Harm Reduction Service Programs / Syringe Service Programs / Needle Exchange Programs

"Syringe services programs (SSPs) are proven and effective community-based prevention programs that can provide a range of services, including access to and disposal of sterile syringes and injection equipment, vaccination, testing, and linkage to infectious disease care and substance use treatment.^{8, 11} SSPs reach people who inject drugs, an often hidden and marginalized population. Nearly 30 years of research has shown that comprehensive SSPs are safe, effective, and cost-saving, do not increase illegal drug use or crime, and play an important role in reducing the transmission of viral hepatitis, HIV and other infections.^11,12 Research shows that new users of SSPs are five times more likely to enter drug treatment and about three times more likely to stop using drugs than those who don’t use the programs.¹³ SSPs that provide naloxone also help decrease opioid overdose deaths. SSPs protect the public and first responders by facilitating the safe disposal of used needles and syringes."

"Syringe service programs (SSPs), which at minimum provide access to and disposal of sterile syringes and injection equipment for people who use drugs (PWUD), were initiated in Australia, Europe, and the United States in response to the hepatitis B and HIV epidemics of the 1980s.^1,2 Over the past 4 decades, SSPs have responded creatively and effectively to these ongoing epidemics^3,4 and to the emergence of new health crises that have faced PWUD, such as hepatitis C virus (HCV), unsafe drug supply, opioid overdose, endocarditis, and skin and soft tissue infections.^5-10 As the novel coronavirus 2019 (COVID-19) pandemic wreaks havoc around the world, SSPs have been forced to pivot and reimagine service delivery to protect the lives of their program participants, volunteers, and staff.

"SSPs have historically been grassroots and community-led responses, designed, implemented, and staffed by current and former PWUD, HIV and social justice activists, and people who deeply care for those who are marginalized and stigmatized by their drug use.^11-15 There is a strong evidence base for the effectiveness of SSPs in reducing injection risk behaviors and infectious disease transmission among program participants.^16,17 SSPs in the United States have developed into multiservice organizations in many cases, providing testing and linkage to care for people with HIV and HCV as well as linkage to substance use treatment.¹⁶

"SSPs receive funding from a variety of sources including city, county, state health departments; private foundations; corporate donations; other community-based organizations; and local fundraising efforts. Services are provided through drop-in centers, mobile service sites, fixed outdoor sites (pop-up tables, mobile vans, etc.), outreach, and delivery, and are often staffed by volunteers as well as paid staff. SSPs are designed to be welcoming and non-stigmatizing and are often the only source of health care with which PWUD engage.^18-20 Thus, SSPs fill a unique role in promoting health and well-being in the lives of PWUD, and engagement with SSPs has consistently been associated with lower risk behaviors and better health outcomes among participants.^21-23 Furthermore, SSPs have integrated overdose education and naloxone distribution (OEND) into service provision and have pioneered opioid-related overdose prevention efforts since the late 1990s.^24-26 As of 2019, 94% of SSPs in the United States were also offering OEND programs,⁹ which prepare laypersons—PWUD, family members, peers—as prospective responders in overdose events by providing training in rescue breathing, access to naloxone, and directions for naloxone administration."

"SSPs [Syringe Service Programs] are widely considered to be an effective way of reducing HIV transmission among individuals who inject illicit drugs and there is ample evidence that SSPs also promote entry and retention into treatment (Hagan, McGough, Thiede, et al., 2000, Journal of Substance Abuse Treatment, 19, 247-252). According to research that tracks individuals in treatment over extended periods of time, most people who get into and remain in treatment can reduce or stop using illegal or dangerous drugs. In addition to promoting entry to treatment, there are studies that document injection reductions for drug users who participate in SSPs. Hagan, et al., found that, not only were new SSP participants five times more likely to enter drug treatment than non-SSP participants, former SSP participants were more likely to report significant reduction in injection, to stop injecting altogether, and to remain in drug treatment."

"While it is not feasible to do a randomized controlled trial of the effectiveness of needle or syringe exchange programs (NEPs/SEPs) in reducing HIV incidence, the majority of studies have shown that NEPs/SEPs are strongly associated with reductions in the spread of HIV when used as a component of comprehensive approach to HIV prevention. NEPs/SEPs increase the availability of sterile syringes and other injection equipment, and for exchange participants, this decreases the fraction of needles in circulation that are contaminated. This lower fraction of contaminated needles reduces the risk of injection with a contaminated needle and lowers the risk of HIV transmission.

"In addition to decreasing HIV infected needles in circulation through the physical exchange of syringes, most NEPs/SEPs are part of a comprehensive HIV prevention effort that may include education on risk reduction, and referral to drug addiction treatment, job or other social services, and these interventions may be responsible for a significant part of the overall effectiveness of NEPs/SEPs. NEPs/SEPs also provide an opportunity to reach out to populations that are often difficult to engage in treatment."

In 1998, Donna Shalala, then Secretary of Health and Human Services in the Clinton Administration, stated: "A meticulous scientific review has now proven that needle exchange programs can reduce the transmission of HIV and save lives without losing ground in the battle against illegal drugs."

"The basic service offered by SSPs [Syringe Services Programs] allows PWID [People Who Inject Drugs] to exchange used needles and syringes for new, sterile needles and syringes. Providing sterile needles and syringes and establishing appropriate disposal procedures substantially reduces the chances that PWID will share injection equipment and removes potentially HIV- and HCV-contaminated syringes from the community. Many SSPs have become multiservice organizations, providing various health and social services to their participants (8). HIV and HCV testing and linkage to care and treatment for substance use disorders are among the most important of these other services. The availability of new and highly effective curative therapy for HCV infection increases the benefits of integrating testing and linkage to care among the services provided by SSPs."

"An impressive body of evidence suggests powerful effects from needle exchange programs. The number of studies showing beneficial effects on behaviors such as needle sharing greatly outnumber those showing no effects. There is no longer doubt that these programs work, yet there is a striking disjunction between what science dictates and what policy delivers. Data are available to address three central concerns:

"Does needle exchange promote drug use? A preponderance of evidence shows either no change or decreased drug use. The scattered cases showing increased drug use should be investigated to discover the conditions under which negative effects might occur, but these can in no way detract from the importance of needle exchange programs. Additionally, individuals in areas with needle exchange programs have increased likelihood of entering drug treatment programs.

"Do programs encourage non-drug users, particularly youth, to use drugs? On the basis of such measures as hospitalizations for drug overdoses, there is no evidence that community norms change in favor of drug use or that more people begin using drugs. In Amsterdam and New Haven, for example, no increases in new drug users were reported after introduction of a needle exchange program.

"Do programs increase the number of discarded needles in the community? In the majority of studies, there was no increase in used needles discarded in public places."

"Syringe exchange programs (SEPs) provide free sterile syringes and collect used syringes from injection-drug users (IDUs) to reduce transmission of bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus (HCV)."

"After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs."

"Among the 342 known SSPs operating at the beginning of 2019, 263 (77%) responded to the online survey; of these, 247 (94%) had an OEND program, 160 (65%) of which had been implemented since 2016 (Figure 1). With regard to phases of OEND implementation, 173 (66%) responding SSPs had been implementing OEND for 12 months or more, 74 (28%) had implemented OEND within the last 12 months, eight (3%) were actively preparing for OEND implementation, and eight (3%) were exploring OEND implementation (Table). Of the 16 SSPs not yet offering OEND, four had previously implemented naloxone distribution but stopped because of an inadequate naloxone supply or funding.

