Syringe Service and Needle Exchange Programs

1. US Surgeon General's Determination of Effectiveness of Syringe Exchange Programs

"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."

Sebelius, Kathleen, Secretary of Health and Human Services, "Determination That a Demonstration Needle Exchange Program Would be Effective in Reducing Drug Abuse and the Risk of Acquired Immune Deficiency Syndrome Infection Among Intravenous Drug Users," Federal Register, February 23, 2011, Vol. 76, No. 36, p. 10038.

2. Effectiveness of Syringe Exchange Programs Acknowledged by Federal Government in 1998

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."

Shalala, D.E., Secretary, Department of Health and Human Services, Press release from Department of Health and Human Services, April 20, 1998.

3. NIDA Director Nora Volkow Endorsed Effectiveness of Syringe Exchange in Reducing Risk of HIV Infection in 2004

"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."

Nora Volkow, Director, US National Institute on Drug Abuse, Correspondence with Allan Clear, "NIH Response on Harm Reduction and Needle Exchange," Aug. 4, 2004.

4. Services Provided By Syringe Service Programs

"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."

Don C. Des Jarlais PhD, Ann Nugent, Alisa Solberg MPA, Jonathan Feelemyer MS, Jonathan Mermin MD, and Deborah Holtzman PhD. "Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013," Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR) 2015;64:1337-1341.

5. What The Research Shows Regarding Syringe Exchange Programs

"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."

National Institutes of Health Consensus Panel, Interventions to Prevent HIV Risk Behaviors (Kensington, MD: NIH Consensus Program Information Center, February 1997), p. 6.

6. How Syringe Exchanges Work

"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)."

"Syringe Exchange Programs - United States, 2008," Morbidity and Mortality Weekly Report (Atlanta, GA: US Centers for Disease Control, Nov. 19, 2010), Vol. 59, No. 45, p. 1488.

7. US Surgeon General's Determination of Effectiveness of Syringe Exchange Programs

"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."

US Surgeon General Dr. David Satcher, Department of Health and Human Services, "Evidence-Based Findings on the Efficacy of Syringe Exchange Programs: An Analysis from the Assistant Secretary for Health and Surgeon General of the Scientific Research Completed Since April 1998" (Washington, DC: Dept. of Health and Human Services, 2000), p. 11.

8. Legal Access to Syringes

"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."

Diebert, Ryan J., MPH, Goldbaum, Gary, MD, MPH, Parker, Theodore R., MPH, Hagan, Holly, PhD, Marks, Robert, MEd, Hanrahan, Michael, BA, and Thiede, Hanne, DVM, MPH, "Increased Access to Unrestricted Pharmacy Sales of Syringe in Seattle-King County, Washington: Structural and Individual-Level Changes, 1996 Versus 2003," American Journal of Public Health, Vol. 96, No. 8, Aug. 2006, p. 1352.

9. Syringe Service Programs Are Proven And Effective Community-Based Prevention 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."

Centers for Disease Control and Prevention. Summary of Information on the Safety and Effectiveness of Syringe Services Programs (SSPs). Last accessed July 8, 2021.

10. State Policies Regarding Disease Prevention and Syringe Service Programs

"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."

Campbell CA, Canary L, Smith N, Teshale E, Ryerson AB, Ward JW. State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2017;66:465–469. DOI:

11. Pediatrician Advocacy for Syringe Service Programs and Needle Exchanges

"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."

"Policy Statement: Reducing the Risk of HIV Infection Associated With Illicit Drug Use," Committee on Pediatric AIDS, Pediatrics, Vol. 117, No. 2, Feb. 2006 (Chicago, IL: American Academy of Pediatrics), p. 569.

12. Number of Syringe Services Programs (SSPs) / Syringe Exchange Programs (SEPs) in US

"As of March 2014, 204 SSPs were known to be operating in the United States in 2013."

