Delaware HIV Consortium

Policy Committee and Planning Council

September 2010

Needle Exchange Program White Paper:

Justification for Continuation and Expansion

of the Delaware Needle Exchange Program

Delaware HIV Consortium Policy Committee

Delaware Needle Exchange Program

White Paper

September 2010

  1. Introduction

Problem Statement

Delaware is the second smallest state in the nation in terms of geographic size, yet its AIDS incidence rate is among the highest in the nation (19.8 cases per 100,000 residents in 2008), ranking consistently among the top ten each year in the rate of new AIDS cases per capita. Further, recent data indicates that the frequency with which AIDS cases are being diagnosed in Delaware is increasing in comparison with other states (10th in the nation in 2006; 6th in 2007).1 The majority of new and existing HIV cases in Delaware are attributable to needle sharing and/or unprotected sexual contact with someone that has shared needles to inject drugs,2 with Delaware’s HIV infection rate from injecting drug users (IDUs) more than twice the national average.3

Needle exchange programs (NEPs)—also called syringe exchange programs (SEPs), syringe access programs (SAPs), and syringe services programs (SSPs)—have become a mainstream approach to substance abuse and HIV prevention in many countries for over twenty-five years.4In 2006, the state of Delaware initiated a five-year pilot NEP in portions of the City of Wilmington for two primary purposes: (1) preventing the transmission of blood-borne illnesses including HIV and the hepatitis B virus; and (2) providing IDUs with referrals to appropriate treatment and other health and social services programs.5

In three years of operation, Delaware’s NEP has been successful in meeting or exceeding the majority of the goals established in its Implementation Plan and has become a key component of the state’s HIV prevention and treatment strategy.6,7 Highlights of the program’s accomplishments from inception through fiscal year 2010 (February 1, 2007 through June 30, 2010) include the following:

  • 1,864 rapid HIV screenings provided to NEP clients and community members
  • 179 persons tested for HIV for the first time
  • 16 persons newly diagnosed with HIV enrolled into medical care
  • 11 formerly-diagnosed HIV-positive persons re-connected to medical care
  • 130 NEP clients enrolled into substance abuse treatment programs
  • 28.6% of clients reporting reduced needle sharing

As Delaware’s NEP nears its sunset date of February 2012, the Delaware HIV Consortium Planning Council, the Consortium’s Policy Committee, and other supporters have made the following recommendations for its continuation, grouped into three categories: capacity, flexibility and funding. Expanded justifications and explanations for the recommendations are provided onpages 9 and 10.

Recommendations for Delaware’s Pilot Needle Exchange Program (NEP)

  1. Increase the NEP’s Capacity to Serve More People:
  1. Move the NEP’s status from “pilot” to “permanent”.
  2. Extend the NEP’s service area from “Wilmington” to “statewide”.
  1. Enhance Flexibility to Respond to Community Needs:
  1. Provide the Division of Public Health (DPH) and the NEP Oversight Committee with the flexibility to approve new locations throughout the state, as evidenced and justified by statistical need.
  2. Provide DPH and the NEP Oversight Committee with the flexibility to approve individualized NEP structures that are most responsive to the needs of participants and varying local communities.
  1. Secure Funding to Maintain and Expand Delaware’s NEP:
  1. Continue state funding for the program.
  2. Maintain and expand capacity to obtain any future federal funds released to support this evidence-based and proven HIV prevention program.
  1. Needle Exchange Overview

What is Needle Exchange?

Needle exchange (also known as syringe exchange, syringe access, and syringe services) refers to a “myriad of approaches geared towards ensuring that people who inject drugs have access to sterile syringes to prevent the transmission of HIV, viral hepatitis and other blood-borne pathogens”.8 In the public health community, needle exchange is considered a harm reduction technique—a method of reducing health risks when eliminating them may not be possible. It is a mainstream approach to substance abuse and HIV prevention in many countries.4

Most NEPs are part of comprehensive HIV prevention efforts that include counseling; testing; education; and referral to drug treatment services, mental health services, HIV counseling, HIV treatment, and traditional public health preventive and therapeutic services for other diseases and medical needs.9-12 The American Foundation for AIDS Research (amfAR)—an international non-profit organization dedicated to the support of HIV/AIDS research, prevention, treatment, education, and advocacy—summarizes research findings on the beneficial effects of NEPs, which show that NEPs:

  • Are associated with reductions in the incidence of HIV, Hepatitis B, and Hepatitis C in the drug-using population and, by extension, their families and communities.
  • Are associated with changes in injection and drug-related behavior among IDUs, thereby reducing risk of infections and transmission to others.
  • Are a cost-effective and cost-saving strategy for reducing HIV transmission.
  • Reduce the circulation of contaminated injection equipment among IDUs and in the community.4
  • Reduce needle stick injuries among police officers.13

General Structure:

NEPs vary in design and operation, with no one model working best for all communities. Program settings can include storefronts, vans, sidewalk tables, and health clinics—any place where IDUs gather—and hours of operation can vary from program to program.14Whatever the model, a study of “Best Practices” identified two key components necessary for the effectiveness and success of all NEPs: flexibility and support.

