Research shows that not setting pre-determined limits on the number of syringes people can access makes it less likely that people re-use non-sterile or dull syringes on themselves and also reduces syringe sharing. Participants also leave each visit with enough safe-disposal containers to return all used syringes safely. An evaluation of Prevention Point was conducted in as reach and distribution efforts were growing.
The study found that the percentage of people who reported sharing needles fell from 66 percent in to 36 percent in In addition, participants who used Prevention Point services were significantly less likely to share needles than people who reported not accessing these services.
HIV rates during that time dropped too : The number of new HIV cases among people who inject drugs reached a peak in with new infections and dropped by half to about new infections in Each year, our team distributes sterile syringes at nearly a dozen different sites across San Francisco to stop the spread of both HIV and hepatitis C.
The program also offers hepatitis C and HIV testing and linkage to care, overdose prevention and education , opioid replacement therapy , easily accessible medical care, support groups, and more. Background: HIV infection has become one of the major public health problems of our time. An estimated See other articles in PMC that cite the published article. Abstract Needle exchange began in the United States as a fragmented and illegal practice initiated by actors at the grassroots level; since the late s, needle exchange has achieved increasing yet variable levels of institutional support across the country, receiving official sanction and funding from state and municipal governments.
Keywords: drugs, governance, population. Introduction The distribution of sterile needles to injection drug users IDUs began in the early s in the United States as a highly fragmented and ostensibly illegal practice initiated by drug user advocates and community organizations. From politics to public health: the ideological cleansing of needle exchange?
The other side of governmentality: unsanctioned ends of needle exchange In considering how NEPs may be deployed toward the greater surveillance and regulation of IDUs, the previous section may be seen to reveal one manifestation of governmentality in the context of needle exchange. Conclusion: needle exchange as a politics of life or death? References Agamben G.
Homo sacer: sovereign power and bare life. American Journal of Public Health. Disciplining addiction: the bio-politics of methadone and heroin in the United States. Culture, Medicine and Psychiatry. Fact sheet on syringe exchange programs. Syringe exchange programs — United States, MMR Weekly. Substance abuse and developments in harm reduction. Canadian Medical Association Journal. What the needles said. Yale Medicine. Governmentality: power and rule in modern society.
London: Sage; Risk, calculable and incalculable. In: Lupton D, editor. Risk and sociocultural theory: new directions and perspectives. Cambridge: Cambridge University Press; Foucault M. An introduction. New York: Vintage Books; The history of sexuality. New York: Picador; Prior to , a number of other studies were published Des Jarlais et al.
A close examination of the manner in which these studies were conducted strongly suggests their reliance on the quality of the evidence in individual studies, which is based on the strength of their research designs. The language of the assessments also reflects the expectation that, when they are taken as a collective across studies, even though the designs are less than ideal, the preponderance of evidence will weigh in favor of or against a definitive conclusion about needle exchange programs.
Taken together, these studies tend to suggest that needle exchange programs are either neutral or positive in terms of potential positive effects and that they do not demonstrate any potential negative effects.
However, each study's conclusions are often less than firm because of its methodological limitations. When the designs of a group of studies are limited, little inferential clarity is gained by looking at the preponderance of evidence, even if it converges across all available studies.
At a minimum, there must be a sufficient number of higher-quality i. For well-designed interventions with well-designed experimental assessment procedures, examining each outcome one at a time is obviously justifiable on statistical and logical grounds.
However, in light of the fact that most studies that have attempted to assess the effectiveness of needle exchange programs have limited study designs and that there are serious practical constraints associated with conducting a randomized control trial, some may conclude that it is impossible to ever determine whether needle exchange programs are effective. In the panel's view, however, such a conclusion is both poor scientific judgment and bad public health policy.
Indeed, to adopt the position that evidence short of a randomized trial is useless amounts to denying the possibility of learning from experience—which, though often difficult, is not impossible. In many areas of social sciences and public health research, the so-called definitive study—a randomized control experiment that is, a randomized double-blind placebo controlled trial —is an ideal that cannot be implemented.
For example, it is unethical to consider use of a clinical trial design to show that smoking causes lung cancer Hill, Scientific judgment develops instead through a series of studies using cross-sectional retrospective and prospective designs, in which later research avoids the flaws of earlier work but may introduce problems of its own. The improbability of being able to carry out the definitive study of the effects of certain HIV and AIDS prevention programs, including needle exchange programs, does not necessarily preclude the possibility of making confident scientific judgments about the effects of such prevention programs.
