Injection of Hope
Needle and syringe programs can lower HIV infection rates and provide important outreach to injection drug users
By Catherine Zandonella*
In Vancouver's downtown eastside, tucked away on a side street, is North America's only supervised injection facility for intravenous drug users. Upon entry, visitors receive a tray with alcohol swabs and sterile needles and syringes to inject the illegal drugs that they have brought with them. The 12 injection booths equipped with mirrors and lights give the impression of a beauty parlor, prompting the facility's nickname-the 'Hair Salon.'
Since opening in 2003, the facility has provided sterile injection equipment to about 7000 registered users and oversees about 20,000 injections a month. "That is 20,000 injections that don't occur in a public site, that are done with clean equipment not shared and is disposed of appropriately," says Dan Small, director of the Portland Hotel Society, a community group that helped to establish the facility.
The safe injection site is one type of program aimed at reducing the risk of HIV transmission by providing injection drug users (IDUs) with sterile needles and syringes. Since the first needle-exchange program began in Edinburgh, Scotland, in the early 1980s, many such programs have started up around the globe. These programs may also offer education and condoms, access to drug rehabilitation, and health services.
Unfortunately these efforts reach only a fraction of the IDUs at risk of HIV infection around the world. HIV prevention activities for IDUs reached at most 5% of all users globally in 2004. About 65 countries have needle and syringe programs but coverage is poor. In some countries these programs are banned due to concerns that they promote drug use. The US, the largest provider of funds for international AIDS prevention programs, refuses to finance needle-exchange programs at home or abroad and has tried to impose restrictions on such programs in United Nations (UN) policies.
Yet studies show that needle and syringe programs are effective at reducing HIV transmission risk. Throughout the world the lack of needle and syringe programs is fostering the transmission of HIV among needle sharers, their sexual partners, and their children. IDUs are often regarded as being at the margins of a society and all but excluded, but that might not be as true as some might like to believe and a growing HIV epidemic among IDUs within a community always has the potential to spill over into the greater population.
As well as directly reducing HIV transmission risk these programs are important outreach mechanisms that establish relationships between public health workers and a marginalized population, and can offer other benefits including improved access to health care and drug treatment, prevention of other blood-borne diseases, and education about how to avoid sexual transmission of HIV. "Needle and syringe programs are a stand-in for the larger issue of how to reach the people who are the least engaged in society yet are at the greatest risk," says Daniel Wolfe, the deputy director of International Harm Reduction Development Program at the Open Society Institute. Because of their high risk these individuals can be important volunteers for AIDS vaccine trials, but it is an ongoing question whether it is ethical to test vaccine candidates in IDU cohorts without providing sterile needles and syringes.
A growing epidemic
Globally, IDUs make up 10% of all HIV cases and, outside of sub-Saharan Africa, an estimated one in three new HIV infections is due to injection drug use. Contaminated needles cause the largest share of new infections in some 20 nations and are fueling some of the world's burgeoning epidemics, including those in Russia, Ukraine, China, Indonesia, central Asia, and much of south and southeast Asia. In the countries of the former Soviet Union roughly 70% of HIV cases are among IDUs. "The biggest problem with HIV infection among IDUs is now occurring in developing and transitional countries, mainly in Asia and Eastern Europe where HIV has spread very rapidly over the last 5 to 10 years," says Don Des Jarlais, research director at the Center for Drug Use and HIV Research in New York City.
To combat these escalating epidemics, most agree that a comprehensive approach is required that includes strategies to reduce the number of individuals who inject drugs, promote safe injection practices and discourage unsafe sex, and provide antiretroviral therapy and other health support for IDUs living with HIV. Programs must include education and community outreach, drug dependence treatment, condom distribution and prevention of sexually-transmitted infections, legislation reform, and public education to create support for harm reduction.
Still, experts say these efforts won't significantly reduce HIV transmission without clean needles. "You don't reduce HIV transmission among IDUs unless you have a good supply of injection equipment," says Des Jarlais. Programs that supply sterile needles and syringes come in a variety of forms, including supervised injection sites-which operate in over 20 European cities-and programs that offer a one-to-one exchange of needles. Other important initiatives include pharmacy and vending machine sales of needles and the roll-back of punitive legislation for the sale or possession of injection paraphernalia.
Figure 1. Percentage of IDUs Among HIV Infections by Region.
