HIV/AIDS remains one of the country's most serious health challenges. According to an overwhelming body of evidence, needle and syringe exchange programs not only reduce the spread of HIV, but also save money, encourage the safe disposal of syringes, minimize the risk of needlestick injuries to law enforcement officials, and help link chemically dependent individuals to vital drug treatment services. In difficult budgetary times, investments in syringe exchange are a wise use of tax dollars.
Each year, 50,000 Americans are newly infected with HIV.1 Injection drug use remains a driving force in the national epidemic, accounting for 14 percent of new HIV infections among women and 7-11 percent of new HIV infections among men in the United States in 2010.2 Reaching the federal goal of an "AIDS-Free Generation"3 requires effective, sustained efforts to prevent new infections among injection drug users (IDUs). Approximately 3.2 million Americans are living with hepatitis C (HCV), and deaths related to HCV have increased substantially over the last decade.4
Sharing contaminated injecting equipment is one of the most efficient means of HIV transmission.5 Scores of studies have conclusively demonstrated that syringe services programs (SSPs) help prevent infection by reducing the re-use and circulation of injecting equipment without increasing drug use or resulting in other negative consequences.13-15 SSPs have helped New York City -- where 50 percent of all IDUs were living with HIV in the early 1980s -- approach the elimination of new drug-related transmissions, saving federal and state taxpayers millions of dollars in treatment costs averted.16-18 SSPs make neighborhoods safer (for police, sanitation workers, and the general public) by supporting the safe disposal of potentially infectious needles and syringes.19,20 SSPs also facilitate recovery from drug abuse by linking drug users to treatment services.21
|How SSPs Work|
SSPs provide free sterile syringes, an approach that reduces the likelihood that users will share injecting equipment.6 Although the provision of sterile syringes is the core service provided by SSPs, these programs also safely dispose of used syringes, and have much broader health benefits.7 Many offer a range of health and supportive services, including on-site medical care; screening and counseling for HIV, hepatitis C, and sexually transmitted infections; distribution of condoms, food, and clothing; and referrals to substance abuse treatment.8 In addition, many SSPs help save lives by providing medications to prevent overdose and support drug treatment.9 SSPs offer tailored services drug users need to keep themselves and others safer and healthier. As a result, drug users often view SSPs as more respectful and less discriminatory than traditional healthcare providers; this makes SSPs better able to connect drug users to health and supportive services they would otherwise not have accessed.10-12
In 2009, Congress removed a 21-year prohibition on the use of federal funds to support SSPs.22 Two years later, however, Congress re-imposed the ban on federal funding for SSPs.23 In 2013, even as injection drug use continues to contribute substantially to the spread of HIV, federal public health funds are unavailable for syringe exchange.
SSPs are not illegal throughout most of the country, and more than 200 SSPs are currently operating in 34 states, the District of Columbia, and the Commonwealth of Puerto Rico.24
2However, without federal funding, these SSPs are only able to provide sterile syringes for fewer than 3 percent of all injections estimated to occur each year.25 SSPs that receive state or local government funding distribute more sterile syringes and offer HIV tests more often than those that do not receive government funding.26 Federal support could amplify this increase in service capacity.
In short, the federal funding ban on SSPs undermines national efforts to prevent new HIV infections. If the country is to realize the goal of an AIDS-Free Generation, coverage for these highly effective programs will need to increase.
"In the cities that have adopted needle exchange programs, there is a dramatic reduction in needle sticks to firefighters who crawl on their hands and knees through smoke-filled rooms to search for victims."
-- Charles Aughenbaugh, Jr., President, New Jersey Deputy Fire Chiefs Association, Retired Deputy Fire Chief, March 2011
Banning federal support for cost-effective needle exchange programs is contrary to the public interest. Although such programs were controversial when they first emerged in the 1980s, nearly three decades of experience has generated substantial support for the approach from local governments, public health officials, and scientific organizations. The public health benefits of SSPs have been well documented, but these programs generate other benefits that may be less familiar.
