Needle-exchange programme - AbsoluteAstronomy.com

A Needle & syringe programme (NSP) or syringe-exchange programme (SEP) is a social policy

Social policy

Social policy primarily refers to guidelines, principles, legislation and activities that affect the living conditions conducive to human welfare. Thus, social policy is that part of public policy that has to do with social issues...

based on the philosophy of harm reduction

Harm reduction

Harm reduction refers to a range of public health policies designed to reduce the harmful consequences associated with recreational drug use and other high risk activities...

where injecting

Injection (medicine)

An injection is an infusion method of putting fluid into the body, usually with a hollow needle and a syringe which is pierced through the skin to a sufficient depth for the material to be forced into the body...

drug users can obtain hypodermic needle

Hypodermic needle

A hypodermic needle is a hollow needle commonly used with a syringe to inject substances into the body or extract fluids from it...

s and associated injection equipment at little or no cost. Many programmes are called "exchanges" because some require exchanging used needles for an equal number of new needles. Other programmes do not have this requirement. The aim of these services is to reduce the damage associated with using unsterile or contaminated injecting equipment.

A 2010 review of reviews led by Norah Palmateer which examined systematic review

Systematic review

A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...

s and meta-analyses

Meta-analysis

In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...

on the topic concluded that there is insufficient evidence that NSP prevents transmission of the Hepatitis C virus

Hepatitis C virus

Hepatitis C virus is a small , enveloped, positive-sense single-stranded RNA virus of the family Flaviviridae...

, tentative evidence that it prevents transmission of HIV

HIV

Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...

and sufficient evidence that it reduces self-reported injecting risk behaviour. In a comment Palmateer warned politicians not to use her team's review of review as a justification to close existing programs or to hinder the introduction of new needle-exchange schemes. The weak evidence on the programs' effectiveness at preventing disease, is rather due to inherent limitations in the designs of the reviewed primary studies and should not be interpreted as that the programs lack preventative effects.

History and development

Needle-exchange programmes can be traced back to informal activities undertaken during the 1970s, however the idea is likely to have been discovered a number of times in different locations. The first government-approved initiative was undertaken in the early to mid 1980s, with other initiatives following closely. While the initial Dutch programme was motivated by concerns regarding an outbreak of hepatitis B, the AIDS pandemic motivated the rapid adoption of these programmes around the world. This reflects the pragmatic response to the pandemic undertaken by some governments, and encapsulated in the harm reduction / minimization philosophy.

Operation

In addition to sterile needles, syringe-exchange programmes typically offer other services such as: HIV and Hepatitis C testing; alcohol swabs; bleach water and normal saline (often as rinse eye drops); aluminium "cookers"; citric acid powder (an imperative agent: enables heroin to dissolve in water); containers for needles and many other items. There was a survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, which showed among the 126 SEPs surveyed, 77% provided to material abuse therapy, 72% provided voluntary counselling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads, and male and female condom

Female condom

A female condom is a device that is used during sexual intercourse as a barrier contraceptive and to reduce the risk of sexually transmitted infections and unintended pregnancy...

s.

According to the Center for Disease Control (CDC), in the United States

United States

The United States of America is a federal constitutional republic comprising fifty states and a federal district...

around 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use.

Needle-exchange programmes are supported by the CDC and the National Institute of Health. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.

Proponents of harm reduction

Harm reduction

Harm reduction refers to a range of public health policies designed to reduce the harmful consequences associated with recreational drug use and other high risk activities...

argue that the provision of a needle exchange therefore provides a social benefit in reducing health costs and also provides a means to dispose of used needles in a safe manner. For example, in the United Kingdom, as the keystone prevention method, proponents of SEPs assert that, along with other programs, they have reduced the spread of HIV among intravenous drug users. The most extensive review of research into their effectiveness backs this claim. As a developed country, especially for medical care, the UK has been seen as a pioneer in establishing SEPs. These supposed benefits have led to an expansion of these programmes in most jurisdictions that have introduced them, aiming to increase geographical coverage, but also the availability of these services out of hours. Vending machine

Vending machine

A vending machine is a machine which dispenses items such as snacks, beverages, alcohol, cigarettes, lottery tickets, consumer products and even gold and gems to customers automatically, after the customer inserts currency or credit into the machine....

s which automatically dispense injecting equipment "pack" have been successfully introduced in a number of locations.

