-seronegative subjects. Among HIV-infected subjects, hospital admission, outpatient medical care and having health insurance independently increased the odds of entering detoxification. After accounting for these and other variables, needle exchange attendance also was independently associated with entering detoxification for both HIV-infected (adjusted odds ratio [AOR]=3.2) and uninfected IDUs (AOR=1.4). However, among HIV-infected subjects, the increased odds of detoxification associated with needle exchange diminished significantly over time, concomitant with statewide reductions in detoxification admissions. These findings indicate that health care providers and NEPs represent an important bridge to drug abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug abuse treatment and serve the important public health goal of increasing the number of drug users in treatment.

COMMENT This study provides a quantitative measure of the association between NEP attendance and subsequent entry into drug abuse treatment in an out-of-treatment population. NEP attendance was independently associated with entry into detoxification programs for both HIV-negative and HIV-infected clients. The researchers noted that the decreased strength of the association over time was likely due to external factors, such as the increased difficulty in obtaining admission for detoxification in Maryland and third party reimbursement barriers that differentially affected HIV-infected IDUs previously eligible for social security benefits. The research supports previous observations that NEPs can be a conduit to drug abuse treatment for very high risk populations.

Heimer R, Khoshnood K, Bigg D, Guydish J, Junge B. Syringe Use and Reuse: Syringe Exchange Programs in Four Cities. Journal of Acquired Immunodeficiency Syndromes and Human Retrovirology. 1998: 18(Suppl 1): S37-S44.

ABSTRACT Summary: We determined the effect of syringe exchange programs (SEPs) on syringe reuse patterns. Five methods were employed to estimate injections per syringe made by exchange clients in four cities. In San Francisco, Chicago, and Baltimore, self-reported data on the number of injections per syringe were obtained. In New Haven, self-reported injection frequencies were combined with syringe tracking data to derive two methods for estimating the mean injections per syringe. The average number of injections per syringe declined by at least half after establishment of SEPs in New Haven, Baltimore, and Chicago, all cities where such an analysis could be made. There were significant increases in the percentages of exchangers reporting once-only use of their syringes in San Francisco, Baltimore and Chicago, all cities where the data were amenable to this form of analysis. Self-report and syringe tracking estimates were in agreement that SEP participation was associated with decreases in syringe reuse by drug injectors. SEP participation was associated with increases in the once-only use of syringes. These findings add to earlier studies supporting the role of SEPs in reducing the transmission of syringe-borne infections such as HIV and hepatitis.

COMMENT This study uses several methods to assess syringe reuse among participants of syringe exchange programs, including syringe tracking data to minimize potential response bias associated with self-reported data. The decreased reuse of contaminated syringes observed over time in these study cohorts is significant in light of the previous study by Abdala et al, irrespective of the absence of a control group of non-SEP clients.

Bluthenthal RN, Kral AH, Erringer EA, and Edlin BR. Use of an Illegal Syringe Exchange and Injection-Related Risk Behaviors among Street-Recruited Injection Drug Users in Oakland, California, 1992-1995. Journal of AIDS and Human Retrovirology, 1998.

ABSTRACT Objective: To determine factors associated with syringe and injection supply sharing among injection drug users (IDUs) in a community with an illegal underground syringe exchange program. Methods: From 1992-1995, semi-annual cross-sectional samples of IDUs were recruited in Oakland, CA. To account for multiple observations from the same individual, we used general estimating equations with logit transformations to determine factors associated with sharing syringes and other injection works. Results: 1304 IDUs were interviewed; 684 (53%) returned for more than one interview. 2830 interviews were available for analysis. SEP use increased and syringe and supply sharing declined from 1992 to 1995 among study participants. In multivariate analysis, SEP users were less likely to share syringes than non-SEP users (adjusted odds ratio [AOR] = 0.57; 95% confidence interval [CI] = 0.46-0.72). SEP use was not significantly associated with the sharing of injection supplies (AOR = 0.85; 95% CI = 0.68 -1.07). Syringe sharing and injection supply sharing were significantly less likely to occur among African American and HIV-positive IDUs. Conclusions: These data suggest that illegal SEPs can be effective HIV prevention programs. Lower rates of syringe-based risk factors among African American and HIV-positive IDUs are encouraging.