The lifetime cost of treating an HIV-positive person is estimated to be between $385,200 and $618,900.27 As HIV-positive IDUs are often uninsured or reliant on public sector programs (such as Medicaid, Medicare, and Ryan White) for their care, taxpayers bear the lion's share of treatment costs associated with new infections related to injection drug use.28,29
HIV is not the only costly infection associated with injection drug use. HCV costs hundreds of millions of dollars annually to treat.30 Needle sharing during injection drug use is the primary driver of hepatitis C infection in the U.S., with an estimated 50-80 percent of drug users becoming infected with HCV within five years of their first drug injection.31 A study of IDUs in New York City found that from 1990-2001, as SSPs grew substantially, HCV prevalence declined from 90 to 63 percent.32
With individual needles and syringes costing less than 50 cents,33 it is far cheaper to prevent a new case of HIV than to assume many years of treatment costs. According to a recent analysis, expanding SSP coverage to 10 percent of all injections (from the current level of 2.9 percent) would avert nearly 500 new HIV infections each year.34 Such an expansion in service coverage would cost an estimated $64 million -- less than one-third the projected lifetime costs (an estimated $193 million) of treating these 500 cases.35 In other words, every dollar spent expanding service coverage to such a level would save at least an estimated three dollars in treatment costs averted.36 Further service expansion would save American taxpayers hundreds of millions of dollars.
|Additional Investment Required and Savings in HIV Treatment Costs (Million 2011 USD) for Each SSP Syringe Coverage Level|
Source: Nguyen, T.Q., Weir, B.W., Pinkerton, S.D., Des Jarlais, D.C., and Holtgrave, D. (July 23, 2012). Increasing investment in syringe exchange is cost-saving HIV prevention: modeling hypothetical syringe coverage levels in the United States (MOAE0204 Oral Abstract). Presented at the XIX International AIDS Conference, Washington D.C. (Date last accessed: December 11, 2012.)
Supporting recovery and breaking the cycle of drug use are key principles of the National Drug Control Strategy.37 SSPs support these aims. They serve as critical entry points for drug users, and link individuals to comprehensive treatment and care, such as in New Jersey, where more than 22 percent (998 individuals) of the 4,482 people served by New Jersey's five SSPs from 2007 to 2009 entered a drug treatment program.38
By facilitating recovery from drug addiction, SSPs help individuals struggling with chemical dependence to repair their lives and become productive members of society. In one study, employment increased 44.8 percent within six months among clients of SSPs who received certain federal funding while the funding ban was removed.39 Clients of these SSPs were 25 percent more likely than non-SSP clients to have been successfully referred to mental health treatment and prescribed medication.40
As bridges to comprehensive treatment, prevention, and social services, SSPs improve individual and public health. SSPs also help clients infected with HIV or hepatitis C learn their status: in 2010, 67 percent of SSPs surveyed nationally offered hepatitis C testing, and 87 percent offered HIV testing and counseling.41 SSP clients who test HIV positive can be connected to life-saving and cost-effective treatment, while those who test HIV negative receive HIV prevention counseling and access to condoms, helping interrupt the cycle of HIV transmission.
|Selected Services Offered by SSPs in 2010|
Source: 2010 Beth Israel Survey Results Summary
The federal government is by far the largest funder of HIV prevention services. Federal prevention funding adheres to recognized principles of federalism, providing essential health assistance while leaving it to states and localities to use limited federal dollars to address needs and priorities that are locally determined. While the federal ban was lifted, federal dollars were used to support SSPs in California, Connecticut, Delaware, Illinois, Massachusetts, Minnesota, New Jersey, New Mexico, New York, Puerto Rico, Vermont, and Washington.42 SSPs operate in 186 cities and a quarter of those surveyed in 2011 were run by state or local health departments.43,44 Authorities in jurisdictions across the country have demonstrated that they believe SSPs promote public health and other local objectives. However, under current law, they are not allowed to decide for themselves whether federal funds they receive should be used to meet these objectives.