Another advantage cited by supporters of these programmes are that SEPs can not only protect attenders themselves, but also provide a safe environment for their social network such as sexual partners, children or neighbours. If people among injecting drug users (IDU) did not attend SEP or share injection equipment with programme attenders, SEPs can also have an indirect influence to control transmission risks. In fact, in those SEPs, nurses are very important in terms of spreading the knowledge about HIV among IDUs. Under this situation, people not only get physical protection from HIV, they also can learn a lot more information about HIV which can help them know well about this disease, and then learn how to protect by themselves and other people.

Other promoted benefits of these programmes include being a first point of contact for drug treatment, access to health and counselling service referrals, the provision of up-to-date information about safe injecting practices, access to condoms, and as a means for data collection from injecting drug users about their behaviour and/or drug use patterns.

A clinical trial of needle exchange found that needle exchange did not cause an increase in drug injection These findings were endorsed by then United States Surgeon General Davis Satcher, then Director of the National Institutes of Health

National Institutes of Health

The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...

Harold Varmus, and then Secretary of the Department of Health and Human Services, Donna Shalala

Donna Shalala

Donna Edna Shalala served for eight years as Secretary of Health and Human Services under President Bill Clinton and has been president of the University of Miami, a private university in Coral Gables, Florida, since 2001. She was awarded the Presidential Medal of Freedom, the nation's highest...

.

These services can take on a wide range of configurations:

Primary needle and syringe programme ("stand alone" service)
Secondary needle and syringe programme (such as incorporated within a pharmacy or health service)
Mobile or on-call Service
Dispensing machine distribution ("vending machine")
Peer service: distribution networks
Peer service: "flooding" or mass distribution
Peer service: underground
Prison-based facilities
Distribution of bleach or other cleaning equipment (rather than needles and syringes)
Ad hoc
Ad hoc
Ad hoc is a Latin phrase meaning "for this". It generally signifies a solution designed for a specific problem or task, non-generalizable, and not intended to be able to be adapted to other purposes. Compare A priori....

or informal distribution

Countries where these programmes exist include: Australia

Australia

Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...

, Brazil

Brazil

Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people...

, Canada

Canada

Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

, Netherlands

Netherlands

The Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders...

, New Zealand

New Zealand

New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...

, Norway

Norway

Norway , officially the Kingdom of Norway, is a Nordic unitary constitutional monarchy whose territory comprises the western portion of the Scandinavian Peninsula, Jan Mayen, and the Arctic archipelago of Svalbard and Bouvet Island. Norway has a total area of and a population of about 4.9 million...

, Portugal

Portugal

Portugal , officially the Portuguese Republic is a country situated in southwestern Europe on the Iberian Peninsula. Portugal is the westernmost country of Europe, and is bordered by the Atlantic Ocean to the West and South and by Spain to the North and East. The Atlantic archipelagos of the...

, Spain

Spain

Spain , officially the Kingdom of Spain languages]] under the European Charter for Regional or Minority Languages. In each of these, Spain's official name is as follows:;;;;;;), is a country and member state of the European Union located in southwestern Europe on the Iberian Peninsula...

, Switzerland

Switzerland

Switzerland name of one of the Swiss cantons. ; ; ; or ), in its full name the Swiss Confederation , is a federal republic consisting of 26 cantons, with Bern as the seat of the federal authorities. The country is situated in Western Europe,Or Central Europe depending on the definition....

, United Kingdom

United Kingdom

The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...

, Ireland

Ireland

Ireland is an island to the northwest of continental Europe. It is the third-largest island in Europe and the twentieth-largest island on Earth...

