Needle Exchange FAQs

1. What is a Needle Exchange Program?

   Needle Exchange Programs (NEPs) help to reduce the risk of HIV and Hepatitis transmissions by increasing access to sterile needles and syringes, removing used needles from circulation in the community and educating clients about the risk of re-using injection equipment (Strike C and Leonard L, 2006 p19).

2. How Long Have Needle Exchange Programs been in existence?

   The first needle exchange program in the world was offered in Amsterdam, (the Netherlands) in 1984. The rationale in establishing the program was that if you can not cure a drug addiction, one should try to minimize the harm that the drug addict does to himself or his environment (Coutinho, R.A, 2000). The British learned from the Dutch and were the first to implement needle exchange programs as a means of reducing the spread of HIV among people who inject drugs. Other European countries and Australian followed.

   The first official needle exchange program in Canada began in 1989 in Vancouver and within a few months, similar programs emerged in Montreal and Toronto. (http://www.cbc.ca/news/background/drugs/needleexchange.html).

3. How Many Needle Exchange Programs exist in Ontario?

   Within the province of Ontario, all 36 Public Health Units have been approved to operate Needle Exchange Programs. In 2006 over 3.2 million clean syringes were distributed to an estimated 41,100 people who inject drugs (Strike, C and Leonard L, 2006). Currently, NEPs distribute a small proportion of the sterile needles needed. It is estimated that approximately 1,000 needles are required per person who injects drugs per year. In Ontario is it estimated that 53 needles are distributed per injector per year (Strike, C and Leonard L, 2006).

4. Why do Needle Exchange Programs make public health sense?

   In Ontario, NEPs are legislated as a mandatory public health program in areas where injection drug use is recognized as a problem in the community (Ontario Ministry of Health and Long Term Care, 1997). The Mandatory Health Programs and Services Guidelines state that “The board of health shall ensure that injection drug users can have access to sterile injection equipment by the provision of needle and syringe exchange programs as a harm reduction strategy to prevent transmission of HIV, hepatitis B, hepatitis C and other blood-borne infections and associated diseases in areas where drug use is recognized as a problem in the community. The strategy shall also include counseling and education and referral to primary health services and addiction/treatment services. The board of health shall produce an annual report of program activities and forward a copy to the Minister of Health. (Mandatory Health Programs and Services Guidelines, Ministry of Health and Long Term Care/Public Health Branch, December 1997, p44).

   The World Health Organization (2004), the United States Preventative Services Task Force (1996) and the American Medical Association (1996) all recognize needle exchange programs as essential prevention programs to reduce HIV transmission among injection drug users.

   If the US government had embraced harm reduction interventions and implemented a national needle exchange program from 1987 through 1995, a conservative estimate of between 4,394 and 9,666 HIV infections could have been prevented (K. Ksobiech, 2004).

   NEPs make good public health sense because:

   1. NEPs reduce transmission of HIV, Hepatitis B virus (HBV), hepatitis C virus (HCV) and other blood-born pathogens among IDUs

   2. NEPs reduce unsafe drug use and sexual behaviours associates with the transmission of HIV, HBV, HCV and other blood-borne pathogens

   3. NEPs reduce the number of used needles discarded in the community

   4. NEPs do not encourage initiation of injection drug use, do not increase the duration or the frequency of injection drug use or decrease the motivation to reduce drug use

   5. There is no available cure nor vaccine for HIV

   6. The lifetime costs of providing treatment for IDUs living with HIV greatly exceeds the costs of providing NEP services

   7. At any given time, most individuals who inject drugs are not receiving drug treatment and NEPS are often the only contact these people have with health or social service providers (Strike C and Leonard L, 2006)

   Researchers at McMaster University examined the needle exchange program in Hamilton, which provided more than 14,200 clean syringes to 275 drug users in 1995. The authors of the study, Gold, Gafni and Nelligan estimated the program would prevent 24 new HIV infections over five years; resulting in a direct cost savings to the publicly funded health care system of $1.3 million. (over 5 years based on the 24 prevented HIV infections)

   In Amsterdam in 1988, Bunning and colleagues reported declines in needle sharing and injection frequency associated with NEP participation. An international comparison showed that in 29 cities with established NEPs, HIV prevalence rates decreased on average by 5.8% per year, while it increased on average by 5.9% per year in 51 cities without NEPs ( Strathdee, S. et al, 2001).

