User-Driven Syringe Exchange Is Best Model to Reduce HIV and Hepatitis C

User-Driven Syringe Exchange Is Best Model to Reduce HIV and Hepatitis C
San Francisco AIDS Foundation

The public health benefits to syringe exchange and distribution are clear. Syringe exchanges and distribution efforts across the U.S. have curbed the spread of infectious diseases like HIV and hepatitis C and also reduce the likelihood that people who inject drugs develop other bacterial infections and poor vein health. In San Francisco, the percentage of people who used injection drugs and were infected with HIV doubled between 1986 and 1987 -- rising from 7% to 14%. When efforts were rolled out in the city to distribute syringes, test for HIV and educate people about how to sterilize injection equipment with bleach, the seroprevalence rate stabilized at about 12% from 1987 into the early 1990s.

But the models that govern syringe exchange and distribution -- that dictate how many syringes a client can receive -- make a big impact on how effective these harm reduction programs are. In other words, not all models of syringe exchange and distribution are equal, and allowing clients to choose the number of needles they receive -- the "distribution approach" -- has been found to be the most effective at preventing infections.

"Distribution approaches to syringe exchanges have a larger impact on reducing syringe sharing and unsafe injection practices than one-for-one exchanges, and do not result in increased unsafe discard of syringes," said Robert Heimer, PhD, a professor of epidemiology and pharmacology and director of emerging infections program at Yale School of Public Health. "This is the policy that works best."

The distribution model is, as Heimer described, a "how many do you need?" way of distributing syringes. "If someone says they need a case [of syringes], you give them a case," he explained. One-for-one syringe exchanges are much stricter: People can get new syringes, but only to replace the exact number that are returned. Often, one-for-one exchanges also have a cap on the number of syringes that can be accessed at one time.

One-for-one exchanges, and other policies that limit the number of syringes that people can access, were developed with the idea that fewer syringes would be improperly discarded when the number of syringes people can access is limited to the number of used syringes they return.

"This has never been shown to be true," stated Heimer. He points to city-level data conducted in three cities across the U.S. -- each with different syringe exchange/distribution policies -- that compared rates of syringe return. The city with the most liberal policy -- Chicago -- also had the highest rate of return of syringes. "Even though they were giving away more syringes, a higher percentage of the syringes came back. Giving out more does not mean those syringes disappear into the ether. If you give more syringes away, you reduce syringe scarcity and more of them come back," he said.

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