While research consistently has found SSPs to be a cost-effective, evidence-based intervention, the federal funding ban continues to force localities facing difficult budgetary times to make a tough choice: if they wish to use limited state and local dollars to fund SSPs, they must do so at the expense of other important, public health programs dependent on local and state financing. In the brief two-year period during which federal funding became available for SSPs, the majority of programs that received federal support used those funds just to maintain or expand existing services; only 14 percent of programs that received federal SSP funding in 2011 were able to use that funding to add new services.45
SSPs reduce circulation of contaminated syringes, collecting used syringes in puncture-proof containers. By discarding used syringes according to hazardous waste disposal procedures, SSPs keep contaminated in-jection equipment off the streets, protecting the public from potential exposure to infectious needles.
SSPs actively encourage participants to return as many used syringes as possible.46 Research indicates that the majority of syringes distributed by SSPs are in fact returned.47,48 In Baltimore, SSPs helped reduce the number of improperly discarded syringes by almost 50 percent.49 In Portland, Oregon, the number of improperly discarded syringes dropped by almost two-thirds after the implementation of an SSP.50 In 2008-2009, in Miami -- where there are no syringe exchange programs -- eight times more syringes were disposed of improperly than in San Francisco, where syringe exchanges are available.51 Safe disposal was much greater in San Francisco, even though the estimated number of injection drug users in San Francisco is more than twice the number in Miami.
Keeping contaminated equipment off the streets improves public safety. SSPs reduce the risk that people -- including children playing in parks, people putting trash in public trash cans, and medical personnel responding to emergencies -- will accidentally come into contact with used and potentially dangerous needles and syringes.
"Clearly needle exchange programs work. There is no doubt about that."
-- Anthony Fauci, M.D., Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health. Testimony before the U.S. House of Representatives Committee on Oversight and Reform, September 16, 2008
Law enforcement and public-safety personnel, who are often exposed to needlesticks on the job, are perhaps the most notable public safety beneficiaries of SSPs. In San Diego, nearly 30 percent of police officers surveyed had been stuck by a needle at least once, with more than 27 percent of those injured experiencing two or more needlestick injuries.52 Syringe services programs have been found to reduce needlestick injuries among police officers.53
Communities of color are at far greater risk for HIV than Americans overall. In 2010, 14 percent of the U.S. population was African American, but that year, 44 percent of all new HIV diagnoses in the U.S. were among African Americans -- more than any other racial or ethnic group.54 In states surveyed from 2007 to 2010, the rate of new HIV infections was eight times higher among African Americans than whites, and three times higher among Latinos than whites.55 In 2010, people of color were overrepresented among both male and female injection drug users newly infected with HIV.56 While AIDS-related deaths for the broader U.S. population have sharply declined over the last 15-20 years, AIDS remains the ninth leading cause of death among African Americans overall and the third leading cause of death for African Americans aged 35-44.57 In light of the disproportionate risk of HIV infection and number orgof AIDS-related deaths among African Americans and other people of color, the National HIV/AIDS Strategy prioritizes intensified efforts to reduce racial and ethnic disparities in HIV-related health outcomes.58 Given the role of injection drug use in contributing to the outsize HIV risks experienced by communities of color, SSPs represent a critical tool for minimizing HIV risks and addressing health disparities.
|Diagnoses of HIV Infection Among Injection Drug Users, by Sex and Race/Ethnicity, 2010 -- 46 States and 5 U.S. Dependent Areas|
As a result of their considerable public health, public safety, and fiscal benefits, SSPs enjoy robust support across the political spectrum, ranging from law enforcement officials to advocates seeking the reform of drug laws. Numerous national medical and public health organizations support SSPs, including the American Medical Association,59 the American Public Health Association,60 the National Academy of Sciences,61 and the American Academy of Pediatrics.62 So too do leading global bodies such as the World Health Organization (WHO),63 the World Bank,64 and the International Red Cross-Red Crescent Society.65 The American Bar Association strongly supports SSPs,66 as does the U.S. Conference of Mayors.67
The evidence is clear and conclusive. SSPs prevent new HIV infections without leading to increased drug use. SSPs also promote broader health aims, save taxpayers money, promote public safety, and enjoy broad public support. Federal support for SSPs should be restored -- not only to advance these important public policy aims, but also to provide the means for states and local communities to determine the best strategies to address their own health needs.