5. What happens at a Needle Exchange Program?

   The main function of a NEP is to make new sterile needles and syringes accessible and to provide drug users with access to other injection equipment (like sterile water, alcohol swabs, filters) for the safe injection/inhalation of drugs. The rationale for providing clean sterile needles reduces unsafe injection practices like needle sharing, reduces transmission of HIV/AIDS and Hepatitis, increases safe disposal of used syringes, so that the syringes are not in the community and helps the injecting drug user in obtaining drug information, treatment, detoxification, social services, and primary health care (www.heretohelp.bc.ca).

   NEPs provide sterile water, alcohol swabs and sterile filters in order to reduce the health risks to the injector like abscesses and infections, which can be costly to heal if the individual ends up in the emergency department with an illness that could have been prevented by having access to clean sterile equipment. By providing the needed equipment for safe injection, injectors have contact with health service staff which can contribute to a stabilization or improvement in their general health and social functioning.

6. Don’t Needle Exchange Programs increase dirty needles in our community?

   An American study on NEPs needle return rates worldwide in 2004 determined that NEPs are relatively successful in taking in used needles. Worldwide, the return rate of used needles is 90%. (Ksobiech, K., 2004) The higher the return rate the less time dirty/used needles are in circulation in the community, the greater the likelihood that injectors are using sterile new needles more often and the lower the probability that injectors are sharing injection equipment.

7. Don’t Needle Exchange Programs encourage drug use?

   Researchers Marx and Strathdee studied the association between adolescent exposure to and understanding of needle exchange programs and their perceptions of the impact of NEPs on the decisions to use illicit drugs. The Baltimore adolescents believed the following factors promoted drug use: peer drug use 49.9%; parental drug use 43.5%; seeing drug users attend NEP 11.1%; school drug education 6.6%; and anti-drug TV advertisements 6.1%. The percentage believing that the above mentioned factors had no influence on illicit drug use was : seeing drug users attend NEP 42.4%; school based drug education 36.9%; anti-drug TV ads 29.8%; peer drug use 21.7%; and parental drug use 19.1%, (Marx and Strathdee, 2001)

   Studies have proven that harm reduction interventions do not: increase drug use; negatively impact upon drug treatment; and do not increase rates of injecting equipment (such as needles or syringes) in the streets Watters et al evaluated all-voluntary syringe exchange programs in San Francisco, California over a 5.5 year period and determined that the program did not increase drug use. Paone et al. reviewed international studies of syringe programs and concluded that harm reduction interventions do not increase drug use. Wolk et al. studied a pilot needle/syringe exchange program in Sydney, Australia which was established next to a methadone maintenance clinic and determined an increase in the availability of needles/syringes did not increase injection drug use. Heimer et al reviewed a city run needle exchange program in New Haven, Connecticut and determined that NEPs are a conduit to drug treatment. Doherty et al studied a needle exchange program in Baltimore, Maryland two years after it opened and determined that there was a significant decrease in the number of discarded needles in the community relative to the number of drug vials and bottles.

   In countries with less severe penalties for drug possession there are no higher rates of drug use than in other counties (Lenton, S, et al, 2000). In fact in such areas, drug users have a better chance of medical attention, access to substitution treatment (like methadone), rehabilitation, and a decreased risk of contracting and or spreading HIV/AIDS, Hepatitis C and other infections.

