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."

"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), 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."

"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."

"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]"

"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."

"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."

"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]."

"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)."

"We found that in cities with NEPs 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."

"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 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."

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."

"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."