Don C. Des Jarlais PhD, Ann Nugent, Alisa Solberg MPA, Jonathan Feelemyer MS, Jonathan Mermin MD, and Deborah Holtzman PhD. "Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013," Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR) 2015;64:1337-1341.

13. People in the US Aged 21-30 Who Inject Drugs

"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."

Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., Patrick, M. E., & Miech, R. A. (2020). HIV/AIDS: Risk & Protective Behaviors among Adults Ages 21 to 30 in the U.S., 2004–2019. Ann Arbor: Institute for Social Research, The University of Michigan.

14. Services Offered by Syringe Services Programs / Syringe Exchange Programs

"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."

Don C. Des Jarlais PhD, Ann Nugent, Alisa Solberg MPA, Jonathan Feelemyer MS, Jonathan Mermin MD, and Deborah Holtzman PhD. "Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013," Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR) 2015;64:1337-1341.

15. Global Review Shows Most Countries Lack Adequate HIV Prevention Resources

"A systematic review undertaken in 2017 of the coverage of interventions to prevent and manage HIV and hepatitis C among PWID showed that needle and syringe programmes were available in only 52 per cent of countries where injecting drug use was reported, while opioid substitution therapy was confirmed to be available in 48 per cent of countries worldwide. In addition, only 34 countries were identified as providing HIV-testing programmes for PWID.119 Besides providing an opportunity to deliver prevention messages and connect patients to health-care and support services, HIV testing services are also a critical entry point to antiretroviral therapy and are therefore a crucial component of HIV prevention programmes. Global data on antiretroviral therapy coverage are scarce. Access to antiretroviral therapy varies considerably, but coverage is reported to be consistently low, with only 8 per cent of people in need receiving effective antiretroviral therapy in the WHO European Region and PWID only accounting for 20 per cent of people receiving that therapy.120"

World Drug Report 2020. Booklet Two: Drug Use and Health Consequences. June 2020. United Nations publication, Sales No. E.20.XI.6).

16. Growth of Syringe Service Programs in the US

"The findings in this report indicate that, in 2008, the number of SEPs and the number of syringes exchanged remained similar to recent years, in contrast to a period of rapid growth from the mid-1990s through the early 2000s. Budgets for SEPs increased from 1994–1995 through 2008, with the majority of funds coming from public sources."

"Syringe Exchange Programs — United States, 2008," Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control, November 19, 2010) Vol. 59, No. 45, p. 1489.

17. SEP Sites, 2008

"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)."

"Syringe Exchange Programs — United States, 2008," Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control, November 19, 2010) Vol. 59, No. 45, p. 1489.

18. Availability of Syringe Exchange Leads to Reduction in HIV Incidence Among Injection Drug Users

"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."

Hurley, Susan F., Damien J. Jolley, John M. Kaldor, "Effectiveness of Needle-Exchange Programmes for Prevention of HIV Infection," The Lancet, 1997; 349: 1797-1800, June 21, 1997.

19. Number of SEPs

"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."

"Syringe Exchange Programs — United States, 2008," Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control, November 19, 2010) Vol. 59, No. 45, p. 1488.

20. OTC Availability of Clean Syringes

"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."

Friedman, Samuel R. PhD, Theresa Perlis, PhD, and Don C. Des Jarlais, PhD, "Laws Prohibiting Over-the-Counter Syringe Sales to Injection Drug Users: Relations to Population Density, HIV Prevalence, and HIV Incidence," American Journal of Public Health (Washington, DC: American Public Health Association, May 2001), Vol. 91, No. 5, p. 793.

21. Other Services Offered by SEPs

"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)."

"Syringe Exchange Programs — United States, 2008," Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control, November 19, 2010) Vol. 59, No. 45, p. 1489.

22. Police Targeting of Legal Syringe Service Programs

"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."

Alexis N. Martinez, Ricky N. Bluthenthal, Jennifer Lorvick, Rachel Anderson, Neil Flynn, and Alex H. Kral, "The Impact of Legalizing Syringe Exchange Programs on Arrests Among Injection Drug Users in California," Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 3, p. 429.