Needle and syringe provision is one of the most studied HIV interventions. The majority of studies find that needle and syringe programs reduce HIV transmission in a safe and cost effective manner, according to a recent meta-analysis of 45 studies conducted from 1989 to 2002 (Int. J. Drug Policy 16, S31, 2005). Twenty-three of 33 studies that looked at HIV risk behavior outcomes showed a positive reduction in syringe sharing, borrowing, lending, or reuse. For example, a study of 5000 IDUs in New York City from 1990 to 1997 found that injection risk behaviors declined significantly accompanied by a substantial increase in syringe exchange participation. HIV seroprevalence in this population also declined from about 45% in 1991 to about 30% in 1996.
Studies involving IDU cohorts are often not simple to interpret though. Six of 10 studies that evaluated HIV seroconversion or seropositivity as outcomes found that needle and syringe program use was protective, but the other four studies found that individuals using needle and syringe programs had higher HIV seroconversion rates. Shortcomings in study design may explain these results, say the authors. Needle and syringe programs tend to attract high-risk individuals with no access to clean equipment elsewhere and some studies failed to note whether an individual was a regular or intermittent attendee. Irregular attendees may be at higher risk of HIV seroconversion because they have less access to sterile equipment and prevention messages.
Making comparisons across studies can also be complicated by the fact that they are often conducted at different stages of HIV epidemics with wide variations in HIV seroprevalence and risk; high seroprevalence will tend to lead to new infections from both needle sharing and sexual behavior, and the relative success of a needle and syringe program may therefore be masked by sexual transmission.
The majority of studies show that needle syringe programs are cost effective. One study in New York City found that the cost per HIV infection averted for a year was estimated to be less than US$3000, far below the then-estimated lifetime cost of medical treatment for an HIV-infected individual of $56,000 to $80,000. Rolling back punitive drug laws can also help decrease HIV transmission risk, according to studies conducted in the US indicating that legal restrictions on syringe and needle availability are correlated with higher HIV seroincidence and seroprevalence.
Drug substitution with methadone or buprenorphine does reduce the sharing of injection equipment, and may also result in fewer exchanges of sex for drugs or money. While methadone programs are available in the US, Canada, Europe and Australia, fewer than 13,000 of the 5.2 million IDUs who live in countries where contaminated needles are the main source of HIV infections have access to substitution treatment.
One thing is clear-studies have failed to show that needle and syringe programs increase illicit drug use or cause migration of IDUs to cities that offer such programs. Nor have they documented greater numbers of discarded needles on city streets.
How much is enough?
One of the biggest hurdles in needle syringe programs is how to determine how many needles are enough to stem HIV transmission. "It is all really about coverage," says Alex Wodak, former president of the International Harm Reduction Association, "reaching the maximum number of people you can reach with the maximum number of needles you can provide in a framework that is attractive to the population that you are trying to reach."
The World Health Organization (WHO) approximates that providing 200 sterile needles and syringes per drug injector per year is likely to control HIV infection, with higher targets where seroprevalence has already reached unacceptable levels. Another often quoted target accepted by a range of agencies, including the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS), is that 60% of all injections be done with a sterile needle and syringe.
Implementing these programs early in the course of an HIV epidemic is critical to success. Australia established its first needle and syringe program in 1986 and annually distributes 30 million needles in a country with a population of less than 20 million. By contrast, the US distributes about 25 million needles each year for a population of 300 million.
The annual AIDS incidence in the US in 2003 was 14.7 per 100,000 population, with 25-33% of the cases among IDUs or sex partners of IDUs, compared with Australia's 1.2 per 100,000 population with about 5% of cases from the IDU community. "Thank God that Australia was settled by convicts and we are a fairly practical country, whereas the United States was settled by puritans and you've been dealing with it ever since," says Wodak.
Around the globe
According to UNAIDS, Russia's HIV epidemic is the fastest growing in the world. Most infected individuals are under the age of 30 and nearly 90% are IDUs, yet needle and syringe programs reach perhaps 2% of the Russian IDU population. Most of these are funded by non-governmental organizations (NGOs) or are supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Moscow has no needle-exchange program, syringes are not available for purchase, and possession of a syringe containing drug residue is a punishable offense. Drug substitution therapy is also illegal in Russia.
