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7 THE EFFECTS OF NEEDLE EXCHANGE PROGRAMS
Pages 198-262

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From page 198...
... Needle exchange programs operate in a rapidly changing environment, and the panel reviews a number of studies that were published subsequent to the major reviews by GAO and the University of California. Two strong lines of evidence emerged from the panel's examination of recent research on the effects of needle exchange programs on the spread of 198
From page 199...
... POTENTIAL OUTCOMES At the outset, it is important to recognize that the effects of needle exchange programs can be viewed from a number of different perspectives. Some of these perspectives involve outcomes relevant to improving the health status of injection drug users, and others reflect community-level concerns regarding potential negative effects that may be associated with the implementation of such programs.
From page 200...
... Assessment of the effects of needle exchanges involves the simultaneous consideration of a number of intended positive and unintended negative outcomes (Table 7.1~. Ideally, a successful exchange program would reduce the risk of new infection among injection drug users without increasing drug use and health risks to the public.
From page 201...
... 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.
From page 202...
... 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 lIIV 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.
From page 203...
... 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.
From page 204...
... 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's Synthesis The panel analyzed the patterns of evidence from five sources: two evaluations of the reseach published before 1993, the findings of studies published since 1993, 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.
From page 205...
... General Accounting Office carry out a review of the effectiveness of needle exchange programs. Procedure GAO researchers carried out an extensive review of the literature to identify empirical evaluation studies that had appeared in refereed or peer
From page 206...
... 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, 1994J. 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.
From page 207...
... SOURCE: Adapted from Needle Exchange Programs: Research Suggests Promise as an AIDS Prevention Strategy (U.S. General Accounting Office?
From page 208...
... UNIVERSITY OF CALIFORNIA REPORT In September 1993, a second government report, The Public Health Impact of Needle Exchange Programs in the United States and Abroad, was published by the University of California for the Centers for Disease Control and Prevention (CDC)
From page 209...
... 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.
From page 210...
... 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.2 The sites were selected on the basis of a published list of programs and reflected the range of existing needle exchange programs with respect to size, legal status, geographical location, injection drug users' HIV seroprevalence, and extent of prior evaluation research. (CDC was consulted during the selection process.)
From page 211...
... 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. Increased Referrals to Drug Treatment The University of California report noted that 17 of 18 U.S.
From page 212...
... (Oliver et al., 1992) (Des Jarlais and Maynard, 1992)
From page 213...
... CRetrospective component. SOURCE: The Public Health Impact of Needle Exchange Programs in the United States and Abroad, Volume 1 (Lurie et al., 1993:414)
From page 214...
... 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., 1993) do not, and for methodological reasons probably cannot, provide clear evidence that needle exchange programs decrease HIV infection rates.
From page 215...
... 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.
From page 216...
... "some evidence that needle exchange programs are not associated with an increase in community levels of injecting or overall drug use." Increase in Number of Contaminated Needles Unsafely Discarded 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.
From page 217...
... These studies utilize a variety of designs, including an ecological design; a comparison of prevalence rates between injection drug users who use and those who do not use needle exchange programs; HIV incidence rates among needle exchange program attenders; and, using data collected prospectively, a comparison of HIV incidence rates between injection drug users who attend and those who do not attend a needle exchange program.
From page 218...
... were conducted with injectors in street settings and drug detoxification clinics. During that time period, multiple prevention efforts targeting injection drug users had been implemented (including outreach, education, voluntary HIV testing and counseling, bleach and condom distribution, and needle exchange programs)
From page 219...
... Although the reduction in high-risk behaviors was based on self-reports of exchange users and no comparison of injection drug users not using the exchange was included in this report, this pattern of reduction in drug-use risk behaviors was found to be relatively stable in recent updates (Des Jarlais et al., 1994b; Des Jarlais et al., 1995; Paone et al., 1994b)
From page 220...
... Moreover, this pattern of findings has also been observed in foreign cities (Davoli et al., 1995; Hunter et al., 1995~. Reduction in HIV Infection Rates Two recent ecological studies examined trends in HIV seroprevalence rates among injection drug users, one in New York City and the other in San Francisco (Des Jarlais et al., 1994a; Watters, 1994~.
From page 221...
... On the basis of recent updates from the 1994 International Conference on AIDS, Des Jarlais (1994; in press) provided descriptive information on HIV incidence among injection drug users who participate in needle exchange programs across 14 different cities (Table 7.5~.
From page 222...
... Moreover, injection drug users in Montreal who elect to purchase sterile needles in pharmacies can do so without a prescription (further biasing the representation of those who elect to acquire their needles in the middle of the night at the exchange program)
From page 223...
... . Although the disparities in observed seroincidence rates between needle exchange participants and nonparticipants could not be attributed to having been exposed to the needle exchange program, the program appeared to serve a relatively high-risk subset of injection drug users.
From page 224...
... . Possible Negative Outcomes Program Participant Drug Use The most recent studies that have examined drug-use behaviors among needle exchange participants show either stable levels of reported drug injection frequency or even slight declines over time among injection drug users who continue to participate in needle exchange programs (Watters et al., 1994; Paone et al., 1994a; Des Jarlais et al., 1994a; Oliver et al., 1994~.
