NEEDLE-EXCHANGE PROGRAMMES IN THE USA

Sir--Respecting your editorial on NEPs in the USA, in the mid 1980s, HIV-1
was identified as a potential threat to intravenous-drug users. In Southern
Derbyshire in the UK, preventive measures taken included education and
needle/syringe schemes, which also contributed to a reduction in acute
cases of hepatitis B--from 17 cases in 1986 to two in 1996.

It was, therefore, noteworthy when six intravenous-drug users in the
district were diagnosed with acute hepatitis B between December, 1996, and
February, 1997. All six lived in inner-city Derby, and were aged in their
mid 20s. The first case had recently moved to the area from a neighbouring
county, and at the time of diagnosis was living in a hostel.

The first case was identified after the local drug agency moved premises in
December, 1996. At the time of the move, and for several months after,
fewer clients used the agency's needle and syringe exchange scheme. This
decline was attributed to the fact that clients did not seem to know where
the new building was sited despite previous publicity. At the same time,
there were also problems in some parts of Derby City with an insufficient
number of syringes and needles available for the community pharmacy needle
and syringe exchange.

A community pharmacist reported that there had been an increase in the
amount of bleach being sold to intravenous-drug users in the winter months.
It was also reported that users in the area pooled their resources to buy
drugs and used several premises as communal meeting places. It seems that
although they used clean needles, the syringe barrels were reused after
being cleaned with bleach from a bowl used by all the drug users present.
Results of the virus typing were received from the Public Health
Laboratory, Colindale, and showed that five of the cases were related.

This outbreak of acute hepatitis B in a well-defined group of
intravenous-drug users raises a number of issues. Programmes for needle and
syringe exchanges should be adequately funded and alternative supplies well
publicised if any disruption to the service is anticipated. Any information
or advice provided about the sharing of drug-taking equipment should
emphasise the fact that it involves all injecting equipment and not just
needles. Bleach should not be promoted as a way of disinfecting needles and
syringes nor should any other method of cleaning, as there is no
satisfactory alternative to single-use sterile equipment.

*K A Ward, M Newlands, D W Bullock *Department of Public Health, Southern
Derbyshire Health Authority, Derby DE1 2FZ, UK; and Derbyshire Royal
Infirmary, Derby

1 Editorial. Needle-exchange programmes in the USA: time to act now. Lancet
1998; 351: 75.

Sir--In your January 10 editorial,1 you urge the USA to adopt
needle-exchange programmes (NEPs) as an officially endorsed means to deter
the spread of AIDS, but choose to ignore facts which do not support that
position. The most poignant and telling indications of the failure of NEPs
are the deaths of two well-known activists: John Watters, spokesperson for
the San Francisco Research Project on Needle Exchange, and Brian Wiel, one
of the founders of New York's NEPs. Neither died of AIDS, both deaths were
from heroin overdose.

I believe the deaths of Watters and Wiel may be the tip of the iceberg with
regard to drug-related deaths among people who use NEPs. How many heroin
users, whose addiction was facilitated by a needle-handout clinic (whether
through easy access to syringes or through use of the facility as a place
to network where to find drugs) have died from drug overdose? That question
is not being discussed or tracked. However, at a scientific meeting I
attended last year, one of the keynote speakers spoke about a study done on
mortality rates. Baltimore Co, Maryland, has the highest mortality rate,
whereas an adjacent county has the lowest mortality rate. Baltimore is
notorious for its aggressive NEPs. Perhaps its high mortality rate is
related to the large number of drug users in that county who are enabled by
NEPs and other permissive programmes related to drug use?

To date, there have been only two controlled studies on NEPs (one in
Montreal and the other in Vancouver, BC). Both studies indicated that the
HIV-1 infection rate is nearly twice as high among drug users who use NEPs
than it is among those who do not. When drug users themselves say they use
NEP exchanges as a place to network to find more drugs, it gives a clear
indication that such programmes prolong and enable drug use and contribute
to the spread of HIV-1 and hepatitis C.

New powerful drug combinations have led to a decline in deaths from AIDS.
So now we must deal with needle handouts for the real danger they
represent--lengthy exposure to heroin with increased risk to the addict of
death from hepatitis C or drug overdose, and health risks associated with
carelessly discarded contaminated needles. A companion concern, rarely
discussed, is the number of drug users whose addiction prevents them from
being gainfully employed. Because addicts are now ranked among the
disabled, society is forced to pay not only for their drugs, but for all
their other necessities of life.

Sandra S Bennett Northwest Center for Health and Safety, PO Box 5853,
Portland, OR 97228-5853, USA

1 Editorial. Needle-exchange programmes in the USA: time to act now. Lancet
1998; 351: 75.