COMMENT The researchers re-examined seven semi-annual waves of interviews from both the baseline and follow-up assessments of IDUs who lived in a community with an illegal SEP. Variables that previous research has suggested would have an impact on syringe sharing, such as substance abuse treatment, marital status, gender, and income were included in the models to control for potential confounding factors, as well as control for the potential effects of temporal trends in use of NEPs and syringe sharing. Substantial declines in syringe sharing were observed over the interview periods among users of the SEP compared to non-SEP users. Use of the SEP increased from 5% in 1992 to 36% in 1995 despite arrests of program volunteers during the study period. The study adds to the literature in that it shows a decrease in syringe reuse is also associated with an illegal SEP, whereas most other reported studies come from legal or community-tolerated SEPs.

Bruneau J, Lachance N et al. Changes in HIV Seroconversion Rates of IDUs Attending Needle Exchange Programs in Montreal: The Saint-Luc Cohort. Canadian Journal of Infectious Diseases, [Supplement] May 1999.  

ABSTRACT Objectives: From 1988 to 1995, we observed a positive association between NEP attendance and HIV seroconversion. Since 1995, modifications have been implemented in needle exchange programs (NEPs) in Montreal, including the opening of new distribution sites and the lifting of the syringe quota. The objective is to examine the association between NEPs and HIV seroconversion in the Saint-Luc Cohort after January 1995. Methods: Recent injection drug users (IDUs) were recruited by word-of-mouth and through substance abuse treatment agencies.

Information was collected and HIV status was assessed at each visit. The association between factors on demographics, drug and sexual behaviours and HIV seroconversion was assessed using univariate and multivariate Cox proportional hazards regression. All current IDUs participating in the Saint-Luc cohort as of January 1995 were included in the analysis. Results: The post-1995 cohort included 981 seronegative subjects, 797 men and 184 women. Mean age was 34.5, and 42% reported NEP attendance in the past 3-6 months. 83% and 34% used cocaine and heroin respectively in the past 3-6 months. 42.3% reported unstable housing. From January 1995 to September 1998, 68 seroconverted for a global incidence of 4.3 per 100 person-years (CI 95%: 3.4-5.5 : 4.2 per 100 person years (CI 95%: 2.8-6. 1) among NEP attenders, and 4.4 per 100 person-years (CI 95%: 3.1-5.9) among non-attenders. (HR: 0.97 [0.60 - 1.58]). In a Cox proportional hazards model, factors independently associated with HIV seroconversion were:

Conclusion- After 1995, no association was found between NEP attendance and HIV seroconversion among current IDUs followed in the Saint-Luc cohort. This situation is different from what was observed from 1988 - 1995, and coincided with modifications of needle exchange programs in Montreal.

COMMENT Remis, Bruneau and Hankins published a related paper titled "Enough Sterile Syringes to Prevent HIV Transmission Among Injection Drug Users in Montreal?", in the Journal of Acquired Immunodeficiency Syndrome and Human Retrovirology; Vol 18, Suppl.I, July 1998. The study compared the estimated number of syringes required by injection drug users in 1994 with the number of syringes distributed through needle exchange programs. Syringes distributed through NEPs addressed less than 5% of the estimated demand for syringes by IDUs in Montreal in 1994. The authors advanced the hypothesis that unless the disparity between unmet need and available syringes was reduced, it is unlikely that sufficient syringes would be available to prevent HIV transmission. The observation in this study that NEP use and IRV seroconversion were not associated since 1995 in the Montreal cohort is coincident with modifications of the NEP program and differs from pre-1995 data.

Robles R, Colon H, Matos T, Finlinson H, Munoz A, Marrero C, Garcial M, Reyes J. Syringe and Needle Exchange as HIV/AIDS Prevention for Injection Drug Users in Puerto Rico. Health Policy, 1998; Vol. 45: 209-220.

ABSTRACT This study evaluated the effectiveness of the first needle exchange program (NEP) established in Puerto Rico. The data for this study were collected during the first months of the NEP from July 1995 to March 1996 in 13 communities of the San Juan metropolitan area. Subjects were the participants of two modalities of the NEP: a mobile team and a community based drug treatment program. During the 3-week evaluation period, 2401 injection drug users (IDUs) were recruited, resulting in a total of 19,195 exchange contacts and 146,123 syringes exchanged. No significant change in drug injection was observed. However, the program was effective in reducing sharing of syringes and cookers. The study suggests that the NEP did help in reducing needle sharing in Puerto Rico. However, the HIV seropositivity in returned syringes suggests the need to continue aggressive prevention programs to arrest the epidemic among IDUs. However, factors related to the socio-cultural environment as well as cultural norms and traditions need to be considered when planning and expanding NEPs.

