Access to clean syringes

Interventions Changing the Context

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What are policies that support access to clean syringes?

Selected Resources
  • HHS Implementation Guidance related to Consolidated Appropriations Act, 2016 (Pub. L. 114-113)
  • Centers for Disease Control and Prevention: Syringe Services Programs
  • North American Syringe Exchange Network

Regulatory, legislative, and other policies that support access to clean needles and syringes allow for the legal sale of needles without prescriptions, and include programs to distribute clean needles and safely dispose of used needles.[1, 2] The purpose of these policies is to reduce the transmission of blood-borne pathogens, including HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV). Policies that authorize the legal sale and exchange of clean needles and syringes are typically enacted at the state level. Sixteen states have passed laws authorizing needle and syringe exchanges.[3] Moving toward this goal, California law supports access to clean needles through the nonprescription sale of syringes and needles.[4] Several states have statutes that remove syringes from lists of illegal drug paraphernalia.[3] In order to reduce potential needle stick injuries among police officers, North Carolina legalized needle possession among people who alert police officers to the presence of needles prior to a search.[5]

What is the public health issue?

Injection drug use (IDU) is a risk factor for contracting blood-borne pathogens such as HIV and HCV, and sharing syringes provides a direct route of transmission for diseases.[6] It is estimated that in 2013, 3,096 of the estimated 47,352 diagnoses of HIV infection in the United States were attributed to IDU.[7] Among persons who inject drugs (PWID), HCV is approximately 10-fold more transmissible than HIV; 50-90% of HIV-infected PWID are co-infected with HCV. ID use has been shown to be the most common means of HCV transmission in the U.S., and an estimated 33 percent of PWID aged 18-30 years are HCV-infected. Older and former PWID have an estimated prevalence of 70-90% due to the increased risk of continued injection drug use and needle sharing in the 1970’s and 1980’s before risks of bloodborne virus transmission were widely known.[8]

The lifetime cost of HIV treatment is estimated to be $379,668 (in 2010 dollars).[9, 10] The initial market prices of HCV treatment ranged from $84,000 to $96,000 in 2014.[11] Since 2014, the cost of HCV medications has fallen to an estimated $40,000 for Medicaid programs. Some payers have negotiated greater reductions in HCV drug costs. HCV treatment can save $14.3 billion in health costs while costing $69.5 billion to implement, raising budgetary issues for Medicaid and other insurance plans.

PWID can substantially reduce their risk of acquiring and transmitting HIV, HBV, HCV, and other blood-borne infections by using a sterile needle or syringe for every injection.[11] Research shows that barriers such as prescription requirements and legal restrictions on needle possession and distribution can prevent access to clean needles and syringes.[12] Prevention of HCV among PWID is most effective when needle or syringe exchange programs are combined with other prevention services such as behavior-change counseling and addiction treatment services. HCV treatment provides another option for preventing transmission among PWID. A number of models suggest that even modest increases in HCV treatment of PWID can lead to substantial declines in prevalence and incidence of HCV infection when combined with other services.[13-15]

What is the evidence of health impact and cost effectiveness?

A systematic review of 15 studies analyzing needle-syringe programs (NSP) found that NSP’s were associated with decreases in the prevalence of HIV and HCV and decreases in the incidence of HIV.[1] For example, a series of three-year longitudinal studies investigating the effect of New York’s legalization of syringe exchange programs between 1990 and 2002 found decreases in:

  • HIV prevalence from 50 percent to 17 percent (p<.001) [16]
  • Person-years at risk for HIV, from 3.55 to 0.77 per 100 person-years (p<.001)[16]

Another study that examined the effect of New York’s exchange program on the prevalence of HCV infection between 1990 and 2001 found that it was associated with a reduction in prevalence from 80 percent to 59 percent among HIV-negative intravenous drug users (p<0.034).[1, 17] An evaluation examining the District of Columbia’s lift of the Congressional ban on syringe exchange programs, which allowed the D.C. Department of Health to initiate an exchange program, showed a 70 percent decrease in new HIV cases among IDU and a total of 120 HIV cases averted in two years [18].