  • Flexibility: Research shows that, to be most effective, NEPs should “match sound operational characteristics with responsiveness to the unique features of their host communities”.
  • Support: To be most successful, NEPs must have at least minimal support from their communities’ respective governing bodies, plus the crucial support of a diverse group of local stakeholders (public health departments, law enforcement, service organizations, legal experts, grass roots organizations, and community leadership). The greater the support, the greater the likelihood of effectiveness.15

Proof of Efficacy

NEPs have been operating in the United States (U.S.) for over 25 years, under the discretion of state and local governments. Extensive studies in the U.S. and around the world have demonstrated their effectiveness. A sampling of organizations and experts that have studied and endorsed NEPs—and their findings—include the following:

  • Over a 20-year period, at least 17 major reviews and assessments of NEPs by experts that include the Centers for Disease Control (CDC), National Institutes of Health (NIH), the Institute of Medicine, and the World Health Organization found that NEPs help reduce the spread of HIV/AIDS without increasing drug use among existing IDUs or encouraging the initiation of drug use.16
  • In 1997, the NIH Consensus Panel on HIV Prevention concluded that NEP studies show a reduction in risk behaviors as high as 80% in IDUs, with estimates of a 30% or greater reduction in HIV in IDUs.17
  • In 1998, Donna Shalala, U.S. Secretary of Health and Human Services, reported to Congress that a review of scientific evidence indicated that NEPs "…can be an effective component of a comprehensive strategy to prevent HIV and other blood-borne infectious diseases..." and recommended lifting the ban against the use of federal funds for NEPs.18
  • Similarly, three former U.S. Surgeons General endorsed NEPs including U.S. Surgeon General David Satcher who, in March 2000, conducted a review of all recent scientific research for the Secretary of Health and Human Services and concluded, “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.”19
  • A 2007 CDC review of 185 NEPs in the U.S. and Puerto Rico concluded that NEPs “…are helping protect IDUs and their communities from the spread of blood-borne pathogens and are providing access to health services for a population at high risk.’’20

Facts About Needle Exchange Programs

The abundance of research on the effectiveness of NEPs, plus the experiences of Delaware’s own NEP, dispel common myths associated with such programs.

Myth / Fact
There is no hard evidence that NEPs work. / NEPs are an effective public health intervention. Extensive studies have shown the effectiveness of NEPs. As stated on page 3, U.S. Surgeon General David Satcher conducted a review of all recent scientific research in March 2000 for the Secretary of Health and Human Services and concluded that “…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.”19 Regarding the effectiveness and successes of Delaware’s NEP, see pages 7 and 8.
NEPs do not reduce HIV or other diseases. / NEPs help reduce HIV and other diseases. NEPs are associated with reductions in the incidence of HIV in the drug-using population and, by extension, their families and communities.4 As stated earlier, the NIH Consensus Panel on HIV Prevention concluded in 1997 that NEP studies show estimates of a 30% or greater reduction in HIV infection in IDUs.17Another study—of IDUs in New York City conducted between 1990 and 2002—showed HIV infections among IDUs decreased 70%.21 A recent University of New South Wales report showed that NEPs in Australia were directly linked to the prevention of 32,000 cases of HIV infection and close to 100,000 cases of hepatitis C.22
NEPs increase drug use among existing IDUs. / NEPs do not increase drug use among existing IDUs; they help get them into treatment. In the 1997 Consensus Statement cited above, the NIH reported that “a preponderance of evidence shows either no change or decreased drug use among persons who had participated in NEPs.”17 Rather than increasing drug use among IDUs, studies show that NEPs can have a positive effect in helping them get into needed treatment. A study published in the Journal of Urban Health in 1999 stated that “findings indicate that health care providers and NEPs represent an important bridge to drug abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug abuse treatment and serve the important public health goal of increasing the number of drug users in treatment.”23
NEPs promote substance abuse. / NEPs do not encourage the start of drug use. An amfAR FactSheet summarizes extensive research that shows that NEPs do not encourage the start of drug use in non-users,4 while the results of a study of a San Francisco NEP over a five-year period indicated that there was no significant increase in new or young injecting drug users.24 Additionally, a CDC summary on NEPs stated, “Studies also show that [NEPs] do not encourage drug use among [NEP] participants or the recruitment of first-time drug users.”14
NEPs increase risky behavior. / NEPs reduce risky behavior. Studies have shown that NEPs actually reduce risky behaviors associated with sharing of needles and NEP participants are “less prone to share, lend, borrow, or reuse a used syringe when they have access (or reliable source) to obtain a new and sterile syringe.”25 As stated earlier, the NIH Consensus Panel on HIV Prevention concluded in 1997 that NEP studies show a reduction in risk behaviors as high as 80% in IDUs.17 Delaware’s own NEP participants reported a reduction of 28.6% in needle sharing, as indicated on page 7.
NEPs increase crime in their communities. / NEPs do not increase crime in NEP communities. Studies have been conducted that indicate that NEPs do not increase crime in the neighborhoods in which they are located.26,27 Rather, they can benefit the health and safety of a community by offering comprehensive social services to needy community members.28,29
NEPs increase the number of visible contaminated needles in the community. / NEPs help keep communities safe. Studies have shown that NEPs reduce the circulation of contaminated needles in the community by educating users on the safe disposal of used needles.30,31 Delaware’s NEP requires the issuance of individual Sharps Containers for safe transportation and return of needles.32
NEPs are costly. / NEPs are cost-effective. Numerous studies have shownNEPS to be a cost-effective and cost-saving strategy for reducing HIV transmission.4 The annual budget appropriation for Delaware’s NEP is $230,500, while the lifetime cost of prescriptions and medical treatment for one HIV-positive person—exclusive of supportive services costs—is estimated to be as high as $618,000.33 Preventing just one HIV infection per year through the NEP saves over $618,000/person in potential treatment funding.
Law enforcement and public health cannot co-exist. / Delaware’s NEP is comprised of a strong partnership between local law enforcement and DPH. Delaware’s Standing Operating Procedures for the NEP mandate extensive and on-going outreach, education, and coordination among all of the NEP program partners, including DPH and the City of Wilmington Department of Public Safety.32 Members of the Wilmington’s Public Safety Department are supportive of the NEP as a result of strong, open lines of communication and education. Wilmington Police have, in fact, referred five IDUs to the NEP, a testament to their confidence in the program’s mission.