"Among the 247 SSPs with an OEND program, 191 (77%) offered OEND every time syringe services were offered, and 214 (87%) provided naloxone refills as often as participants requested them (Table). SSPs reported offering OEND for a median of 15 of the past 28 days. Only 29 (12%) SSPs entered OEND data directly into an electronic data system. During the preceding 12 months, 237 (96%) of 247 SSPs with OEND programs reported distributing 702,232 naloxone doses, including refills, to 230,506 persons (an average of 3 doses per person). Sixty-two (26%) SSPs reported distributing naloxone to >1,000 persons in the last 12 months; these programs had distributed naloxone to 186,603 laypersons, who represented 81% of all recipients in the past 12 months. Overall, 14 (6%) SSPs reported distribution of ≥10,000 naloxone doses during the last 12 months, accounting for 382,132 naloxone doses, 54% of all doses distributed by SSPs in the past 12 months. These 14 SSPs are located throughout six of the nine census divisions. Seventy-two (29%) SSPs ran out of naloxone or needed to ration their naloxone in the preceding 3 months."

"Despite the proven and potential benefits, SSPs remain somewhat controversial in the United States owing to the 'war on drugs' ideology and the misconception that substance use disorders (SUD) represent a moral failing, as well as the fear that SSPs might lead to drug use initiation.^10,24 At the time of inaugural SSP development in the 1980s, one notable barrier was the 1988 ban on the use of federal funding for SSP programs until they could be proven safe and effective.^10,24

"As evidence on the benefits of SSPs mounted, over the decades there were several attempts to lift the funding ban.²⁴ After the HIV outbreak in Scott County, Indiana, brought national attention to the event and SSPs were included in the public health response, the federal ban was removed again in 2015 to allow for the use of federal funds to support SSP operations in areas or jurisdictions deemed at risk for outbreaks, excepting the actual purchase of needles and syringes.¹⁰ This change has facilitated SSP expansion.²⁵ However, SSPs have been slow to spread to vulnerable areas, reflecting continuing stigma as well as hurdles posed by state and local drug paraphernalia laws.²⁶ By 2015, many states had updated policies to allow for licensed SSPs, but today there are still several states that prohibit them.¹¹ Other regulations also affect the number of syringes that can be distributed or exchanged, for example, requiring a used syringe to be collected for each clean syringe dispensed (ie, 1-for-1 syringe exchange).²⁷ Overall, in the United States there continues to be a complicated regulatory landscape that hinders adequate access to sterile injection supplies.

"In contrast, other countries including Canada, Australia, and many European Union nations are permissive and supportive of SSPs, with costs shared by national and local governments and even international organizations.^4,28"

"Eighteen states had laws that were categorized as least comprehensive related to the prevention of HCV transmission among persons who inject drugs. In particular, these 18 states had no laws authorizing a syringe exchange program, decriminalizing possession and distribution of syringes and needles, or allowing the retail sale of syringes without a prescription. Three states (Maine, Nevada, and Utah) had the most comprehensive laws related to prevention; each state had laws that authorized syringe exchange without jurisdictional limitations, removed barriers to possessing and distributing syringes and needles through drug paraphernalia laws, and explicitly allowed for the retail sale of syringes to persons who inject drugs (Figure 2).

"Twenty-four states had restrictive Medicaid treatment policies that required some period of sobriety to receive HCV treatment through Medicaid, including 11 of the states with the least comprehensive set of laws related to prevention. Sixteen states had permissive Medicaid HCV treatment policies that did not require a period of sobriety or only required screening and counseling to receive HCV treatment through Medicaid (Figure 3). Among the seventeen states with high HCV incidence, five (Massachusetts, New Mexico, North Carolina, Pennsylvania, and Washington) had permissive Medicaid treatment policies.

"Only three states (Massachusetts, New Mexico, and Washington) had both a most comprehensive or more comprehensive set of laws and a permissive Medicaid treatment policy that might affect access to both HCV preventive and treatment services for persons who inject drugs."

"Pediatricians should advocate for unencumbered access to sterile syringes and improved knowledge about decontamination of injection equipment. Physicians should be knowledgeable about their states' statutes regarding possession of syringes and needles and available mechanisms for procurement. These programs should be encouraged, expanded, and linked to drug treatment and other HIV-1 risk-reduction education. It is important that these programs be conducted within the context of continuing research to document effectiveness and clarify factors that seem linked to desired outcomes."

"Syringe service programs (SSPs) are community-based prevention programs that can provide a range of services, including access to and disposal of sterile syringes and injection equipment; linkage to substance use disorder treatment; distribution of naloxone, a medication that reverses overdoses; and vaccination, testing, and linkage to treatment for infectious diseases. Nearly 30 years of research shows that comprehensive SSPs are safe, effective, and cost-saving; do not increase illegal drug use or crime; reduce transmission of viral hepatitis, HIV, and other infections; and increase the chance that a participant will stop injecting drugs."

"We estimated nearly 3.7 million people, or 1.5% of the US adult population, injected drugs in 2018. This estimate is more than 5 times the most recent US estimate of ∼774,000 from 2011 [25]. Much of this increase is likely attributable to increases in IDU, but it is important to consider methodological differences in the creation of this 2018 estimate vs the 2011 estimate. The 2011 estimate was based on self-reported IDU among respondents to household surveys [26], but the present estimate combines available data on substance-specific overdose deaths and treatment admissions with cohort and cross-sectional data collected from known PWID. Applying the same data sources and analytic methods used for the 2018 estimate to 2011 yields an estimated 1.3 million PWID in 2011, which suggest the 2018 estimate is closer to 3 times higher than in 2011. By any measure, these estimates suggest the number of PWID has increased substantially in the U.S. during the past decade.

"One of the primary contributions of this estimate is the transparent, replicable nature of the methods described. Overdose data specifically among PWID in the United States continue to be relatively sparse, both in research and surveillance data. We used the best data currently available for each input, which are subject to limitations in some cases given data sparsity. For example, we used the meta-analyzed ratio of fatal to nonfatal overdose among PWID in OECD countries rather than a ratio specific to the United States, which was unattainable given currently available data. The uncertainty associated with this meta-analyzed ratio is reflected in confidence intervals around estimates presented here. Our intention is that, as surveillance systems implemented in the United States in recent years mature [39], resulting data can be used to refine and update this PWID population size estimate.

"Notwithstanding data input limitations, this updated estimate provides a data point for monitoring the US PWID population size over time and can inform strategies to reduce transmission of infectious diseases. In recent years, political will has been building to eliminate HCV and HIV infections in the United States [27, 28]. Both bloodborne infections disproportionately affect PWID but are highly preventable using evidence-based interventions, such as provision of sterile syringes through syringe services programs and substance use treatment [40–43], as well as treatment of prevalent infections with antiretroviral therapy [44] and direct-acting antivirals [45]. Increases in IDU prevalence will threaten the success of elimination strategies for HCV and HIV infections in the absence of concomitant increases in availability of harm reduction services and treatment for both infectious diseases and substance use. These services will need to be substantially scaled up nationally to meet the needs of nearly 4 million people [46].

"In addition to the high burden of infectious diseases, PWID experience preventable mortality and morbidity due to drug overdose. Overall, the rate of overdose deaths increased from approximately 6 per 100,000 persons to 22 per 100,000 persons during 1999–2019 [21], and provisional data indicate the number of overdose deaths increased by another 31% during just 1 year of the pandemic era from March 2020 to March 2021 [24]. During the pandemic era in particular, many questions remain about the extent to which increased overdose mortality rates are attributable to injection initiation vs changes in injection behaviors or the drug supply as well as to disruptions in access to treatment and recovery support services and harm reduction services. These estimates provide a prepandemic baseline and can improve our understanding of potential increases vs changes in pandemic-era injection behavior."