Bradford Hill , one of this century's foremost biostatisticians, commented three decades ago:. All scientific work is incomplete—whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time. Sooner or later there comes a time for decision on the basis of evidence in hand.
In the case of the efficacy of needle exchange programs, urgency is added because the disease in question—AIDS—is fatal, is contagious, and has been seen to spread rapidly in various settings. Previous assessments of individual studies as well as the panel's own did not rate them as highly conclusive, because none of them used the gold standard of randomized controlled research designs.
The panel therefore elected to rely on an approach that assesses the pattern of evidence in determining the effects of these HIV and AIDS prevention programs rather than relying on a preponderance of evidence approach. In this approach to assessing the effects of needle exchange programs and the credibility of evidence surrounding a needle exchange program, we look at the consistency of the pattern of evidence that is available from multiple data sources about the same program.
Taking this approach greatly expands the depth and breadth of the evidentiary base, because we try to understand the relationships among the parts of the intervention model, the process, and their outcomes. Rather than interpreting the effects of the intervention on individual outcomes, in isolation, the pattern of evidence approach considers interrelated conditions, such as intermediate outcomes Cordray, For example, consider the evaluation of a needle exchange program that reveals a reduction in new HIV infections over time among injection drug users who used the program.
By traditional standards, this design would be classified as relatively weak because there is no control or comparison condition. Without further information, it is not possible to confidently conclude that the introduction of the needle exchange program is responsible for the observed decline on the basis of this one piece of evidence the observed decline alone. By examining whether certain required conditions were present, it is possible to probe the plausibility that the needle exchange program was responsible, at least in part, for the reduction.
This type of assessment requires the specification of a series of if-then propositions. That is, if there is a real connection between the introduction of the needle exchange program and the observed decline in new infections, then a series of conditions must be present in order to increase confidence in the conclusion that the program is at least partially responsible for the observed outcome.
The conclusion that the needle exchange program is plausibly connected to the decrease in new HIV infections is more credible if there is evidence that, as the putative causal agent, it was actually present in the community. This means that there must be an empirical pattern of evidence that, in effect, rules in its plausibility. Programmatically, the pattern of evidence might include:.
The argument that undergirds this approach is that programs have a structure and mechanisms that establish a logical pattern of expectations that can be tested empirically. To the extent that the empirical evidence supports these propositions, the plausibility that the needle exchange program was responsible for the observed change should increase. That is, the plausibility increases through repeated assessments. As a simple example, if there is a reduction in HIV incidence but the needle exchange program failed to exchange a single needle, it is not reasonable to conclude that the needle exchange program was responsible for the decline, regardless of the strength of the design underlying the HIV incidence data.
However, through multiple assessments, involving a logical network of evidence, it may be possible to derive a portrait of the plausibility that the needle exchange program is implicated in the change process. Ruling in the plausibility that the needle exchange program is a causal agent, through empirical assessment, is only half the story. It is still possible that other features of the program or research process contain biases that affect the HIV incidence. In traditional discussions of causal analysis, the notion of excluding or rendering implausible rival explanations has been the hallmark of competent experimental analysis.
To the extent that repeated efforts to probe the results fail to disconfirm the plausibility that the intervention was at least partially responsible, its plausibility should be enhanced. Therefore, an assessment of the pattern of evidence not only entails ruling in the plausibility that the needle exchange program is a causal agent, but also requires ruling out plausible alternative explanations.
The panel analyzed the patterns of evidence from five sources: two evaluations of the research published before , the findings of studies published since , and two sets of studies that provide the best available detailed account of how needle exchange programs impact risk behaviors and viral infections—one on New Haven, the other on Tacoma. The process of selecting studies for detailed examination involved a comprehensive analysis of the research findings of individual needle exchange and bleach distribution projects.
The panel generated a list of published papers and presentations on needle exchange evaluation projects in the United States, Canada, and Europe. A meeting was held to judge which reports included data that might be used in a review. The projects were subsequently grouped by city and divided among panel members so that each city project had two independent reviewers. The studies from each city were reviewed, annotated on a formal evaluation form, and then discussed with the full panel at a subsequent meeting.
