SYRINGE-EXCHANGE PROGRAMS AND HIV PREVENTION

If They're Effective, What's The Controversy?

Abstract

Overview: Injection drug users and their sexual partners and children
represent an increasing proportion of Americans living with HIV or
AIDS. Syringe-exchange programs (SEPs), which are based on the theory
of harm reduction, are effective in preventing the transmission of
HIV and other pathogens through injection drug use. Most programs
also serve as gateways to other vital medical services. Yet SEPs
remain controversial. This article describes the controversy,
considers the evidence, and discusses the nursing implications.

It is indisputable that the HIV and AIDS epidemic has become a global
health crisis. Through the end of 2005, an estimated 40.3 million
people worldwide (including more than 1 million in North America)
were living with HIV or AIDS, according to a report by the Joint
United Nations Programme on HIV/AIDS and the World Health
Organization. [1] In this country (and some others, including
Canada), injection drug users and their sexual partners and children
represent an increasing proportion of this population. Regardless of
how one feels about injection drug use, its role in HIV transmission
makes it a pressing public health concern.

According to the Centers for Disease Control and Prevention (CDC), an
estimated 26% of AIDS diagnoses among people age 13 or older through
2003 are associated with exposure to injection drug use. [2]

Among women, 57% of all AIDS cases are so associated. [3]

(Although this article focuses on the association between injection
drug use and HIV transmission, injection drug users are also at high
risk for contracting hepatitis B and C, as well as parasitic and
bacterial infections.)

There are several strategies that can prevent the spread of HIV and
other pathogens through injection drug use. One such strategy,
syringe-exchange programs (SEPs; also known as needle-exchange
programs), remains controversial. Although estimates vary, in 2002 at
least 148 SEPs were operating in the United States; collectively,
they reported distributing 24.9 million syringes that year. [4]

Opponents of SEPs believe these programs are ineffective and may even
encourage injection drug use; proponents believe SEPs can effectively
reduce HIV transmission rates.

Theoretical Approaches: Prohibition And Harm Reduction

There are two main approaches to the problem of drug abuse in this
country. The predominant strategy is commonly known as the war on
drugs. The term reportedly was first used at a June 1971 press
conference by President Richard Nixon, and the war has been raging since. [5]

It is an expensive one; in 2004 alone, the federal government poured
almost $12.1 billion into the fight. [6]

Yet the 2004 National Survey on Drug Use and Health found that about
8% of the population age 12 years or older reported current illicit
drug use, a prevalence that has remained virtually unchanged for
several years. [7]

The war on drugs relies heavily on criminal law enforcement and
incarceration, strategies the Lancet 's editors have called a largely
futile effort to stem the influx of drugs, one that results in the
imprisonment of hundreds of thousands of offenders. [8]

This, despite the fact that study after study has shown that
treatment and prevention help far more people at far less cost than
do prohibitive and punitive measures. [8]

For example, a study commissioned by the Drug Policy Alliance found
that states like New Jersey that increased their use of prison for
drug offenses . . . did not experience less drug use than other
states that made more moderate use of prison for drug offenders. [9]

In Drug Wars, an installment of the national public television show
Frontline that aired in October 2000, almost every interviewed drug
enforcement official agreed that current strategies needed to be revamped. [5]

According to the Lancet, only about one in four Americans who need
treatment for substance abuse are in treatment programs. [8]

A recent study by McAuliffe and Dunn found treatment availability did
not meet treatment need in 32 states; the largest gaps were found in
southern and southwestern states. [10]

In U.S. prisons, where drug offenders constitute about 21% of the
state and 63% of the federal prison population, the percentage
receiving treatment is even lower. [11]

A 1997 Department of Justice survey among state and federal prisoners
found, of those admitting to illicit drug use in the month before
their offense, only 15% participated in drug treatment programs while
incarcerated, down from almost 37% in 1991. [11]

Many treatment programs offer outpatient services or short-term stays
only or require that clients be drug free on admission; others accept
only self-paying clients or clients with private insurance, and few
accept Medicaid or Medicare. (To locate a program in any state, visit
the Substance Abuse and Mental Health Services Administration's
treatment facility locator at http://dasis3.samhsa.gov .)