"As of 2020, 86 countries globally have at least one NSP [Needle and Syringe Program], though on the ground this has meant NSP closures and openings in several countries since 2018. Algeria opened NSPs in the Middle East and North Africa region, but in Palestine and Jordan, NSPs stopped completely; in Asia, NSPs closed in Mongolia; in sub-Saharan Africa, NSPs opened in Benin, Nigeria and Sierra Leone, while in Uganda NSPs ceased to operate. Eurasia, North America, Oceania and Western Europe remained the regions where almost all countries with reported injecting drug use implemented NSPs.^[1]

"The availability of NSPs, however, does not ensure adequate coverage and accessibility. There is a large disparity in NSP implementation globally. While NSPs in Australia distribute almost 700 syringes per person who injects drugs per year, in Benin in sub-Saharan Africa, only ten syringes are given in a month to a client visiting the programme.² In Macau, Asia, the number of NSPs has decreased since 2018, and only one NSP is still open. While NSPs are available in the majority of countries in Eurasia, there are several countries where coverage is very limited as services are implemented solely on a volunteer basis.^[3,4] New estimates from India suggest that just 35 syringes (down from 250) are distributed per person who injects drugs, despite an increase in the number of NSP sites in the country. Coverage could also vary within a country. In Western Europe, for example, the coverage of NSPs in urban areas is sufficient and there are no major barriers in access, but rural areas have less coverage in many countries (e.g. Austria, Belgium, the Netherlands, Germany and Portugal).^[5–9] Rural populations are also underserved in both the United States and Canada, and an uneven geographical distribution of NSPs is a problem in Australia and New Zealand.^[10,11]"

"Methods

"The research literature on the effectiveness of syringe services programs in controlling HIV transmission among persons who inject drugs and guidelines for syringe services program that are 'functioning very well' were used to estimate the cost-saving threshold at which a syringe services program becomes cost-saving through preventing HIV infections versus lifetime treatment of HIV. Three steps are involved: (1) determining if HIV transmission in the local persons who inject drugs (PWID) population is being controlled, (2) determining if the local syringe services program is functioning very well, and then (3) dividing the annual budget of the syringe services program by the lifetime cost of treating a single HIV infection.

"Results

"A syringe services program in an area with controlled HIV transmission (with HIV incidence of 1/100 person-years or less), functioning very well (with high syringe coverage, linkages to other services, and monitoring the local drug use situation), and an annual budget of $500,000 would need to prevent only 3 new HIV infections per year to be cost-saving.

"Conclusions

"Given the high costs of treating HIV infections, syringe services programs that are operating according to very good practices ('functioning very well') and in communities in which HIV transmission is being controlled among persons who inject drugs, will almost certainly be cost-saving to society."

"In this study, there was no indication that needle-exchange use was associated with increasing drug use. Indeed, IDUs who were former users of the exchange were more likely than never-users to report substantial reductions in drug use or stopping injection altogether. Our analysis also suggested that among heroin injectors, needle-exchange participation was wholly compatible with the goals of drug treatment. Compared to those who had never used an exchange, new exchange users were five times more likely to enter methadone treatment and ex-exchangers were 60% more likely to remain in methadone treatment over the 1-year study period.

"Many factors may influence drug injection frequency in a population, including cost and availability of different drugs and access to drug treatment (Frykholm & Gunne 1980, Nurco et al. 1981, Robins 1980). The natural history of drug injection is also characterized by a progression toward daily use (Robins 1980). The ability of an exchange program to override these underlying factors is not well-understood, however, there is a well-recognized motivation to reduce or cease drug use exhibited by some users (Koester et al. 1999). It is conceivable that exposure to needle exchange could accelerate or facilitate this process by offering encouragement and support for risk reduction and improved self-care, and as a conduit to drug treatment services.

"In this study, baseline rate of injection was an important determinant of subsequent change in injection frequency. In all subject categories, most subjects who initially reported fewer than one injection per day progressed to daily injection by the end of the follow-up period. In contrast, reduction in drug use was more common among those who were daily injectors at the baseline visit. Since it was a potential confounder, we examined the association between needle exchange and reduction in injection, adjusted for baseline injection frequency and within separate strata of daily and nondaily injectors. This method of analysis would tend to reduce the influence of regression to the mean on our results. Further, we found that the group with the highest proportion of subjects reporting reduction in injection frequency (ex-exchangers) reported a relatively lower mean number of injections at study enrollment. Thus, it was unlikely that regression to the mean was responsible for the observed association."

"In the sixteen-year (2004–2019) combined samples of young adults aged 21–30, 1.5% report having ever used any drug by injection not under a doctor’s orders, and 0.5% reported doing so on 40 or more occasions (Table 4-1a). Thus, about 1 in every 67 respondents has ever used an illicit drug by injection, and about 1 in every 200 respondents reports an extended pattern of use as indicated by use on 40 or more occasions. There are appreciable gender differences—2.2% of males vs. 0.9% of females indicate ever injecting a drug (p<.001), and the percentages saying they injected on 40 or more occasions are 0.7% for males and 0.3% for females (p<.001). The percentages of young adults who have injected drugs during the past 12 months without medical supervision are considerably smaller: 0.5% overall—1 in every 200 respondents—including 0.8% of males and 0.3% of females (p<.001). The percentages using 40 or more times in the past 12 months are 0.2% overall—0.3% for males and 0.1% for females."

"Syringe services programs are harm reduction programs that provide a wide range of services including, but not typically limited to, the provision of new, unused hypodermic needles and syringes and other injection drug use supplies, such as cookers, tourniquets, alcohol wipes, and sharps waste disposal containers, to PWID. Comprehensive SSPs also either directly provide, or offer linkage or referrals to entities that provide: substance use disorder treatment, including medication for addiction treatment; vaccination for viral hepatitis; screening for viral hepatitis, HIV, sexually transmitted infections, tuberculosis, and other infectious diseases; provision of pre- and post-exposure prophylaxis for HIV; naloxone and other overdose prevention tools; peer support services; educational materials and training in areas related to injection drug use; and referral and linkage to other services, including medical care, mental health services, and other support services.¹⁶ Contrary to popular perception, SSPs do not increase crime in areas where programs are based and do not increase illegal drug use.¹⁷ Further, “Nearly 30 years of research has shown that comprehensive SSPs are safe, effective, and cost-saving … and play an important role in reducing the transmission of viral hepatitis, HIV, and other infections.”¹⁸ Additionally, PWID who participate in an SSP are “five times more likely to enter drug treatment and about three times more likely to stop using drugs than those who don’t use the programs.”¹⁹ Individuals who regularly use an SSP are also “nearly three times as likely to report a reduction in injection frequency as those who have never used an SSP.” SSPs are also an important tool in the fight against unintentional drug overdose by teaching PWID how to recognize and respond to a drug overdose, as well as by providing participants with naloxone and training on administration.²¹

"Although only 38 states, the District of Columbia, and Puerto Rico either explicitly or implicitly authorize SSPs through statute, regulation, or executive order, as of September 2021, there are 392 operational SSPs in 44 states, the District of Columbia, and Puerto Rico.^22,23

"This study indicates that the SSP+MOUD [Syringe Service Program + Medications for Opioid Use Disorder] combination program is an effective harm-reduction strategy to prevent HCV cases among opioid IDUs and is cost-effective if payers are willing to pay $4,699 or more per avoided case of HCV. There is evidence to support the effectiveness of these harm-reduction strategies in reducing injection-risk behaviors as well as reducing HCV and HIV transmission.^17,18 The base-case analysis suggested that (a) the combination strategy, compared with SSP alone, would cost $4,699 to avoid an additional HCV case; (b) the combination and the SSP-alone groups dominated both the MOUD-alone and no intervention groups; and (c) the MOUD-alone group dominated the no intervention group.