Following this review, at a separate meeting, the panel decided to limit itself to studies conducted in the United States, because the legal and cultural environments of other countries are sufficiently different to raise questions about whether data are applicable to the United States.
Two U. Various criteria were used in deciding to pursue the New Haven and Tacoma sets of studies. Consistent with the logic of the patterns of evidence approach, the first criterion applied in selecting studies was that the site or project had to have been comprehensively studied. That is, there had to be empirical evidence establishing that the needle exchange program was operational, that the mechanisms of the exchange process had been studied, and that there was an estimate of HIV incidence or, as in the case of New Haven, a proxy measure.
The level of activity in the prevention environment can make it difficult to isolate the influence of the needle exchange program. A second criterion was that, in the sites and projects selected, the needle exchange program had to be the predominant if not the only intervention ongoing at the time of the assessment.
This criterion implies a selection process that focuses on high-contrast sites i. General Accounting Office carry out a review of the effectiveness of needle exchange programs.
GAO researchers carried out an extensive review of the literature to identify empirical evaluation studies that had appeared in refereed or peer-reviewed journals. Their review identified a total of 20 published studies and 21 abstracts on evaluations of needle exchange programs originating from nine distinct research projects, all but one of which the Tacoma study involved programs outside the United States. Among the nine research projects were one from Australia, one from Canada, two from the Netherlands, one from Sweden, and three from the United Kingdom.
The GAO team developed a list of eight relevant outcome measures: 1 rate of needle sharing; 2 prevalence of injection drug use; 3 frequency of injection; 4 rate of new HIV infections; 5 rate of new entrants to injection drug use; 6 incidence rate of other blood-borne infections; 7 rate of other HIV risk behaviors; and 8 risk to the public's health. They also identified three methodological criteria that had to be satisfied before findings could be considered: 1 the findings had to have been published in a scientific journal or government research monograph; 2 they had to have reached statistical significance ; and 3 the reported effects of the needle exchange program could not have been attributed by the authors to any other source.
Of the eight listed outcome measures, only three outcomes met the methodological standard of evidence set by the GAO team: 1 rate of needle sharing, 2 prevalence of injection drug use, and 3 frequency of injection. The GAO team summarized descriptive information, whenever it was available, on the ability of needle exchange programs to reach out to injection drug users and refer them to drug treatment and other health services.
Tables 7. Regarding the potential positive outcomes, of the nine research projects reviewed, two reported a reduction in needle sharing, and a third reported an increase. It should be noted that the increase in sharing by needle exchange participants resulted from their passing on more used injection equipment Klee et al.
The earlier finding from that study appears to have been a transient effect that occurred before the needle exchange programs in the area reached full operation; that is, needle exchange participants were being used as a source of needles among their respective networks of injection drug users Klee and Morris, The researchers concluded, moreover, based on the data available from six of the nine projects, that the needle exchange programs were successful in reaching injection drug users and providing a link to drug treatment and other health services.
Regarding potential negative outcomes of needle exchange programs, all five projects that reported findings on injection drug use by program participants—four on frequency of injection and one on prevalence of use—found that use did not increase.
Note that three of these findings did not reach statistical significance. GAO reported that there was sufficient evidence to suggest that needle exchange programs "hold some promise as an AIDS prevention strategy" p. In summary, the GAO report, which was the first government report to evaluate needle exchange programs, concluded that such programs hold promise as interventions to limit HIV transmission. The criteria for assessing the validity of the study findings and for including reports in the review were quite stringent.
In particular, the criterion of statistical significance means that studies that showed no difference in the frequency of injection or needle sharing were excluded. Therefore, the argument that needle exchange programs cause no harm is not fully characterized because studies with high level of statistical power that showed no difference were excluded.
This report consists of a summary volume with two supporting volumes and addresses a number of the questions that this panel was asked to address. The University of California report was the work of a team of 12 individuals with expertise in clinical medicine, nursing, psychology, anthropology, sociology, cost-benefit modeling, and epidemiology. None of the team members was identified in published writings as either in favor of or opposed to needle exchange programs.
In a process that included discussions with an advisory committee, public health officials, needle exchange program staff members, researchers, experts in drug abuse treatment and injection drug use, and community leaders, a list of 14 research questions was generated: 1 How and why did needle exchange programs develop? The investigators conducted a formal review of existing research; made site visits and sent mail surveys to needle exchange programs; formed focus groups with injection drug users; and applied statistical modeling techniques.