In the 1980s an approach based on the idea of harm reduction received
increasing attention. As the Harm Reduction Coalition (HRC) (
www.harmreduction.org ), a nonprofit organization, describes it, this
approach accepts that substance abuse exists and, instead of ignoring
or condemning it, works toward minimizing its harmful effects. [12]

The injection drug user is seen as the primary agent of harm
reduction; community and individual well-being, not cessation of drug
use, are the criteria by which the success of an intervention is
measured. As Edith Springer, a cofounder of the HRC's Harm Reduction
Training Institute, recently put it, harm-reduction treatment models
rely on a combination of respect for the customer, nonjudgmental
stances, compassion, empathy, and practicality. [13]
This is in keeping with the ANA's Code of Ethics for Nurses with
Interpretive Statements, which states that the nurse practices with
compassion and respect for the inherent dignity, worth, and
uniqueness of every individual, unrestricted by considerations of
social or economic status, personal attributes, or the nature of
health problems. [14]

Current harm-reduction strategies for injection drug users include
SEPs, methadone clinics, condom distribution, free screening for HIV
and other illnesses, treatment referrals, and counseling.

Are SEPs Effective?

Opponents of SEPs have contended that such programs do not reduce HIV
transmission or injection-related risk behaviors. Some believe that
SEPs actually lead to increased drug use by making syringes more
readily available. Proponents of SEPs argue that they are effective
in reducing HIV transmission and risk behaviors and do not lead to
increased drug use. Most of the evidence appears to support the
latter contentions.

According to the CDC, the one-time use of sterile syringes remains
the most effective way to limit HIV transmission associated with
injection drug use. [3]

Although some studies have found little or no reduction of HIV
transmission in association with SEPs, [15,16] the majority of
studies demonstrate significantly reduced rates of HIV transmission
and injection-related risk behaviors (such as needle sharing or
inconsistent use of bleach for cleaning syringes) among SEPs clients.
For example, an analysis of New York State-approved SEPs found that
during a 12-month period, an estimated 87 HIV infections were averted
as a direct result of the use of SEPs. [17]

A literature review found strong support for the role of SEPs in
reducing HIV transmission rates; in one study of 81 cities, the mean
annual HIV seroprevalence rate decreased 5.8% in the 29 cities with
SEPs, but increased 5.9% in the 52 cities without SEPs. [18]

A metaanalysis from 47 studies concluded that SEPs effectively
reduced injection-related risk behaviors. [19]

A recent study on the long-term effects of SEPs found that
injection-related risk behaviors did not increase among participants
over a four-year period despite factors such as homelessness and
depression. [20]

New HIV diagnoses in this country have been declining both overall
and among injection drug users in recent years, [21, 22] and most
experts attribute this in part to SEPs and other harm-reduction strategies.

SEPs also function as gateways to other medical services. A 2002
survey conducted by Beth Israel Medical Center in New York City and
the North American Syringe Exchange Network found that of the 126
SEPs surveyed, 77% provided referrals to substance abuse treatment,
72% provided on-site voluntary counseling and HIV testing, and more
than two-thirds provided supplies such as bleach, alcohol pads, and
male and female condoms. [4]

Many also provided screening for hepatitis and tuberculosis and
offered on-site medical care. Moreover, many injection drug users who
use SEPs will informally provide information about health maintenance
and risk reduction to other drug users outside the exchange program. [23]

Injection drug users are more likely than nonusers to be homeless,
mentally ill, unemployed, or a combination thereof, [24] and some
SEPs offer assistance with social services.

Yet, as Human Rights Watch recently reported, most states continue to
restrict access to sterile syringes by enforcing 'drug paraphernalia'
laws against needle-exchange program participants and regulating the
purchase and sale of syringes in pharmacies. [25]

Although the CDC has given SEPs a central place in their HIV
Prevention Strategic Plan, [26] many people remain unconvinced of
their merit. Some of the main areas of ongoing discussion are outlined here.

Ethics

A common assertion is that a desired end, no matter how good, cannot
justify the use of ethically reprehensible means. Accordingly, some
opponents of SEPs contend that although such programs may result in
reduced HIV transmission rates, providing sterile syringes
facilitates injection drug use; therefore SEPs are ethically wrong.