"Most of the recent studies on the cost-effectiveness of SSP and MOUD alone and in combination were conducted outside the United States, were conducted from a societal or health care system perspective, did not directly compare the interventions used in the base case, had moderate evidence of the cost-effectiveness in some sites, estimated the outcome in terms of quality-adjusted life years, and did not examine the number of cases avoided in a 1-year time horizon.^{19,31,32,37-39} To date, studies have not examined the cost-effectiveness of these harm-reduction strategies in terms of incremental cost savings per HCV case avoided, and none has undertaken a public payer perspective in the United States.

"Based on the analysis, the combination of MOUD and SSP appears to be the most effective policy, from a public health perspective. By including both the direct medical and nonmedical costs due to injection drug use-related crime in the calculation, the combination program will save public payers $347,573 per HCV case avoided compared with costs for no intervention. SSP-alone and MOUD-alone interventions will also save public payers $363,821 and $317,428, respectively. Given that the total direct economic burden of HCV-related liver disease in the United States is estimated to be $6.5 billion ($4.3 to $8.2 billion) annually and 2.4 million people in the United States live with an HCV infection, these interventions could dramatically reduce HCV-related annual costs.^7,40,41 The savings associated with these interventions would allow public institutions to redirect funds toward other health care services or public service investments. In addition, the results indicated that all the harm-reduction strategies were less costly and more effective than no intervention even though they required some up-front investments. It is also important to point out that the largest benefits could occur in the future. This is because HCV-related liver disease such as cirrhosis and hepatocellular carcinoma may take several years to occur, and SSPs are associated with reducing the risk of other diseases transmitted via needle sharing, such as HIV.^23,26

"The 1-way sensitivity analysis shows that the base-case cost effectiveness analysis was sensitive to the probabilities of injection-risk behavior for the SSP and SSP+MOUD combination groups, probability of no HCV with no intervention, and costs of MOUD and HCV antivirals. Despite varying the model parameters by ± 50%, the base-case ICER was not sensitive to a majority of the key variables in the model. Considering that the cost for the combination intervention was assumed to be the sum of the costs of the SSP and MOUD individual interventions, our results can be considered as conservative estimates, given that in reality, savings and economies of scale can be achieved by a combination of efforts."

"This analysis presents the first study, to our knowledge, to quantitively examine the impact of SSP closure on HIV incidence using a modeling approach. In a rural American setting that had previously experienced an HIV outbreak among PWID, our modeling results suggest that closing an existing SSP would likely lead to a rebound HIV outbreak, with a 1.6-fold increase in incident infections among PWID in 5 years relative to SSP sustainment. The potential impact of SSP closure was found to be substantially greater for other settings with lower baseline HIV prevalence (in which a larger share of the population is susceptible to HIV infection). Although delaying SSP closure with another renewal was found to reduce the size of the rebound, sustaining SSP operation and associated health services will be imperative to maintain long-term epidemic control."

"Effective treatment has increased life expectancy after HIV infection, and deaths from non-AIDS-related causes now exceed deaths from AIDS for those with HIV in the US [35]. Medical costs of treating HIV-infected individuals as they age now include costs of both HIV-related and HIV-unrelated medical care. We estimated the medical cost saved by averting one HIV infection in the United States, taking into account the costs that would have been incurred by similar at-risk individuals in the absence of HIV infection. We project discounted medical cost savings of $229,800 by permanently averting one HIV infection based on current care patterns in the US and $49,500 if one HIV infection is delayed by 5 years. Our analysis shows that as HIV care becomes more effective, the cost avoided by averting one HIV infection also increases. Improved care is cost-effective by accepted standards in the US, it is not cost-saving [36]. The added years of life, however, result in additional costs for treatment that would not have occurred in the absence of an infection.

"Our projections of lifetime medical costs for HIV-infected individuals of $326,500 in the base case and $435,200 in the optimal care case are comparable to recent model-based estimates of lifetime costs for individuals in the US entering care with CD4 201–350/μl ($332,300 in 2012 US dollars) and >500/μl ($443,000) respectively [37], and costs from entry into care (not shown) are consistent with previous estimates of these costs in France using the CEPAC model [38]. Our projection of medical cost savings of $229,800 is substantially lower than the previous estimate of $303,100 in 2004 US dollars ($361,400 in 2012 US dollars) [7] for several reasons. First, we now account for medical costs that would have been incurred in the absence of an HIV infection. Second, our previous analysis did not adjust mortality for risk group characteristics that lower average life expectancy [23], thereby reducing costs, nor did they adjust costs for health service utilization by different risk groups. Our life expectancy estimates are lower than two other recent model-based analyses in the United States and the United Kingdom [37, 39], likely reflecting the race/ethnicity and risk-category mortality effects in our model. Our results are consistent with these models, however, in projecting substantial life expectancy losses associated both with becoming HIV infected and with delayed initiation of treatment after infection.

"Consistent with other analyses [7, 37], we found that ART medications represent the largest component of cost for HIV-infected individuals. We found that non-HIV chronic care medications represent a substantial component of cost as well, emphasizing the significant cost of managing non-HIV comorbidities in an aging HIV-infected population [13, 40]. These comorbidities are frequently managed by HIV primary care providers [41]. Our results are somewhat sensitive to assumptions about future use of generic HIV drugs in the US. This points to the potential importance of future availability of generic drugs in lowering the cost of HIV care, depending on regimens selected and adherence [32].

"Our analysis also indicates that the value of HIV primary prevention may be greater when the effects of preventing secondary transmission to HIV-uninfected partners are taken into account, which would increase the value of interventions targeting individuals at high risk of transmitting to multiple partners. The magnitude of this impact is greater the longer individuals remain uninfected after avoiding a secondary transmission. The current relatively stable HIV incidence trends in the US [15] suggest these uninfected partners are at high risk for eventual HIV infection. If the probabilities of secondary transmission we used already take into account this additional risk, the value of primary prevention would be even higher."

Editor's Note: This article has the following correction:

"In the December 1, 2019 Supplement 2 of JAIDS Journal of Acquired Immune Deficiency Syndromes, in the article titled 'Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia', the authors mistakenly reported the estimated cost savings for Baltimore to be $62.4 million annually and $624 million over 10 years, and the 1-year return on investment (ROI) factoring in the cost of syringe exchange programs to be $46.8 million. The correct cost savings estimates are $43.4 million annually and $434.3 million over 10 years, and the correct 1-year ROI estimate is $32 million."