Data collected from each approach were sorted into 1 of the 14 questions about impact of needle exchange programs. The aim of the literature review was to identify a maximum of written works relating to the effectiveness of needle exchange programs.
Computer searches of AIDS line and Medline provided a first cut and were augmented by items from the bibliographies of articles found therein. In addition, the research team reviewed abstracts from the annual International Conference on AIDS from to and the annual meetings of the American Public Health Association from to To identify unpublished materials, needle exchange program staff were contacted about internal reports, and a search was made for newspaper and magazine clippings, government and institutional reports, and relevant book chapters.
From this effort, 1, data sources were identified, which included journal articles, conference abstracts, reports, unpublished materials, newspaper and magazine articles, 94 books or chapters, and personal communications or other sources.
All materials were reviewed and coded according to which research question s they addressed. Project members were assigned responsibility for synthesizing information for each of the 14 research questions. Each of the studies was assessed using a standardized format and ranked on a scale from 1 to The final ranking of an article was determined by agreement of at least two project members.
Only studies ranked 3 or higher were used in the synthesis. In addition to the review of existing research, the University of California team conducted site visits to 15 cities, 10 of which were in the United States, 3 in Canada, and 2 in Europe. CDC was consulted during the selection process. At each site, the research team used multiple data collection methods with multiple iterations, consisting of interviews, focus groups, and observation using a formal qualitative research strategy.
The methodology was codified in a manual. Standardized training of the research staff was provided. In the 15 cities, 33 needle exchange sites were visited and a total of interviews with needle exchange directors and staff, public health officials, injection drug use researchers, community leaders, program participants 11 focus groups , and injection drug users not enrolled in programs 7 focus groups were completed.
Observation guidelines were pretested at two sites and the results were compared qualitatively for interrater reliability before adopting the final guidelines. Of the nine outcomes and expectations for successful needle exchange programs listed in Table 7. That is, research findings concerning four of the five possible positive outcome domains were reviewed: reduction in drug-related and sexual risk behaviors, increase in referrals to drug abuse treatment, and reduction in HIV and other infection rates.
The report addressed all four possible negative outcomes: increases in 1 drug use by program participants; 2 new initiates to injection drug use; 3 drug use in the community in general; and 4 the number of contaminated needles discarded. The University of California report reviewed data on reported needle-sharing frequency in studies of needle exchange programs. Of the 26 evaluations addressing behavior change associated with the use of needle exchange programs that were identified, 16 were deemed of acceptable quality rating 3 or higher.
Of the 16 studies, 14 presented data on the frequency of needle sharing; 9 of these had comparison groups reported. As Table 7. Regarding sexual risk behavior change, the report concluded that the findings were neutral. That is, four studies reported beneficial effects of needle exchange programs relating to sexual risk associated with number of partners and two reported mixed or neutral effects.
When reviewing studies that addressed risk associated with partner choice, three showed beneficial effects and two reported mixed or neutral effects. Finally, beneficial effects of needle exchange programs relating to condom use were observed in one study, mixed or neutral results in another, and adverse effects in three studies.
The University of California report noted that 17 of 18 U. Of 33 U. The extent to which referrals enter treatment and are retained was described—the 6 programs that collect data on referrals reported 2,—but was not studied. The report noted Lurie et al.
This affects the likelihood that a needle exchange program will refer and that a referral will link a client with treatment. The University of California report identified 21 studies that were relevant to the issue of whether needle exchange programs impact rates of HIV infection: 2 case studies, 7 serial community cross-sectional studies, 6 serial needle exchange program cross-sectional studies, 1 case-control study, and 3 prospective studies.
The quality of studies was rated on a 5-point scale ranging from a low of 1 not valid to a high of 5 excellent and a mid-point of 3 acceptable. Only two of the studies received a quality rating of 3 or higher, and two others were rated between 2 and 3. None of the studies showed increased prevalence or incidence of HIV infection among needle exchange participants. Given the quality rating of the studies, it is not surprising that the University of California report concluded that the studies available up to the time of the report Lurie et al.
However, needle exchange programs do not appear to be associated with increased rates of infection. It is intrinsically difficult to measure effects of intervention on the incidence of new infections of rare diseases, whose victims ordinarily do not show symptoms at the time of infection.