A cost-effectiveness analysis of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. [19] Another cost-effectiveness analysis estimated that expanding access to clean syringes through an additional annual U.S. investment of $10 million would result in:

  • 194 HIV infections averted in one year
  • A lifetime treatment cost savings of $75.8 million1
  • A return on investment of $7.58 for every $1 spent (from the national perspective)[20]

1 Net present value in U.S. 2011 dollars

  1. Abdul-Quader, A.S., et al., Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review. AIDS and Behavior, 2013. 17(9): p. 2878-2892.
  2. Fowler, W. Syringe Services Programs: A Proven Public Health Strategy. Knowledge Center 2010 September 28, 2010 [cited 2016 June 6]; Available from: Syringe Services Programs: A Proven Public Health Strategy.
  3. Coleman, A. Needle Exchange Legality By State. Knowledge Center 2015 June 25, 2016 [cited 2016 June 6]; Available from: Needle Exchange Legality By State.
  4. California Department of Public Health, Access to Sterile Syringes. 2016 5/2/2016 [cited 2016 June 6]; Available from: Access to Sterile Syringes.
  6. Centers for Disease Control and Prevention, HIV and Injection Drug Use in the United States. HIV/ AIDS 2015 October 27, 2015 [cited 2016 February 18]; Available from: HIV and Injection Drug Use in the United States.
  7. Centers for Disease Control and Prevention, HIV Surveillance Report, 2014; vol. 26. 2015.
  8. Centers for Disease Control and Prevention, Hepatitis C FAQs for Health Professionals. 2016 [cited 2016 June 6]; Available from: Hepatitis C FAQs for Health Professionals.
  9. Schackman, B.R., et al., The lifetime cost of current human immunodeficiency virus care in the United States. Medical care, 2006. 44(11): p. 990-997.
  10. Centers for Disease Control and Prevention, HIV Cost-effectiveness. HIV/ AIDS 2015 September 23, 2015 [cited 2016 June 14]; Available from: HIV Cost-effectiveness.
  11. Centers for Disease Control and Prevention, Syringe Services Programs. HIV/ AIDS 2016 May 17, 2016 [cited 2016 June 6]; Available from: Syringe Services Programs.
  12. Burris, S., S.A. Strathdee, and J.S. Vernick, Syringe Access Law in the United States, A State of the Art Assessment of Law and Policy. Center for Law and the Public’s Health, Johns Hopkins and Georgetown Universities. Retrieved September, 2002. 5: p. 2008.
  13. Martin N.K., et al., Combination interventions to prevent HCV transmission among people who inject drugs: modeling the impact of antiviral treatment, needle and syringe programs, and opiate substitution therapy. Clinical Infectious Diseases, 2013. 57(Supplement): p. 7.
  14. Martin N.K., et al. , Hepatitis C virus treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct-acting antivirals. Hepatology, 2013. 58(5): p. 12.
  15. Vickerman P., et al., Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings. Addition, 2012. 107(11): p. 12.
  16. Des Jarlais, D.C., et al., HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services. American Journal of Public Health, 2005. 95(8): p. 1439-1444.
  17. Des Jarlais, D.C., et al., Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990–2001. Aids, 2005. 19: p. S20-S25.
  18. Ruiz, M.S., A. O’Rourke, and S.T. Allen, Impact Evaluation of a Policy Intervention for HIV Prevention in Washington, DC. AIDS and Behavior, 2016. 20(1): p. 22-28.
  19. Belani, H.K. and P.A. Muennig, Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New York City. Journal of HIV/AIDS & Social Services, 2008. 7(3): p. 229-240.
  20. Nguyen, T.Q., et al., Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. AIDS and Behavior, 2014. 18(11): p. 2144-2155.