Following is the original, uncorrected quote:

"Our findings also demonstrate that averted HIV diagnoses translated to cost savings for cities where most PLWH are recipients of publicly funded healthcare. The forecasts estimated an average of 1059 HIV diagnoses in Philadelphia and 189 HIV diagnoses in Baltimore averted annually. Multiplying the lifetime costs of HIV treatment per person ($229,800)²⁵ by the average number of diagnoses averted annually in both cities yields an estimated annual saving of $243.4 million for Philadelphia and $62.4 million for Baltimore. Considering diagnoses averted over the 10-year modeled period, the lifetime cost savings associated with averted HIV diagnoses stemming from policy change to support SEPs may be more than $2.4 billion and $624 million dollars for Philadelphia and Baltimore, respectively. Because SEPs are relatively inexpensive to operate,²⁶ overall cost savings are substantial even when deducting program operational costs from the total amount. Considering annual program expense ($390,000 in 2011 for Philadelphia²⁷ and $800,000 estimated in FY 2017 for Baltimore²⁸) (Kathleen Goodwin, Baltimore City Health Department, personal communication, January 3, 2017) and cost savings in each city, and a conservative estimate that 75% of these savings would be experienced in the public sector, the 1-year return on investment in SEPs remains in the hundreds of millions of dollars ($182.5 M for Philadelphia, $46.8 M for Baltimore). Small investments in SEPs may yield large savings in HIV treatment costs, so implementing SEPs may liberate resources for other important interventions, such as expanded access to medication-assisted treatment, overdose prevention, and housing.

"Another implication pertains to how variations in SEP implementation may have influenced intervention effectiveness. Policies governing SEPs affect not only the overall number of syringes distributed annually but also the ability of PWID to obtain sufficient coverage for all injection events. For example, PPP's clients may exchange syringes for themselves and others; recent data show that the mean number of syringes exchanged per exchange event increased from 1.53 in 1999 to 1.82 in 2014.¹³ In addition, PPP's annual syringe distribution has consistently increased from approximately 811,000 in 1999 to 1.2 million in 2014,¹³ allowing for greater coverage of injection events and more opportunities for disease prevention.

"By contrast, Baltimore's SEP had a one-for-one (1:1) exchange policy from 1994 to 1999 but, in 2000, switched to a more restrictive policy, where clients were allowed 1:1 exchange for program-distributed syringes but could receive 1 sterile syringe in exchange for 2 nonprogram syringes. From 2005 to 2014, the SEP returned to the less restrictive 1:1 policy, after which they shifted to a need-based distribution model whereby PWID could access as many syringes as needed. Baltimore City's health commissioner estimated that moving from the 1:1 to the needs-based distribution policy could increase coverage of injection events from 42% to 61%.²⁹ More flexible approaches to syringe access in Baltimore could have resulted in greater injection coverage and more dramatic declines in IDU-associated HIV diagnoses earlier. Regulations limiting clean needle and syringe distribution are important operational issues to consider if policy changes supporting harm reduction for PWID are to have optimal impact."

"People who use heroin (PWUH) have increased morbidity and mortality compared to the general population [1]. A syndemic of opioid overdose, human immunodeficiency virus (HIV), hepatitis C virus (HCV), skin and soft tissue infections (SSTI), and infective endocarditis accounts for many of the poor health outcomes among PWUH [2,3,4,5]. Heroin can be consumed in several ways, including injection and smoking [6]. High-risk injection behaviors, including syringe sharing and reuse of non-sterile injection equipment, are established routes of HIV and HCV transmission and increase risk of SSTI and infective endocarditis [7,8,9]. Opioid overdose is a common cause of mortality among PWUH, with higher overdose risk among those who inject [10,11,12].

"Because smoking heroin does not injure the skin or introduce non-sterile equipment into blood or tissue, this method of consumption does not entail the same risk of blood-borne infections or SSTI compared to injection. While similar pharmacological effects can be achieved by smoking or injecting heroin, peak plasma concentrations are 2–4 times lower when heroin is smoked, which may reduce risk of lethal opioid overdose [13, 14]. Programs that encourage PWUH to transition from injecting to smoking heroin may decrease injection frequency and thereby reduce harms associated with heroin use, including risks of infection and overdose [15]. Distribution of smoking equipment may also help PWUH avoid using pipes fashioned from cans or other poor-quality materials that easily crack or overheat, thereby reducing risk of developing burns or cuts on the lips that can serve as sites of infection [16,17,18]. Pipe distribution programs may also reduce pipe sharing, a risk behavior potentially associated with respiratory virus or HCV transmission [17,18,19,20]."

"Despite differences in program size, operating budgets, and staffing among SSPs [Syringe Services Programs] in rural, suburban, and urban locations, there were similarities in on-site services (Table 3). Most SSPs offered HIV counseling and testing (87% among rural SSPs, 71% among suburban SSPs, and 90% among urban SSPs) and HCV testing (67% among rural SSPs, 79% among suburban SSPs, and 78% among urban SSPs). A minority of SSPs reported having referral tracking systems for HCV-related care and treatment (33% of rural SSPs, 43% of suburban SSPs, and 44% of urban SSPs). Rural SSPs were less likely to provide naloxone (for reversing opioid overdoses) (37%) compared with suburban (57%) and urban (61%) programs that provided this service."

"The emergence of xylazine has led to several unintended consequences for PWUD [People Who Use Drugs] across North America, such as tissue necrosis and heightened sedation, the latter of which has potential implications for elevated risk of overdose and social consequences (such as being robbed or assaulted) [5, 21]. Here, we identified how the emergence of xylazine has also precipitated a range of behavioral responses among PWUD, with implications for their individual health and the broader healthcare system [22].

"We identified dynamic communication processes through which information about xylazine emerged and spread among SSP staff and clients, ultimately leading to a formal response by the SSP via the use of XTS [17]. Notably, the initial identification of xylazine was driven by clients’ firsthand experiences with the unregulated opioid supply. Clients then shared their observations and experiences with SSP staff, underscoring the importance of building trust and listening to client expertise, which can serve as an early warning system for emerging adulterants prior to adverse consequences. In contrast, many of the official accounts of xy-lazine adulteration are based on overdose surveillance data or medical examiner reports [9, 13–15, 23], which can take time to process. In addition, most official early warning systems focus on mass spectrometry or drug seizure data, which may involve a time lag and is resource intensive [24, 25], especially in the Southern U.S. where comprehensive drug-checking services are sparse [26, 27]. Integrating qualitative insights from PWUD into current early warning systems may provide another avenue for proactive intervention that can indicate the presence of a novel adulterant using relatively few resources and can be scaled locally via SSPs or other settings that serve PWUD (e.g., drug treatment facilities). Indeed, improved collaboration between harm reduction programs and surveillance professionals, including medical examiners and crime laboratory personnel, could circumvent and augment delays in reporting systems. Of course, caution is needed in the development and deployment of warning systems to avoid sensationalizing harms or generating “alert fatigue,” where PWUD and their communities are inundated with information [28, 29]. These findings also emphasize the benefit of embedding research within harm reduction settings to further empower these organizations in responding to emerging challenges."

"Our systematic review identified 55 NSP unit cost estimates from 14 middle and high-income countries. Higher unit costs were associated with countries with higher HSRI and fewer syringes distributed, and with newer programs, which confirmed our hypothesis. The number of intervention components included was not seen to affect the unit cost, possibly because the majority of programs did not include any additional WHO-recommended intervention components. Using our best performing model, the cost per syringe distributed of a comprehensive NSP was extrapolated to 137 countries. We find that current spend on NSP among 68 countries examined needs to increase by 2.1-times the current spend to achieve the WHO/UNODC/UNAIDS 2020 target goals of 200 syringes distributed per PWID. Reaching the high-coverage targets for NSPs can reduce the burden of HIV and HCV infection among PWID ^[22] and has been found cost-effective in several settings ^[15,23,24]."