23. Prevalence of Injection Drug Use and Risk Behaviors in the US

"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"

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (October 29, 2009). The NSDUH Report: Injection Drug Use and Related Risk Behaviors. Rockville, MD, p. 1.

24. Syringe Need and Availability

"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."

Daliah I Heller, Denise Paone, Anne Siegler and Adam Karpati, "The syringe gap: an assessment of sterile syringe need and acquisition among syringe exchange program participants in New York City," Harm Reduction Journal (London, United Kingdom: January 2009), p. 1.

25. US Demand for Clean Syringes

"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."

Burris, Scott, JD, Lurie, Peter, MD, et al., "Physician Prescribing of Sterile Injection Equipment to Prevent HIV Infection: Time for Action", Annals of Internal Medicine (Philadelphia, PA: American College of Physicians, August 1, 2000), Vol. 133, No. 3, p. 219.

26. Social Marginalization and Fear of Police Prevent People from Obtaining Adequate Numbers of Syringes from SEPs

"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."

Daliah I Heller, Denise Paone, Anne Siegler and Adam Karpati, "The syringe gap: an assessment of sterile syringe need and acquisition among syringe exchange program participants in New York City," Harm Reduction Journal (London, United Kingdom: January 2009), p. 4.

27. SEP Program Components

"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."

Committee on the Prevention of HIV Infection among Injecting Drug Users in High-Risk Countries, Institute of Medicine, National Academy of Sciences, "Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence" (Washington, DC: National Academy Press, 2006), p. 175.

28. Lifetime Cost of HIV Treatment

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."

Lurie, P. & Reingold, A.L., et al., "The Public Health Impact of Needle Exchange Programs in the United States and Abroad" (San Francisco, CA: University of California, 1993), Vol. 1, Executive Summary, pp. iii-v.

29. Effectiveness of Needle and Syringe Exchange Programs (NSPs) in Sweden

"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)."

Swedish National Institute of Public Health. "2012 National Report (2011 data) To the EMCDDA by the Reitox National Focal Point: Sweden: New Development, Trends and in-depth information on selected issues." Östersund: Swedish National Institute of Public Health, 2012, p. 67.

30. Cost Effectiveness of Needle and Syringe Programs

"It was estimated that:
"• For every one dollar invested in NSPs, more than four dollars were returned (additional to the investment) in healthcare cost-savings in the short-term (ten years) if only direct costs are included; greater returns are expected over longer time horizons.
"• NSPs were found to be cost-saving over 2000-2009 in seven of eight jurisdictions and cost-effective in the other jurisdiction. Over the longer term, NSPs are highly cost saving in all jurisdictions.
"• The majority of the cost savings were found to be associated with HCV-related outcomes. However, when only HIV-related outcomes were considered in the analysis, it cost $4,500 per DALY gained associated with HIV infection.
"• If patient/client costs and productivity gains and losses are included in the analysis, then the net present value of NSPs is $5.85bn; that is, for every one dollar invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon.
"• NSPs are very cost-effective compared to other common public health interventions, such as vaccinations (median cost per QALY of $58,000), allied health, lifestyle, and in-patient interventions (median cost of $9,000 per DALY gained), and interventions addressing diabetes and impaired glucose tolerance or alcohol and drug dependence (median cost of $3,700 per DALY gained)[2]."

National Centre in HIV Epidemiology and Clinical Research (2009). Return on investment 2: Evaluating the cost-effectiveness of needle and syringe programs in Australia 2009. The University of New South Wales, Sydney, pp. 8-9.

31. Return on Investment for Needle and Syringe Programs

"Investment in NSPs (2000-2009) has resulted in:
"• An estimated 32,050 HIV infections and 96,667 HCV infections averted;
"• Substantial healthcare cost savings to government related to HCV and HIV;
"• Substantial gains in Disability Adjusted Life years.
"For every dollar currently spent on the activities of NSP, more than four dollars will be returned (in addition to the investment; i.e., five times the investment) and approximately 0.2 days of disability-adjusted life gained. Over a longer time horizon there is even greater return."