Although most of the early studies used prevalent infection as the outcome measure, the more appropriate measure is incident or new infection.
However, a further complication is that incidence is low in most locations, thereby requiring larger study populations to demonstrate program effects. The University of California report noted Lurie et al. Well-conducted, sufficiently large case-control studies offer the best combination of scientific rigor and feasibility for assessing the effect of needle exchange programs on HIV rates.
The University of California report noted that eight "acceptable" studies were identified that presented data on the issue of reported injection frequency. This last study also found reduced needle sharing reported among needle exchange participants. This study noted that the apparent increase in injection could be attributed to several other factors, including the differential dropout of low-level injectors.
The report also reviewed the methodological limitations of the studies, including the potential for socially acceptable responses by injection drug users. On balance, because of methodological problems, the report drew no strong conclusions about levels of injection drug use.
The University of California report reviewed a variety of studies and used focus groups to understand whether needle exchange programs could encourage persons to initiate injection drug use. In reviewing the demographic data from the programs, the report noted that the median age of participants across programs ranged from 33 to 41, and the median duration of injection drug use from 7 to 20 years. This suggests that most participants initiated injection drug use prior to using the needle exchange program.
A review of serial cross-sectional studies of injection drug users in San Francisco noted an increase in the mean age of the samples over time from 34 in to 40 in , suggesting that there was not an increase in young new injectors over time. Researchers in Amsterdam used a capture-recapture method to estimate the number of injection drug users between and Despite initiation of a needle exchange program in , no change in the number of injection drug users was reported, and the average age of drug users increased over time.
Furthermore, the number of drug users under age 22 decreased from 14 percent in to 3 percent in The authors concluded that there was no increase in the number of new initiates into injection drug use. The report concluded, on the basis of evidence from surveys, that Lurie et al. Focus groups were consulted. Of 10 focus groups from needle exchange programs, comprising 65 injection drug users, 2 individuals thought needle exchange programs could encourage nonparenteral drug users to start injecting.
Among seven nonprogram focus groups comprising 47 injection drug users, 2 individuals thought needle exchange programs could encourage nonparenteral drug users to start injecting. The focus group data were viewed as corroborating evidence for the data available from surveys arguing against an effect of needle exchange programs on increasing the community levels of injection drug use. The University of California report addressed the potential for increased drug use in the community by reviewing the studies noted in the previous section.
Researchers searched for additional data by examining established data sets of drug abuse indicators and answers to additional questions asked of focus groups of injection drug users. The University of California researchers attempted to relate the presence or absence of needle exchange programs to ongoing statistical series like the Drug Abuse Warning Network DAWN , Drug Use Forecasting DUF , and Uniformed Crime Reports UCR , which might reflect altered patterns of drug-related events, such as drug cases in hospital emergency rooms, positive urine drug screens, and drug-related arrests, respectively.
The report noted wide variation in these drug-use indicators over time, which suggests inherent lack of precision and limits the manifestation of patterns—if any—relating to needle exchange. The University of California report also noted that, because needle exchange programs are relatively new, changes in drug use might yet appear with longer follow-up. The report concluded that Lurie et al. The report also noted that the San Francisco and Amsterdam surveys described above provide Lurie et al.
The University of California report noted that adverse community responses to needle exchange programs are likely to be centered on the issue of discarded needles and the risk to the public of accidental needlestick injury. However, the report noted that one-for-one exchange rules cannot, in theory, increase the total number of discarded needles, although programs could affect the geographic distribution of discarded syringes.
Data on a surveillance project with the Portland, Oregon, needle exchange program noted a decrease in the prevalence of discarded syringes near the program Lurie et al. Passive surveillance of health or police department reports over time indicated either declines or small increases in needlestick injuries, with the trends due to changes in reporting patterns.
The University of California report concluded that needle exchange programs "have not increased the total number of discarded syringes" and, if structured as a one-for-one exchange with no starter needles, "they cannot increase the total number of discarded needles" Lurie et al. Using multiple data sources, the University of California reviewed a number of questions about needle exchange programs. As far as possible positive outcomes are concerned, the report concluded that the data available at the time of the report "do not … provide clear evidence that needle exchange programs decrease HIV infection rates," p.
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