"Community pharmacies are essential healthcare destinations that serve as an optimal resource for addressing non-urgent inquiries, such as safe injecting practices, management of adverse drug reactions, and medication provision, thus reducing the burden on general practitioners (GPs) [1, 2]. Pharmacists also have a role in addressing social determinants of health and promoting health equity, including the support of primary prevention strategies such as harm reduction interventions [3], for example through needle and syringe programs (NSPs) [4, 5]. In addition to offering advice and facilitating HIV/Hepatitis testing, pharmacists serve as a vital referral mechanism to various social, medical, and treatment services [6]. The experiences of pharmacists in this context have demonstrated predominantly positive outcomes associated with NSP provision [7, 8]. However, consumer attitudes to harm reduction service provision have been mixed [9], largely as a result of perceived systemic barriers for consumers which are often evident at sites of delivery [10, 11]. McVeigh et al. underscored the necessity for enhancing pharmacists' harm reduction training and implementing appropriate strategies to raise awareness of the needs of substance consumers, cater to the diverse needs of individuals who inject drugs, foster trusting relationships, and facilitate engagement within a confidential service setting [12]."

"The infectious disease consequences of injection drug use place a heavy toll on entire communities and are a serious threat to the health and well-being of our nation. The estimated cost of providing health care services to persons living with chronic HCV infection is $15 billion annually.¹⁸ The average cost of a hepatitis A–related hospitalization in 2016 was $16 610, and recent hepatitis A virus outbreaks alone have cost the nation at least $270 million since 2016.¹⁹ In 2019, HIV care and treatment cost the US government more than $20 billion.²⁰ The cost for treating HIV infections related to the Scott County outbreak is projected to be more than $100 million.²¹ SSPs are associated with an approximately 50% reduction in HIV and HCV incidence.¹⁸ A 2019 study in Philadelphia found that SSPs averted 10 582 HIV infections during a 10-year period. This number equates to a 1-year return on investment of $243.4 million.²² By helping reduce the economic burden of drug use and associated infections, SSPs should be considered an important partner in my Community Health and Economic Prosperity initiative, which views community health as inherently linked with economic outcomes.^23"

"With the growing availability of AAS [Anabolic-Androgenic Steroids] through online platforms [71, 72] the traditional reliance on social networks and healthcare providers for access to injecting equipment and safer use information has diminished [73–76]. This unregulated supply of AAS and other PIEDs from online sources is accompanied by misleading information regarding the benefits and risks associated with their use [13, 23], posing significant concerns. Given the potential harms of AAS use among the general population [14, 77], current evidence indicates the potential of their growing impact on the health of this substance cohort globally [78, 79]. Therefore, enhanced harm reduction measures are imperative to effectively engage with the increasing diversity of individuals currently engaged in AAS use [41, 80], particularly considering the potential for emerging dangers associated with the uptake of harsher AAS varieties [81]. Our data indicate that community pharmacies represent sites which can establish an enabling environment conducive to harm reduction for this group, and so we provide an immediate practical application of doing so drawn from our data.

"To enhance privacy and confidentiality, community pharmacies can utilise dedicated spaces more effectively, such as private counselling rooms, where AAS consumers can have confidential discussions with pharmacists [55, 82]. Increasing awareness among both pharmacists and consumers about these private spaces has been met with receptivity in relation to mental health [82] and licit substance use [59]. As trust is a crucial component in the pharmacist-consumer relationship, pharmacists have a professional responsibility to establish community pharmacies as ‘safe spaces’ where individuals feel comfortable discussing their health concerns, including AAS use. By adhering to the Code of Ethics, which prioritises the health and wellbeing of consumers [83], pharmacists should set aside judgments and create a non-judgmental environment that fosters open communication. However, our findings revealed a knowledge gap among pharmacists regarding these substances, highlighting the need for further training and education initiatives. Despite this gap, pharmacists demonstrated receptivity to learning and enhancing their understanding of AAS and other PIEDs, indicating a potential for improved engagement in harm reduction efforts within community pharmacy settings. Further research is needed to understand knowledge gaps, training needs, and the effectiveness of educational interventions for pharmacists in addressing AAS use. These efforts can contribute to fostering a conducive environment for harm reduction for AAS consumers, a necessity that demands immediate attention."

"Although model projections can only provide estimates of health benefits and costs, such analyses can provide intuition around critical mechanisms and assumptions to inform decision making. Our main finding is that, over 20 y, high coverage (enrollment of 50% of the eligible population) of OAT [Opioid Agonist Therapy], NSPs [Needle and Syringe Programs], and Test & Treat in combination could avert nearly 43,400 (95% CI: 23,000, 74,000) HIV infections among PWID [People Who Inject Drugs] and reduce HIV prevalence among PWID by 27% (95% CI: 12%, 45%). The construction of such a portfolio has the potential to be cost-effective at each incremental expansion, with projected ICERs below US$50,000 per QALY [Quality-Adjusted Life Year] gained. Moreover, our analysis suggests that the estimated benefit obtainable by PrEP alone (measured in QALYs) could potentially be achieved and even surpassed at substantially lower cost by combining other prevention interventions into high-value portfolios.

"Advocates for efficient investment in PWID-specific interventions have asked, “What good is preventing HIV if we do not first save that life at HIV risk?” [77]. Our analysis suggests that the high competing mortality risks of PWID can explain why interventions that immediately improve quality of life can have substantially higher estimated benefits than those that focus on HIV prevention alone. Our analysis estimates that OAT, in particular, which we assume has a direct impact on the length and quality of life of treated individuals [27,28,30–32,60,61], can provide substantially more benefit, measured in QALYs, than other interventions, even when it prevents fewer infections (Table 2).

"Although our analysis did not identify a scenario in which OAT was not a cost-effective addition to a high-value portfolio, deterministic and probabilistic sensitivity analyses can provide intuition regarding scenarios in which NSPs could replace OAT as the priority investment. Because the assumed delivery cost of NSPs is so much lower than that of other programs, our findings suggest that it is reasonable to invest in NSPs concurrent with OAT scale-up. While Test & Treat is often estimated in our analysis to be a cost-effective addition to the portfolio, our model does not project it to be a priority investment. Our estimates for ART’s reduction of transmission risk via injection-based contact [13,44] are lower than those for sexual contact [14,41,44], which may explain our projection of smaller benefits in the PWID population. It should also be noted that HIV prevalence in US PWID is less than 10% [18], and the direct QALY increases from Test & Treat programs were therefore low relative to programs that served the entire PWID population."

"Creating a bridge between public health and drug policy in the context of AAS would be a significant step towards providing adequate healthcare to this, often overlooked, group of substance consumers (Dunn et al., 2023; Piatkowski et al., 2022, 2023a). The risk environments framework provides a theoretical foundation for doing so (Rhodes, 2002), emphasising the importance of enabling contexts and resources in advancing harm reduction (Duff, 2009, 2011). Substance use, including AAS, is influenced by various interacting factors within a social context. Hanley Santos and Coomber (2017) indicate that patterns of AAS use among consumers varied based on their motivations, prior knowledge, and experiences. Many users had limited knowledge about AAS before starting their use, relying on information from peers or suppliers, which was sometimes inaccurate or incomplete (Hanley Santos & Coomber, 2017). As Hanley Santos and Coomber (2017) suggest, when developing interventions targeting AAS use, it is crucial to consider the broader context (e.g., motivations and experiences). Therefore, we extend this study by investigating how individuals' social contexts and cultural interpretations of risk practices shape their engagement with and perceptions of drug checking services, aiming to enhance our understanding of the complexities surrounding risk behaviours and informing drug policy and practice in the context of drug checking. While there is some integration of AAS consumers in harm reduction, predominantly through needle service provision (Kimergard & McVeigh, 2014; Piatkowski, Hides et al., 2022), ensuring the delivery of sterile injecting equipment should be regarded as a minimal requirement (Bates et al., 2021), Scholars have suggested harm reduction frameworks should expand to encompass a comprehensive range of harm reduction interventions that address the needs of individuals using AAS throughout their entire usage cycle, including those who opt for temporary or permanent cessation of use (Bates et al., 2021; Bates & Vinther, 2021). Therefore, further establishing the position of AAS within harm reduction frameworks can facilitate an alliance between public health policy and AAS consumers."