8. Info and Stats should be specific to the NEP—example from SITE in Ottawa

   The SITE needle exchange program has been in existence since 1991 in Ottawa. The programs and services at SITE help to reduce the spread of infections and diseases and studies have shown this helps to prevent future health-care costs. There are approximately 3,500 individuals who inject drugs in the City of Ottawa. SITE distributes and collects more than 100,000 used needles annually through its main clinic, mobile clinic and street outreach programs and another 400,000 needles are distributed through a network of eleven partner agencies. In 2004, SITE had a 98% return rate, that is, they distributed 109,000 clean needles and collected 107,000.

   SITE helps to keep used needles off the streets of Ottawa which helps to prevent the spread of HIV and other infections. The HIV infection rate among people who inject drugs has been relatively stable for the past four years following a sharp rise in the 1990s. SITE estimates that one in five users of injection drugs is HIV positive and 60% have hepatitis C. The sharing of needles and other equipment is a major reason for such high rates of infection and reinforces the need for a needle exchange program.

   SITE is often the only positive contact many drug users have with the health-care system. Counseling and referrals are made for about 200 people annually to treatment programs. SITE also provides education on safer sex practices and provides testing for HIV virus and hepatitis B and C. Clients who get needles from SITE are educated about proper needle disposal to help keep the whole community safer. Staff show clients how to dispose of needles safely if they aren’t able to get to the needle exchange program. Staff remind clients not to inject in public places and to never inject or discard needles or other injection equipment in or near the “safe zones”. Safe zones are areas the SITE mobile clinic does not deliver services to, which is a 100 metre distance from parks, schools, day care centes in order to protect children and the general public.

9. How much does the SITE program cost?

   SITE’s annual budget for direct program delivery is $260,000 and another $100,000 for staffing and for the needle clean up program. The main cost is shared 50:50 with the Province as needle exchange programs are provincially mandated. It costs $150,000 to treat one AIDS patient in their lifetime, two such patients represents the entire annual SITE program budget.

10. Sources

    Coutinho, R.A., “Needle Exchange, Pragmatism and Moralism”, American Journal of Public Health, vol. 90, no. 9, Sept. 2000, p1387-1388)

    Strike, C. and Leonard, L. et al. “Ontario Needle Exchange Programs: Best Practice Recommendation”, Health Canada, March 2006

    Ontario Ministry of Health and Long Term Care, “Mandatory health programs and services guidelines., Toronto , Ontario ,1997

    Ksobiech, K., “Return Rates for Needle Excahnge Programs: A Common Criticisms Answered”, Harm Reduction Journal 1:2,. 2004).

    Bunning, E.C., et al, “Preventing AIDS in drug addicts in Amsterdam”, Lancet, 1:1 (8495).

    Strathdee, S. et al., “The effectiveness of needle exchange programs: A review of the science and policy”, AIDScience, vol 1 no 16, December 2001.

    Marx, M. and Strathdee, S., et al., “ Impact of Needle Exchange Programs on Adolescent Perceptions about Illicit Drug Use”, AIDS and Behavior, vol 5 no 4 December 2001 pp 379-386.

    www.heretohelp.bc.ca/publications/state-of-knowledge/

    Watters, JK. et al, Syringe and needle exchange as HIV/AIDS prevention for injection drug users. JAMA, 271:117-120 (1994).

    Paone, D. et al., Syringe Exchange: HIV prevention, key findings and future direction. International Journal of Addictions. 30, 1647-1683. (1995).

    Wolk, J. et al., The effect of a needle and syringe exchange on a methadone maintenance unit. British Journal of Addictions, 85, 1445-1450 (1990).

    Heimer, R. et al., Needle exchange programs as a conduit to drug treatment: the New Haven experience. Paper presented at the 11th International Conference on AIDS, Vancouver, Canada, (1996).

    Doherty, MC., et al., The Effect of a needle exchange program on the number of discarded needles:2 year follow-up., American Journal of Public Health, June , 90(6); 936-939, 2000.

    Lenton, S. et al., Infringement versus conviction: The social impact of a minor cannabis offence in SA and WA. Drug and Alcohol Review. 19, 257-264. (2000).