But this argument is unsupported by evidence. No studies have shown
that, lacking sterile syringes, injection drug users stop injecting;
rather, they are likely to inject whether or not sterile syringes are
available. As a participant in VanderWaal and colleagues' study said,
I've seen guys pick up needles off the street. [27]

A study by Hagan and colleagues found that injection drug users who
use an SEP were more likely to report reduced injection frequency or
to stop injecting, and to remain in drug treatment, than those who
did not. [28] New SEP clients were also five times more likely to
enter drug treatment than those who had never used an SEP.

Another point of contention involves a fundamental tenet of the
health care profession: the obligation to do no harm
(nonmaleficence). Opponents of SEPs argue that health care workers
who provide drug users with syringes, knowing they will be used to
inject drugs, violate that tenet. But proponents of SEPs point out
that there is another fundamental tenet to consider-the obligation to
do good (beneficence). They argue that health care professionals have
a responsibility to protect the public health; and by reducing the
transmission of HIV and other infectious diseases, SEPs serve that end.

Public Perceptions And Fears

Federal government funding for SEPs has often been withheld on the
grounds that the public will perceive such funding as official
sanction of illicit drug use. Just say no has been the government's
message for years. But is it ethical for the government to fail to
support SEPs (and thus fail to prevent many cases of HIV transmission
on the basis of public misperception)?

Residents often fear that if an SEP opens in their neighborhood, it
will bring with it increased crime. It's well known that drug abuse
and drug trafficking are often linked with community devastation,
manifesting in high rates of unemployment, homelessness, and crime.
But several studies have demonstrated that neighborhood crime rates
do not rise after an SEP opens. [18, 29, 30] Nor does the presence
of an SEP increase the number of discarded syringes found in its
vicinity. [31, 32]

Strong opposition to the harm-reduction approach has sometimes come
from black community leaders. Blacks have been disproportionately
affected by the HIV and AIDS epidemic; in 2003 the rate of new AIDS
diagnoses in blacks was nearly 10 times that in whites and three
times that in Hispanics. [33]

In a study that explored barriers to HIV prevention among
predominantly black injection drug users, VanderWaal and colleagues
stated that many black leaders view SEPs as quick-fix, low-budget
substitutes for much needed drug user treatment programs and economic
support. [27]

As one black elected official reportedly stated, I cannot condone my
government telling communities ravaged by twin epidemics of drugs and
AIDS that clean needles are the best we can do for you. [34]

And at worst, VanderWaal and colleagues stated, SEPs are seen as an
attempt [by] the white power establishment to weaken or eliminate the
black population by supporting continued drug use. [27]

As they note, given the exploitation of black communities by past
public health initiatives (such as the Tuskegee Syphilis Study), that
distrust isn't completely unjustified. VanderWaal and colleagues
conclude that it underscores the importance of providing reliable,
readily accessible harm-reduction services, including SEPs. In the
face of opposition, they recommend working with community members and
tailoring services and education to the needs of that community.

Implications For Nursing

The International Council of Nurses'Code of Ethics for Nurses speaks
of the nurse's responsibility for initiating and supporting action to
meet the health and social needs of the public, in particular those
of vulnerable populations, a category that includes injection drug users. [35]

In its position statement on needle exchange and HIV, the ANA states,
nurses support the availability of needle exchange programs [that]
include adherence to public health and infection control guidelines,
access for referral to treatment and rehabilitation services, and
education about the transmission of HIV disease. [36]

Nurses need to identify pragmatic and effective strategies for
working with injection drug users. Areas of focus should include
provision of care, advocacy, and program development.