"Canada is in the midst of a devastating overdose crisis that has been further exacerbated by the COVID-19 pandemic and, in particular, the subsequent increased toxicity of the drug supply [1]. Between January 2016 and June 2022, close to 33,000 people died from an overdose in Canada, with the provinces of British Columbia, Ontario, and Alberta accounting for 88% of those deaths [2]. Fentanyl, and to a lesser extent fentanyl analogues, have contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses [2]. Between January and June 2022, fentanyl was detected in 76% of overdose deaths in Canada [2]. In Ontario, fentanyl is involved in 88% of fatal overdoses [3]. In Toronto, this number rises to 93% [3]."

"In 2008, many SEPs operated multiple sites, including fixed sites and mobile units. The total number of hours that clients were served by SEPs was summed for all sites operated by each program. The total number of scheduled hours per week ranged from <1 to 168 (mean: 29 hours per week; median: 24 hours per week). Delivery of syringes and other risk-reduction supplies to residences or meeting spots was reported by 41% of SEPs. A total of 111 (90%) SEPs allowed persons to exchange syringes on behalf of other persons (i.e., secondary exchange)."

"In addition to exchanging syringes, SEPs provided various supplies, services, and referrals in 2008; the percentage of programs providing each type of service was similar for the period 2005–2008 (Table 3). In 2008, all SEPs provided alcohol pads, and nearly all (98%) provided male condoms. Most (89%) provided referrals to substance abuse treatment. Other services also offered by SEPs included counseling and testing for HIV (87%) and HCV (65%), and screening for sexually transmitted diseases (55%) and tuberculosis (31%). Vaccinations for hepatitis A and B were provided by nearly half the programs (47% and 49%, respectively)."

"Anti-OTC laws [laws against the over-the-counter sale or purchase of syringes without prescriptions] are not associated with lower population proportions of IDUs. Laws restricting syringe access are statistically associated with HIV transmission and should be repealed."

"Rapid growth occurred in the number of SEPs in the United States in the 1990s and early 2000s, followed by more incremental growth through 2008. The 123 SEPs participating in the 2008 survey reported operating in 98 cities† in 29 states and in DC."

"Combined 2006 to 2008 data indicate that an annual average of 425,000 persons aged 12 or older (0.17 percent) used a needle to inject heroin, cocaine, methamphetamine, or other stimulants during the past year
"One eighth (13.0 percent) of past year injection drug users had used a needle that they knew or suspected someone else had used before them the last time they used a needle to inject drugs
"Less than one third (29.0 percent) of past year injection drug users cleaned the needle with bleach prior to their last injection
"More than one half (52.8 percent) of past year injection drug users purchased the last needle they used from a pharmacy, and 12.4 percent obtained the needle through a needle exchange program"

"Studies on behalf of the US government conducted by the National Commission on AIDS, the University of California and the Centers for Disease Control and Prevention, the National Academy of Science, and the Office of Technology Assessment all concluded that syringe prescription and drug paraphernalia laws should be overturned or modified to allow IDUs to purchase, possess, and exchange sterile syringes."

"Respondents reported injecting a median of 60 times per month, visiting the syringe exchange program a median of 4 times per month, and obtaining a median of 10 syringes per transaction; more than one in four reported reusing syringes. Fifty-four percent of participants reported receiving fewer syringes than their number of injections per month. Receiving an inadequate number of syringes was more frequently reported by younger and homeless injectors, and by those who reported public injecting in the past month."

"We found that the odds of being arrested or cited for drug paraphernalia in a 6-month period were significantly higher for clients of legal SEPs [syringe exchange programs] when compared to clients of illegal SEPs. Although both illegal and legal SEPs operate in neighborhoods with heavy drug use and drug sales, policing strategies may be heavily concentrated around the known presence of a legal SEP. Illegal SEPs may operate in more hidden venues or use program methods, such as syringe exchange delivery and satellite exchange models to reduce or eliminate exposure to law enforcement."

"We found that in cities with NEPs [Needle Exchange Programs] HIV seroprevalence among injecting drug users decreased on average, whereas in cities without NEPs HIV seroprevalence increased. A plausible explanation for this difference is that the NEPs led to a reduction in HIV incidence among injecting drug users.

"NEPs have the potential to decrease directly HIV transmission by lowering the rate of needle sharing and the prevalence of HIV in needles available for reuse, as well as indirectly through activities such as bleach distribution, referrals to drug treatment centres, provision of condoms, and education about risk behaviour. Although these mechanisms have strong theoretical support, the published evidence for NEP effectiveness is limited. Previous studies of the effect of NEPs on HIV incidence used observational designs or statistical models.

"Observational designs included case studies; crosssectional, serial cross-sectional, and cohort studies (often without comparison groups); and case-control studies.^4,5 Only one study assessed the impact of NEPs on HIV incidence. Des Jarlais and colleagues⁷ estimated that the hazard for incident HIV infection was 3·3 for injecting drug users in four high-seroprevalence cities without NEPs, compared with continuous users of NEPs in New York City. One case study investigated HIV prevention activities for five cities with low seroprevalence, but did not formally compare these with other cities that had high seroprevalence.¹³ The most frequently cited statistical model for assessment of NEP effectiveness was developed by the New Haven NEP evaluators, and is based on the theory that NEPs decrease HIV transmission rates by lowering the time that needles are in circulation.¹⁴

"The conclusion of a 1993 review by a University of California team' was that NEPs are associated with decreased HIV drug risk behaviour and are not associated with negative outcomes, but that there is no clear evidence that they decrease HIV infection rates.⁵ Few new data were available for the most recent US review by the Panel on Needle Exchange and Bleach Distribution Programs,⁴ which concluded that NEPs are effective, but acknowledged that the evidence was weak.

"Our study is distinguished from previous work by its worldwide scope and its design, which compares changes in HIV seroprevalence in cities with and without NEPs, rather than changes within a single city."

"We found that a large proportion of SEP [syringe exchange program] participants in NYC do not obtain adequate numbers of syringes from the SEPs to meet their monthly injecting needs. In addition, characteristics of social marginalization and vulnerability – homelessness and public injecting – were associated with inadequate syringe acquisition. For SEP participants with inadequate coverage, most reported 'not needing' more syringes, but many also identified program limits and fear of police contact as main reasons for not obtaining adequate syringes at their most recent visit to the SEP."

"Estimates of the annual number of syringes required to meet the single-use standard run in the range of 1 billion. The most recent estimate of the number of syringes distributed by needle exchange programs in the United States (1997) was 17.5 million."

"For injecting drug users who cannot gain access to treatment or are not ready to consider it, multi-component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risk behavior, including self-reported sharing of needles and syringes, unsafe injecting and disposal practices, and frequency of injection. Sterile needle and syringe access may include needle and syringe exchange (NSE) or the legal, accessible, and economical sale of needles and syringes through pharmacies, voucher schemes, and physician prescription programs. Other components of multi-component HIV prevention programs may include outreach, education in risk reduction, HIV voluntary counseling and testing, condom distribution, distribution of bleach and education on needle disinfection, and referrals to substance abuse treatment and other health and social services."

