Increase Access to Syringe Exchange Programs

Introductory Paragraph

Needle exchange programs (NEPs) distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood-borne diseases like HIV and Hepatitis C. According to the CDC, syringe services programs (SSPs) are community-based prevention programs that can provide a range of services, including linkage to substance use disorder treatment; access to sterile syringes and injection equipment; and vaccination, testing, and referral to care and treatment for infectious diseases. NEPs and SSPs promote harm reduction to help protect the community by providing exchange programs and sterile supplies which help prevent the spread of infectious disease.

Key Information

Needle exchange programs have decades of evidence behind them - but not public support. Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, and the World Health Organization. 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. As such, sharing needles has become the most common mode of HIV transmission among injection drug users. In addition, used syringes and needles are a potential biohazard. Harm reduction services such as the provision of sterile needles and syringes can effectively prevent Hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale. Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. The CDC promotes SSPs and states that they "reduce HIV and HCV infections and are an effective component of comprehensive community-based prevention and intervention programs that provide additional services."

There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:

• Primary and Secondary Needle and Syringe Programs are fixed sites which are typically located in areas with high levels of injecting drug use. They can be found in community centers, pharmacies, or specialized voluntary counseling and testing centers. Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia.

• Mobile or On-Call Service operate from a van or bus with clean needles which are distributed. Larger mobile programs typically provide testing and other healthcare services and operate along regular routes at fixed times, often at night when increased use occurs. Mobile services can also be smaller and choose to target specific populations. Mobile programs are more accessible to injection drug users and face less opposition from a community.

• Dispensing Machine Distribution. Australia and countries in Europe have adopted a newer strategy and have begun to use syringe vending machines. They use non-currency tokens which are distributed by outreach workers to injection drug users in return for harm reduction packs. Australia’s machines include needles, syringes, alcohol swabs, cotton, wool, sterile water, and spoons. Others sometimes contain educational materials. Typically, these machines act in conjunction with fixed sites which provide needles and syringes 24 hours a day, 7 days a week. A clinical trial found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.

• Peer Service Distribution Networks. This is a strategy in which clients of needle exchanges provide services to their peers, distributing needles, syringes, and associated injection equipment. These clients are trained to assist peers to access exchangers, to distribute information about safer drug use and safer sex, and to facilitate referrals to other health services. This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have the psychological impact of making interventions more effective.

• Prison-Based Facilities are still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public. They meet a high need because prison populations have more cases of Hepatitis C and HIV than the average population.

Relevant Research

• Three Studies Documenting Positive Results. A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used. Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). The National Research Council report on the topic states: “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange.”

• Two Cost-Benefit Analyses. Needle exchanges have been projected to be a cost-effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis estimated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to a decrease of 194 HIV infections per year and a lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent.

• Meta-Analysis on Community Impact. This literature review found that supplying injecting drug users with clean or sanitized needles does not lead to more "dirty" needles in a community.

Impactful Federal, State, and Local Policies

• The Consolidated Appropriations Act, 2016 restricted the use of federal funds for programs distributing sterile needles or syringes for HHS programs. However, HHS also provides a guidance document that outlines how federal funds may be used for other aspects of SSPs based on evidence of a demonstrated need, in consultation with CDC.

• Currently each state has their own laws surrounding syringe exchange programs.

• A Comprehensive Guide to Syringe Services Programs and Syringe Possession Laws delineates how syringe possession polices impact ease of access to sterile syringes for injection drug users.

Available Tools & Resources

• SAFE Project:
  • "Have A Safety Plan" is a SAFE Project resource that instructs drug users on how to create a safety plan to prevent overdoses.
  • See the wiki titled "The Linkage Between Syringe Use and Infectious Disease" for more detailed information on drug use and the concern for those with an SUD catching or spreading infectious diseases.

• The World Health Organization has published a "Guide to Starting and Managing Needle and Syringe Programs."

• CDC provides a fact sheet on harm reduction to promote prevention of transmission of infectious disease, including blood-borne infections. They have published a document titled "Syringe Services Programs: A Technical Package of Effective Strategies and Approaches for Planning, Design, and Implementation." They have also provided guidance to state, local, tribal, and territorial health departments to determine if they have adequately demonstrated need for SSPs according to federal law.

• SAMHSA provides specific guidance for Minority HIV/AIDS Initiative (MAI) Programs that are implementing SSPs.

• The National Association of County Health Officials (NACCHO). In collaboration with the CDC and in partnership with the University of Washington, NACCHO provides funding and technical assistance to local health departments and community-based SSPs.

• The North American Syringe Exchange Network provides a directory of locations for SSPs.

• The Comer Family Foundation provides harm reduction grants for free sterile syringes. It has also published "A Guide to Establishing Syringe Services Programs in Rural, At-Risk Areas."

• The Syringe Access Fund awards grants in two categories: 1) SSPs providing direct services, and 2) harm reduction organizations at the local, state and federal levels conducting community education and mobilization activities focused on legalizing or SSPs and other health interventions for people who use drugs.

Promising Practices

• Miami, Florida. In three years of operation, Miami's pilot program pulled more than a quarter million used needles out of circulation. By handing out Narcan at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and Hepatitis C and connects people to medical care and rehabilitation services.

• Philadelphia, Pennsylvania. A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 people from contracting HIV over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion.

• Scott County, Indiana. Before Scott County set up its syringe exchange program in 2015, this rural county was seeing 10-20 new HIV cases every week. Almost immediately, the number of new cases was slowed to 1-2 a month.

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