Provision Of Care

In addition to educating injection drug users on HIV prevention and
risk reduction, nurses can inform them about SEPs and other community
resources. The needs and experiences of the individual should be
considered. For example, some people may be unable to read or
understand English; others may not trust the verbiage of national
prevention campaigns or of professionals whom they may view as
sterile entities largely out of touch with their needs and struggles. [27]

Handing out brochures and pamphlets is not enough. Nurses must be
able to communicate effectively and comfortably with clients who, for
example, may be experiencing withdrawal symptoms or are not adhering
to a treatment plan. Participating in a professional workshop or
continuing education program on injection drug use may be useful.
Family Drug Support, an Australian nonprofit organization, offers a
fact sheet on communicating with drug users that may assist health
care professionals as well as family members:
www.fds.org.au/pdf/factsheet18 cwdu.pdf . Educating clients and
providing referrals to SEPs and other resources can also indirectly
foster informal communication and support networks among drug users.

Nurses who work with SEPs can help clients to access other services
available at the exchange site. Some SEPs provide lists of emergency
shelters, referrals, and food and clothing donations. In areas
without SEPs, other harm-reduction programs such as HIV-prevention
programs may provide nurses with similar opportunities. For example,
in New Hampshire, where one of us (Fogg) resides, SEPs are currently
unavailable. Her community-outreach work has included identifying
pharmacies that will sell needles without a prescription and
informing injection drug users where to purchase them.

Advocacy

In order to achieve policy change, nurses may need to educate the
general public and public leaders regarding the efficacy of SEPs in
decreasing the transmission of HIV and other infectious pathogens.
Collaboration with other health care professionals and policymakers
can add clout. In April 1989, Seattle became one of the first U.S.
cities to legally adopt an SEP, largely because of the joint efforts
of local health care workers and public health officials.[37]

Some people may be unable to read or understand English. Handing out
brochures and pamphlets is not enough.

By becoming familiar with state laws and regulations, nurses can
serve as resources for the public and work toward legislative change.
According to a summary of state law concerning nonprescription access
to sterile syringes ( www.temple.edu/lawschool/phrhcs/otc.htm ), 13
states and the District of Columbia have affirmatively authorized
SEPs, and 11 states have fully or partially deregulated syringe sales. [38]

Moreover, the retail sale of syringes to an injection drug user-even
when the seller know[s] of the intended use-is clearly legal in 22
states and has reasonable claim to legality in 22 others; only in
eight states and the District of Columbia are such sales clearly illegal. [38]

In support of SEPs, the CDC recommends the collaborative review of
the public health impact of repealing drug paraphernalia laws with
regard to syringe possession, as well as community-based discussion
of SEPs and their role in preventing HIV transmission. [39]

Both actions would benefit from nurses' involvement.

There has been a ban on federal funding for SEPs since 1988. [37]

Nurses should advocate the lifting of this ban. In conducting its war
on drugs, the federal government has consistently spent more on law
enforcement and interdiction than on treatment and prevention. Of the
$12.1 billion spent in 2004, 55.5% went to law enforcement and
interdiction efforts, while 44.5% went to treatment and prevention efforts. [6]

Public officials should be encouraged to redirect more antidrug money
into improving and expanding drug treatment programs.

Program Development

Many states have limited rehabilitative services for injection drug
users. For example, in 1998 Rich and colleagues surveyed patients
enrolled in one of the two state-funded detoxification facilities in
Rhode Island. [40]

Although both facilities offered medical and counseling services, the
longest stay permitted was seven days, and the average length of stay
was just four and a half days. Twenty-nine percent of patients left
before completing treatment; only 53% of those who completed it left
with an aftercare referral plan. [40]

New models of treatment and detoxification programs are needed. Bed
shortages aren't the only reason more substance abusers aren't in
treatment. Many drug users, realizing one week of treatment will be
inadequate to help them overcome long-term addiction, don't want to
enroll in seven-day programs. Some programs aren't equipped to accept
people with certain disabilities. Nurses can collaborate with other
health care professionals to develop and run treatment programs that
can more realistically meet the needs of long-term drug users.

Nurses can support the development of comprehensive educational
programs for nurses and other health professionals regarding drug
abuse and related health concerns such as risk behaviors, the
harm-reduction approach, and effective treatment and prevention
modalities. Being able to interact effectively with injection drug
users and helping them to set realistic, attainable goals are essential skills.

Eventually, more effective, less controversial approaches to the
problem of HIV transmission associated with injection drug use may
emerge. Until then, SEPs and other harm-reduction strategies remain
the best approach to curbing the adverse health effects of injection drug use.

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