From page 225...
... New Initiates to Injection Drug Use The concern that having the opportunity to use a needle exchange may lead persons who are not currently injecting to begin injecting demands attention, and some information about this is available. If the opportunity to participate in needle exchange programs were to lead to an increase in the number of new injection drug users, one would expect to see relatively large numbers of young newer injectors at the needle exchange programs.
From page 226...
... found an increase in the mean age of injection drug users in the city during the years of operation of the needle exchange programs (i.e., mean age in 1986 was 36 compared with 42 in 19923. Moreover, the author reported that during that 5.5-year period, the median reported frequency of injection declined from 1.9 to 0.7 injection per day and that the percentage of new initiates into injection drug use decreased from 3 to 1 percent.
From page 227...
... Specifically, the evaluation reveals significant and substantial reductions in the infectivity of the syringes exchanged through the needle exchange program. The data also reveal increases in referral to drug treatment and no change in the number of injection drug users.
From page 228...
... Using estimates of the size of the population of injection drug users in New Haven derived by Kaplan and Soloshatz (1993) , it appears that about half of the injection drug users have had contact with the needle exchange program (Lurie et al., 1993~.
From page 229...
... Estimated Effects on HIV Incidence Kaplan and colleagues (Kaplan and Heimer, 1992; Kaplan and O'Keefe, 1993) could not directly observe HIV infection in needle exchange program clients (as they could in needles)
From page 230...
... By focusing on how NEP needles alter the characteristics of needles in circulation, the model circumvents reliance on injection drug user self-reports of behavior change. Rather, the model uses syringe tracking and testing data to demonstrate that even if injection drug users made no effort to change behavior (aside from obtaining needles at the NEP)
From page 231...
... Several other outcome variables were also studied at the New Haven needle exchange program, and these are described below. New Initiates to Injection Drug Use If needle exchange programs attracted new initiates to injection drug use, a drop in the average age of program participants who enroll over time would be expected to be observed, coupled with a downward shift in the
From page 232...
... The authors also provided an additional observation that counters the argument that needle exchange programs encourage the initiation of injection drug use. They argued that, if the presence of a needle exchange program did enhance use, an increase in the number of new initiates to injection drug use would be most prominent following public disclosure of the first report on the effects of the program.
From page 233...
... Finally, Kaplan and others (Kaplan, 1994a; O'Keefe et al., 1991) report that up to 60 percent of the New Haven needle exchange program participants dropped out.
From page 234...
... As a U.S. city with an ethnically diverse population of injection drug users and high rates of both heroin and cocaine injection, Tacoma may be more relevant to the circumstances of other U.S.
From page 235...
... During the past 6 years, the needle exchange has developed into a broad public health program of prevention and education for injection drug users. At present, the Tacoma needle exchange program consists of two fixed outdoor exchange sites, one located two blocks from the original location and another in a Tacoma neighborhood.
From page 236...
... It is estimated that 900,000 syringes were exchanged in Tacoma needle exchange programs in 1994 (90,000 from the pharmacy, the remainder from the fixed outdoor and mobile programs) .6 Assistance from injection drug users willing to act as "secondary exchangers" is encouraged, and several have been identified via the mobile ~ , exchange program.
From page 237...
... Methadone drug treatment programs, in particular, noted that recruitment at the exchange resulted in enrolling a higher proportion of injection drug users with no previous history of treatment. Furthermore, in 1991 and 1992, the needle exchange was the largest single source of recruitment to methadone treatment programs in the county (Hagan et al., 1993: 1694- 1695~.
From page 240...
... The continued maintenance of such a low HIV seroprevalence in a population of injection drug users cannot be unequivocally attributed to the needle exchange program and its many program components. However, this stands in sharp contrast with experience in many places, where no systematic prevention programs were in place and seroprevalence among injection drug users was observed to rise rapidly from low to high levels.
From page 241...
... An outbreak of hepatitis B was observed among injection drug users in Pierce County beginning in 1985: 43 incident cases as of December 1985 (Figure 7.11. The incident cases of hepatitis B among injection drug users persisted until several months after the needle exchange opened (i.e., Au 45 40 35 to ~ 30 o Q of 1 5 25 10 5 Z: to\ ~\ = I \ ~ ' · ID Us Undetermined I Sexual ~1 VIA by o JumB5 Decals - 1 l l Jum90 Dec-92 Date FIGURE 7.1 Hepatitis B incident cases by 6-month intervals, between January 1985 and December 1992.
From page 242...
... reduction in new hepatitis B infections among injection drug users following the opening of the needle exchange program could be in part due to the exchange. Hepatitis B and C Case-Control Study Injection drug users who reported to the sentinel hepatitis surveillance system in Pierce County from January 1991 to December 1993 and who met the hepatitis B or hepatitis C case definition (see the previous section)
From page 243...