Needle exchange programs can "prevent significant numbers of [HIV] infections among clients of the programs, their drug and sex partners and their offspring. In almost all cases, the cost per HIV infection averted is far below the $119,000 lifetime cost of treating an HIV infected person."

"Alanko-Blomé and colleagues (Alanko-Blomé et al., 2011) have done a follow-up covering the years 1997-2005 of 831 IDUs at the NSP in Malmö. In view of the low HIV prevalence among IDUs in Malmö the study focuses on the incidence of surrogate markers of HIV - particularly hepatitis C, because the risk of HBV infection is affected by the introduction of hepatitis B vaccination. HIV incidence remained very low. However, the corresponding incidence rates for HCV was 38.3 / 100 person-years at risk and for HBV 3.4 / 100 person-years at risk. RNA testing (Ribonucleic acid) showed that 12% already when entering the NSP was affected with hepatitis C virus, but antibodies had not yet developed. This subgroup was therefore already hepatitis C infected before they had access to clean syringes and needles through the NSP. If one corrects for those already infected, the HCV incidence rate decreases to approximately 30 per 100 / person-years at risk, which is still a high level of blood contamination. When the study period was divided into three periods, there was no trend of improvement in recent years. Risk factors for anti-HCV seroconversion were injection of both amphetamine and heroin and imprisonment. The strong improvement for hepatitis B may be entirely attributed to the introduction of hepatitis B vaccination11 (SOU 2011:6).

"The aim of a Swedish study from 2011 was to analyze the burden of HCV-associated inpatient care in Sweden, to demonstrate the changes over time and to compare the findings with a non-infected population. The authors conclude that drug-related care was common in the HCV-infected cohort, the demand for liver-related care was very high, and SLC increased notably in the 2000s, indicating that the burden of inpatient care from serious liver disease in HCV-infected individuals in Sweden is an increasing problem (Duberg et al., 2011)."

"SEC. 520. Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to purchase sterile needles or syringes for the hypodermic injection of any illegal drug: Provided, That such limitation does not apply to the use of funds for elements of a program other than making such purchases if the relevant State or local health department, in consultation with the Centers for Disease Control and Prevention, determines that the State or local jurisdiction, as applicable, is experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV outbreak due to injection drug use, and such program is operating in accordance with State and local law."

"Programs that provide access to sterile syringes have been proven time and again to reduce HIV transmission without either encouraging drug use or increasing drug related crime. Syringe exchange, as well as similar measures such as nonprescription pharmacy sale of syringes, is an effective and life-saving health intervention. Yet syringe exchange is banned in much of the United States and, where it is allowed, is obstructed by laws forbidding the possession of drug paraphernalia. Other modes of syringe access, such as nonprescription pharmacy sale of syringes, are as of this writing forbidden in five states: California, Massachusetts, New Jersey, Delaware, and Pennsylvania. Almost all fifty states have enacted drug paraphernalia laws similar to model legislation written by the Drug Enforcement Agency in 1979 under President Jimmy Carter. Drug paraphernalia laws are encouraged by United Nations anti-drug conventions, which call on governments to take aggressive law enforcement measures against illicit drug use."

"Recommendation 1. Local service planners need to review local needle and syringe services (and be supported in this work) in order to take steps to increase access and availability to sterile injecting equipment and to increase the proportion of injectors who receive 100 per cent coverage of sterile injecting equipment in relation to their injecting frequency."

"The purchase of syringes through pharmacies may be a major source of contact with the health service for some injectors, and the potential to exploit this contact point as a conduit to other services clearly exists. Work to motivate and support pharmacists to develop the services they offer to drug users could form an important part of extending the role of pharmacies, but to date only France, Portugal and the United Kingdom appear to be making significant investments in this direction."

"Although most US states have legal restrictions on the sale and possession of syringes, pharmaceutical practice guidelines often allow pharmacists discretion in syringe sales decisions; this may lead to wide variation in syringe sales by individual pharmacists and to discrimination based on gender, age, race, ethnicity, or socioeconomic status. Individual-level factors associated with pharmacists' relative willingness to sell syringes include familiarity with customers; concerns about deception, disease transmission, improperly discarded syringes, and staff and customer safety; business concerns, including fear of theft and harassment of other customers by IDU patrons; and fear of increased drug use because of easier syringe access."

"The data in this report offer no support for the idea that anti-OTC laws prevent illicit drug injection. However, the data do show associations between anti-OTC laws and HIV prevalence and incidence. In an ongoing epidemic of a fatal infectious disease, prudent public health policy suggests removing prescription requirements rather than awaiting definitive proof of causation. Such action has been taken by Connecticut, by Maine, and, recently, by New York. After Connecticut legalized OTC sales of syringes and the personal possession of syringes, syringe sharing by drug injectors decreased. Moreover, no evidence showed increased in drug use, drug-related arrests, or needlestick injuries to police officers."

"Access to sterile needles and syringes is an important, even vital, component of a comprehensive HIV prevention program for IDUs. The data on needle exchange in the United States are consistent with the conclusion that these programs do not encourage drug use and that needle exchanges can be effective in reducing HIV incidence. Other data show that NEPs help people stop drug use through referral to drug treatment programs. The studies outside of the United States are important for reminding us that unintended consequences can occur. While changes in needle prescription and possession laws and regulations have shown promise, the identification of organizational components that improve or hinder effectiveness of needle exchange and pharmacy-based access are needed."

"In multivariate analyses, we found that police contact was associated independently with residing in the area with no legal possession of syringes; among SEP users, those with access to SEPs without limits had lower syringe re-use but not lower syringe sharing; and that among non-SEP users, no significant differences in injection risk were observed among IDUs with and without pharmacy access to syringes.

"Conclusion: We found that greater legal access to syringes, if accompanied by limits on the number of syringes that can be exchanged, purchased and possessed, may not have the intended impacts on injection-related infectious disease risk among IDUs."

The US Office of National Drug Control Policy in 2005 was caught by the Washington Post misrepresenting the results of research on syringe exchange programs. According to the Post in its editorial, "Deadly Ignorance":

"An official who requested anonymity directed us to a number of researchers who have allegedly cast doubt on the pro-exchange consensus. One of them is Steffanie A. Strathdee of the University of California at San Diego; when we contacted her, she responded that her research 'supports the expansion of needle exchange programs, not the opposite.' Another researcher cited by the administration is Martin T. Schechter of the University of British Columbia; he wrote us that 'Our research here in Vancouver has been repeatedly used to cast doubt on needle exchange programs. I believe this is a clear misinterpretation of the facts.' Yet a third researcher cited by the administration is Julie Bruneau at the University of Montreal; she told us that 'in the vast majority of cases needle exchange programs drive HIV incidence lower.' We asked Dr. Bruneau whether she favored needle exchanges in countries such as Russia or Thailand. 'Yes, sure,' she responded. 'The Post further noted: 'The Bush administration attempted to bolster its case by providing us with three scientific articles. One, which has yet to be published in a peer-reviewed journal, was produced by an author unknown to leading experts in this field who is affiliated with a group called the Children's AIDS Fund. This group is more renowned for its ties to the Bush administration than for its public health rigor: As the Post's David Brown has reported, it recently received an administration grant despite the fact that an expert panel had deemed its application 'not suitable for funding.' The two other articles supplied by the administration had been published in the American Journal of Public Health. Although each raised questions about the certainty with which needle-exchange advocates state their case, neither opposed such programs."