, Iran

Iran

Iran , officially the Islamic Republic of Iran , is a country in Southern and Western Asia. The name "Iran" has been in use natively since the Sassanian era and came into use internationally in 1935, before which the country was known to the Western world as Persia...

and the United States

United States

The United States of America is a federal constitutional republic comprising fifty states and a federal district...

; however in the United States such programmes may not receive federal funding.

U.S. programmes

The use of federal funds for needle-exchange programmes was banned in the United States of America in 1988, but this ban was overturned in 2009. In the past, many U.S. states criminalized the possession of needles without a prescription, even going so far as to arrest people as they leave private needle-exchange facilities. Nonetheless, as of 2006, 48 states in the United States had a programme that supported needle exchange in some form or the purchase of new needles without a prescription at pharmacies.

These programmes were introduced during the Clinton Administration but were disbanded following negative public reactions to the initiatives. Covert programmes still exist within the United States.

One such state operating with covert needle operations is Colorado. Current laws in Colorado leave room for interpretation on the requirement of a prescription to purchase syringes. Because of this law the majority of pharmacies will not sell needles without prescription, and police will arrest people in possession needles without prescription. Groups including The Works (Boulder) and The Underground Syringe Exchange of Denver (the USED) attempt to ease the burden this legislation places on IDUs in Colorado. Both exchanges operate covertly to avoid legal prosecution and are entirely funded by donations and operated by volunteers. Because of the illegal nature of the organization, the USED website specifies that new clients must be referred in order to exchange needles. Both organizations have been highly successful in supplying IDUs with an alternative to using dirty needles. According to The Works website this year they have received over 45,000 dirty needles, and distributed around 45,200.

Research

The two 2010 Palmateer et al. 'review of reviews' scrutinised previous formal reviews of needle exchange studies and after critical appraisal four reviews met the inclution criteria, where three where deemed to be of good quality (Gibson et al., 2001; Tilson et al., 2007; Wodak and Cooney, 2004) while one was of poor quality (Käll et al., 2007). Tilson et al. was judged to be the most rigorous of these studies, with its review determining that the evidence was modest concerning the effectiveness of needle exchange programmes in keeping back HIV prevalence, modest the strength of the evidence is limited by study designs. For Gibson et al., "as for Wodak and Cooney, their conclusions seemed inconsistent with the HIV studies reviewed". The Käll et al. review was reported to have noted that "errors in categorising studies in favour of NEPs have been made (Wodak and Cooney, 2004; Wodak and Cooney, 2006) and studies claiming positive results have not been adequately scrutinized." The Palmateer review also considered the evidence from the relevant reviews on the effectiveness of NEPs in preventing Hepatitis C (HCV) transmission and self-reported injecting risk behaviours. They concluded that "there is insufficient evidence that NSP prevents transmission of the Hepatitis C virus

Hepatitis C virus

Hepatitis C virus is a small , enveloped, positive-sense single-stranded RNA virus of the family Flaviviridae...

, tentative evidence that it prevents transmission of HIV

HIV

and sufficient evidence that it reduces self-reported injecting risk behaviour."

The Palmateer reviews have been criticized by drug prevention organization, Drug Free Australia, as themselves reaching conclusions at odds with two of the four 'core' reviews scrutinised. They noted that Palmateer et al. had relied for its conclusion of 'tentative' support for HIV prevention on an unscrutinized acceptance of positive findings from the Wodak/Cooney World Health Organization (WHO) review, which had been found by Käll et al. to have been based on "significant errors which, when corrected, would alter the WHO finding from positive to inconclusive."

Discarded needles dangerous to the community

An Australian bi-partisan Federal Parliamentary inquiry which published recommendations in 2003 registered government concern about the lack of accountability of Australia’s needle exchanges, inadequate exchange and lack of a national register of resulting needle stick injuries. Community concern about discarded needles and needle stick injury led the Australian Federal Government to allocate $17.5 million in 2003/4 to investigating the provision of retractable technology for syringes.

History and development

Operation

U.S. programmes

Research

Discarded needles dangerous to the community

See also