Nationwide Legislative Status

Currently, NEPs have received legislative approval in all states and territories of the U.S. National statistics provide a stark picture of the relationship between injecting drug use and the proliferation of HIV and other diseases throughout the country, as well as the need for NEPs to help in the prevention of those diseases and the linkage of people to care. In the U.S.:

  • 8,000 people are reported newly infected with HIV annually through sharing contaminated syringes.
  • 1/3 of people with HIV in the U.S. were infected directly through injection drug use.
  • An estimated 61% of AIDS cases among women are due to injection drug use or the result of sexual contact with someone who contracted HIV through injection drug use.
  • Over 50% of all AIDS cases attributed to injection drug use were African Americans, while Latinos account for nearly 25%.
  • 15,000 people are newly infected annually with Hepatitis C through sharing syringes and other contaminated injection equipment, with IDUs generally becoming infected with Hepatitis C within two years.34

In 2009, Congress lifted the ban on the use of federal funds for NEPs, and President Obama signed the Consolidated Appropriations Act of 2010 on December 19 finalizing the action. However, no federal funding has been allocated for any needle exchange program to date.

  1. Delaware’s Needle Exchange Program

Delaware’s History

As noted in the opening Problem Statement, Delaware is the second smallest state in the nation in terms of geographic size, yet its AIDS incidence rate is among the highest in the nation (19.8 cases per 100,000 residents in 2008), ranking consistently among the top 10 each year in the rate of new AIDS cases per capita. Further, recent data indicates that the frequency with which AIDS cases are being diagnosed in Delaware is increasing in comparison with other states. Delaware ranked 10th in the nation in 2006 and 6th in 2007.1 The majority of new and existing HIV cases in Delaware are attributable to needle sharing and/or unprotected sexual contact with someone that has shared needles to inject drugs,2 with Delaware’s HIV infection rate from IDU more than twice the national average.3 The potential reductions in new HIV infections from a NEP, therefore, is significant.

Delaware’s history in implementing a NEP extends back to 1996, when the Substance Abuse Treatment Services Evaluation Task Force first recommended consideration be given to exploring strategies to reduce HIV transmission through infected needles and syringes in the Report to the Delaware Legislature. A draft NEP bill was submitted to the Delaware State Legislature that year but was not passed. Each year thereafter it was re-written and re-submitted. Finally, on June 30, 2006, the State Legislature approved implementation of a NEP, effective through February 2012, codified under Title 29, Subchapter VIII.5 The code includes basic provisions regarding the structure of the NEP, plus allows for the provision of traditional public health preventive and therapeutic services for other sexually-transmitted diseases, tuberculosis, family planning, pregnancy, prenatal care, and nutrition.