COMMENT In this study, 40% of a sample of 1075 syringes returned to the NEP and studied showed a 27% seropositivity rate for HIV. A significant increase in the number of returned syringes was observed over the evaluation period (12.4% rising to 32.5% at 8 months). The importance of decreasing needle circulation time as an HIV prevention intervention is particularly acute in this setting with high rates of HIV seropositivity in contaminated syringes. Entry into substance abuse treatment among study participants increased over time, with 28% of the NEP participants reporting treatment entry by the seventh month after the NEP began. Both short term and long term harm reduction goals among IDUs were advanced by the NEP.

Des Jarlais DC, Perlis T, Friedman SR, Deren S et al. Declining Seroprevalence in a Very Large HIV Epidemic: Injecting Drug Users in New York City, 1991 to 1996. Am J Public Health, 88(12); 1801-1806, 1998.

ABSTRACT Objective: This study assessed recent trends in HIV seroprevalence among injecting drug users in New York City. Methods: We analyzed temporal trends in IRV seroprevalence from 1991 to 1996 in 5 studies of injecting drug users recruited from a detoxification program, a methadone maintenance program, research storefronts in the Lower East Side and Harlem areas, and a citywide network of sexually transmitted disease clinics. A total of 11,334 serum samples were tested. Results: From 1991 through 1996, HIV seroprevalence declined substantially among subjects in all 5 studies: from 53% to 36% in the detoxification program, from 45% to 29% in the methadone program, from 44% to 22% at the Lower East Side storefront, from 48% to 21% at the Harlem storefront, and from 30% to 21 % in the STD clinics (all p<.002 by chi square tests for trends). Conclusions: The reductions in HIV seroprevalence seen among injecting drug users in New York City from 1991 through 1996 indicate a new phase in this large HIV epidemic. Potential explanatory factors include the loss of HIV seropositive individuals through disability and death and lower rates of risk behavior leading to low HIV incidence.

COMMENT This article is included here as a snapshot of HIV prevalence among IDUs in a major city with the largest AIDS epidemic among IDUs in the world. Risk reduction programs including needle exchange programs, street outreach, and detoxification programs were components of the public health response to the epidemic during the years studied. An overall reduction in HIV seroprevalence among IDUs was found, in the setting of a stable number of IDUs. Declines in HIV transmission-related behavior, such as reusing contaminated injection equipment and lending it to others, were reported from several sites. Many factors might contribute to the decline in HIV seroprevalence. The presence of a broad-based prevention effort focused on IDUs, which has included NEPs, has been associated with lower infection rates among the IDU population.

Hagan H, McGough J-P et al. Volunteer Bias in Non-Randomized Evaluations of the Efficacy of Needle Exchange Programs. Journal of Urban Health (Accepted for publication)

ABSTRACT Objective: Nonrandomized comparisons of the incidence of HIV and hepatitis between injection drug users (IDUs) who do and do not attend voluntary needle exchange programs may be subject to bias. To explore possible sources of bias, we examined characteristics associated with voluntarily beginning or ceasing to participate in the Seattle needle exchange. Methods: In a cohort of 2879 IDUs, a standardized questionnaire measured characteristics present at enrollment. We examined the relation of these characteristics to the proportion of IDUs who began to use the program during the ensuing 12-month follow-up period, and to the proportion of current exchangers who dropped out during that period of time. Results: Thirty-two percent of the 494 never-exchangers at baseline attended the program during follow-up: those who reported sharing syringes or who were homeless at enrollment were more likely to become new exchanger users (adjusted risk ratio for becoming an exchange user (ARR) = 1.8 for those who shared syringes, and ARR = 2.2 for those who were homeless). Sixteen percent of 1274 current exchangers stopped using the exchange during follow-up, with daily injectors (ARR = 0.6) and those who reported backloading (ARR = 0.6) being relatively less likely to drop out of the exchange. Conclusions: The analysis suggests that IDUs participating in needle exchange programs at a given point in time may include a particularly high proportion of those injectors whose pattern of drug use puts them at elevated risk of blood-borne viral infections.

COMMENT This study of participants in SEP programs shows that individuals who were homeless and those sharing needles were the most likely to utilize an SEP, and persons who stopped attending the SEP were less likely to be injecting daily or using risky injection techniques. This SEP is attracting and retaining those persons with greatest risk factors for bloodborne disease transmission.

Continue with Annotated Bibliography -- part 2.

Review by the Surgeon General 

Statement from Congresswoman Nancy Pelosi releasing the Surgeon General's review, April 13, 2000.

Letter from Secretary of Health and Human Services Donna E. Shalala submitting the Surgeon General's review to Congresswoman Nancy Pelosi.