... A total of 28 injection drug users with acute hepatitis B and 20 with acute hepatitis C who met study eligibility criteria were reported to the sentinel surveillance system in Pierce County during the time period 1991 to 1993 (Hagan et al., 1994a:8-9~. Controls were 38 injection drug users with no serologic markers of exposure to hepatitis B and 26 with no markers for hepatitis C who were attending health department services during the same calendar period and met all study criteria.
From page 244...
... From 1990 to 1991, a referent group of Pierce County injection drug users not participating in the exchange (nonexchangers) was enrolled in a cross-sectional study (Hagan et al., l991b)
From page 245...
... Other potential contributing factors may have been legal sales of sy ringes by pharmacies or saturation of hepatitis infections in the pc~nulation of injection drug users. However, by taking into account the results of the two interview studies (i.e., reduction in risk behaviorsJ and the case-control study (protective effect of the needle exchange program)
From page 246...
... The exchange might simply have attracted injection drug users who were concerned about health and were practicing safer injection prior to the implementation of the needle exchange. However, this alternative explanation is not consistent with the exchange users' report of their frequent risk behavior prior to beginning use of the exchange and the community-wide reduct~on in hepatitis B incidence and the low community prevalence rate of HIV infection.
From page 247...
... Also, prospective studies of factors associated with entry into treatment note similar injection risk behaviors, but increased complications of drug abuse in those entering treatment (Schulz et al., 1994~; this suggests that the effect of sampling treatment entrants for the purpose of studying viral infection is likely to be minor. Nevertheless, the issue of potential of bias for controls selected among treatment entrants and injection drug users who arrive for HIV testing could be real if the needle exchange program makes active referrals into treatment and HIV testing.
From page 248...
... Thus, the panel concludes that the Tacoma studies show that a needle exchange program can lead to behavior change and reduced transmission of blood-borne viruses. Program Effects on New Initiates to Drug Use or Abuse The Tacoma and New Haven studies and previous reviews had few, if any, empirical data on the impact of needle exchange programs on drug initiation or drub abuse among noninjection drug users.
From page 249...
... An increase in clean needles and syringes may lead to a reduction in the perceived risk of AIDS and other blood-borne diseases associated with injection drug use. Furthermore, changes in federal regulations banning the use of federal funds for needle exchange programs may result in the perception that societal resolve against drug use is weakened.
From page 250...
... Since needle exchange programs are likely to affect only risk due to injection, and because nondrug users are extremely unlikely to begin their drug-using careers by using injectable drugs (Kandel et al., 1978, 1992) , it is not likely that changes in community or personal norms and attitudes as a result of having needle exchange and bleach distribution programs will increase the risk of the transition of nondrug users into drug use.
From page 251...
... The act of giving a needle however clean-to an injection drug user has a powerful symbolism that has sparked fears about the potential negative effects of needle exchange programs. Similar fears sometimes appear in response to proposals to distribute bleach
From page 252...
... (Long-term effects are necessarily not yet known, providing a reason for continued monitoring for potential negative effects.) · The available scientific literature provides evidence based on selfreports that needle exchange programs: do not increase the frequency of injection among program participants and do not increase the number of new initiates to injection drug use.
From page 253...
... 102-394, section 514, 1993, necessary to rescind the present prohibition against applying any federal funds to support needle exchange programs. Observe that the panel does not recommend a mandated national program of needle exchange and bleach distribution.
From page 254...
... Needle exchange programs should make special efforts to reach and retain hard-to reach subgroups of injection drug users, such as young injection drug users and women. · The National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Health Care Policy and Research should support evaluation research examining the programs and the key outcomes, including HIV risk behavior and reduced lIIV transmission.
From page 255...
... This was determined by introducing some additional modeling assumptions concerning the dynamics of the epidemic. These calculations, together with additional assumptions about the proportion of infections among injection drug users resulting from needle sharing as opposed to sexual transmission, estimated that between 1 and 4 HIV infections were prevented per 100 injection drug users per year.
From page 256...
... fl993) explain that, for demographics to account for these results, assuming that needle exchange programs have no effect' the contribution to the overall prevalence rates for earlier and late time periods should be proportionate to the fractional size of each group at each time point.
From page 257...
... Sotheran, and S.R. Friedman 1995 New York City Syringe Evaluation: HIV Risk Behavior and Seroincidence Among Injecting Drug Users in the New York City Syringe Exchange Programs.
From page 258...
... Alter in press Reduced risk of hepatitis B and hepatitis C among injecting drug users participating in the Tacoma syringe exchange program. American Journal of Public Health.
From page 259...
... 1994b Operational modeling of needle exchange programs.
From page 260...
... Fauvel 1993 Seroprevalence of and risk factors for HIV-1 infection in injection drug users in Montreal and Toronto: A collaborative study. Canadian Medical Association Journal 149(7)
From page 261...
... Caloir, and P Friedmann 1993 AIDS Risk Reduction Behaviors Among Participants of Syringe Exchange Programs in New York City, USA.
From page 262...
... Watters, J.K. 1994 Trends in risk behavior and HIV seroprevalence in heterosexual injection drug users in San Francisco, 1986-1992.


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