National Centre in HIV Epidemiology and Clinical Research (2009). Return on investment 2: Evaluating the cost-effectiveness of needle and syringe programs in Australia 2009. The University of New South Wales, Sydney, p. 9.

32. Modification and Partial Lifting of the Federal Ban on Funding of Syringe Exchange Programs, 2016

Laws & Policies

"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."

HR2029, "Consolidated Appropriations Act, 2016," Passed by 114th Congress and Signed Into Law on December 18, 2015.

33. Laws Restricting Syringe Availability

"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."

Human Rights Watch, "Injecting Reason: Human Rights and HIV Prevention for Injection Drug Users," (September 2003)

34. Recommendation of British Advisory Council on Misuse of Drugs

"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."

Advisory Council on the Misuse of Drugs, "The Primary Prevention of Hepatitis C Among Injecting Drug Users," (London, United Kingdom: February 2009), p. 28.

35. Syringe Access Through Pharmacies

"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."

"Annual Report 2006: The State of the Drugs Problem in Europe," European Monitoring Centre for Drugs and Drug Addiction (Luxembourg: Office for Official Publications of the European Communities, 2006), p. 79.

36. Legality of Syringe Possession

According to a study in 1996, "Drug paraphernalia laws in 47 U.S. states make it illegal for injection drug users (IDUs) to possess syringes." The study concludes, "decriminalizing syringes and needles would likely result in reductions in the behaviors that expose IDUs to blood borne viruses."

Bluthenthal, Ricky N., Kral, Alex H., Erringer, Elizabeth A., and Edlin, Brian R., "Drug paraphernalia laws and injection-related infectious disease risk among drug injectors", Journal of Drug Issues, 1999;29(1):1-16.

37. Syringe Access Through Pharmacies

Pharmacy Access to Sterile Syringes

"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."

Diebert, Ryan J., MPH, Goldbaum, Gary, MD, MPH, Parker, Theodore R., MPH, Hagan, Holly, PhD, Marks, Robert, MEd, Hanrahan, Michael, BA, and Thiede, Hanne, DVM, MPH, "Increased Access to Unrestricted Pharmacy Sales of Syringe in Seattle-King County, Washington: Structural and Individual-Level Changes, 1996 Versus 2003," American Journal of Public Health, Vol. 96, No. 8, Aug. 2006, p. 1347.

38. Over The Counter Syringe Availability

"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."

Friedman, Samuel R. PhD, Theresa Perlis, PhD, and Don C. Des Jarlais, PhD, "Laws Prohibiting Over-the-Counter Syringe Sales to Injection Drug Users: Relations to Population Density, HIV Prevalence, and HIV Incidence," American Journal of Public Health (Washington, DC: American Public Health Association, May 2001), Vol. 91, No. 5, p. 793.

39. SEPs and HIV Prevention

Effectiveness, Effects, and Other Research

"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."

Vlahov, David, PhD, and Benjamin Junge, MHSc, "The Role of Needle Exchange Programs in HIV Prevention," Public Health Reports, Volume 113, Supplement 1, June 1998, p. 79.

40. Limitations On Syringe Access And Infection Risk

"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."

Bluthenthal, Ricky N., Mohammed Rehan Malik, Lauretta E. Grau, Merrill Singer, Patricia Marshall & Robert Heimer for the Diffusion of Benefit through Syringe Exchange Study Team, "Sterile Syringe Access Conditions and Variations in HIV Risk Among Drug Injectors in Three Cities," Addiction Journal, Vol. 99, Issue 9, p. 1136, Sept. 2004.

41. ONDCP's Misrepresentation of Research

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."

"Deadly Ignorance," The Washington Post, Feb. 27, 2005.