Other former Soviet states are more progressive. Ukraine hosts about 250 projects sponsored by the Global Fund that reach about 70,000 IDUs. Among the central Asian countries of the former Soviet Union, where about 70% of the HIV cases are among IDUs, Kyrgyzstan offers substitution treatment and needle and syringe programs, including for prisoners. Tajikistan, which shares a long border with the opium-producing Afghanistan, has NGO-sponsored programs where volunteers travel the mountainous border region offering drug treatment programs and clean needles.
China has made recent strides in its commitment to stemming the HIV epidemic among IDUs, which make up about 44% of the 650,000 people officially estimated to be HIV infected. The Chinese government plans to spend approximately $185 million on HIV prevention, doubling current spending, between 2005 and 2007. Over the next five years, the Global Fund plans to disburse more than $60 million in funds to prevent HIV transmission among IDUs and sex workers in the seven Chinese provinces that harbor 90% of the HIV-infected IDUs. As of November 2005, 91 needle-exchange projects were operating throughout China and the National Center for AIDS/STD Prevention and Control plans to provide sterile injection equipment to 105,000 IDUs by 2010. About 6,500 patients receive methadone in 58 treatment programs around the country. However, concerns remain about the human rights of drug users, who may be forced to enroll in treatment programs.
Indonesia, a country with strict drug laws, is making attempts to stem its injection-driven HIV infection rate of 44%. Limited drug substitution pilot programs and needle and syringe programs operate in Jakarta and Bali, including a pilot prison program. However, efforts vary widely from island to island in the archipelago. In the past two years about 80% of new HIV cases have been due to unsafe injection practices, an infection rate among IDUs second only to the former Soviet Union. Injection-related infections are on the rise in Afghanistan, Cambodia, and Pakistan, countries where most HIV infections to date have been sexually transmitted.
Vietnam in 2005 made a strong national commitment to providing sterile needles and drug substitution therapy for its IDUs, which make up 52% of the nation's HIV cases. Roughly 30 needle and syringe programs operate in the country, which receives influxes of illegal drugs across its borders with China and Myanmar. On Vietnam's northern border with China, HIV infection rates have declined in some areas due to a program offering 25,000 needles/syringes per month, which is funded by the Ford Foundation and is being studied for efficacy by the US National Institute on Drug Abuse. At the same time harsh anti-drug laws have resulted in the executions of 44 people in 2004, according to Amnesty International. UNAIDS estimates that more than 55,000 drug users are currently held in rehabilitation centers that human rights activists say more closely resemble labor camps.
US policy, global impact
The US is the largest donor for AIDS prevention programs worldwide but the current administration views providing needles and syringes as promoting drug use. This is despite seven reviews conducted by US-funded agencies concluding that such programs reduce HIV transmission and do not increase the use of illegal drugs. Within the US needle and syringe programs have found ways around the federal funding ban and operate in most major cities, using state and local government funding, or private donations.
Outside the US, however, the refusal to support needle and syringe programs could have far-reaching consequences. During a March 2005 meeting of the UN Commission on Narcotic Drugs (CND) the US delegates successfully lobbied to exclude the mention of needle exchange or the human rights of drug users from any CND resolutions. The US policies were criticized by numerous NGOs, foreign governments, and on the pages of theNew York Times and Washington Post. US delegates made the same arguments later that year at the UNAIDS global HIV prevention strategy meeting in Geneva, but the final language of the UN resolution recognized the importance of access to sterile injection equipment and measures to protect the human rights of drug users.
Vietnam is the only country selected by the US President's Emergency Plan for AIDS Relief (PEPFAR) in which injection drug use comprises the majority of new HIV infections. None of the $34 million that PEPFAR provides may be used for needles or syringes, although some funds will go to a drug-substitution program. Other US aid programs find ways to work around the ban. For example, while the United States Agency for International Development (USAID) cannot provide funding for needle and syringe programs, it partners with providers of those services.
IDUs are considered important participants in HIV prevention trials because of their elevated risk of acquiring HIV. Yet while sex workers who participate in clinical trials are given condoms and education it is not considered necessary to give IDUs sterile needles and syringes. Some researchers think this is ethically questionable. "The condom equivalent for IDUs is clean needles and syringes," says Chris Beyrer, director of the Fogarty AIDS International Training and Research Program at Johns Hopkins Bloomberg School of Public Health. "Needles and syringes should obviously be provided. It is good research ethics, and good public health."
The Thai Drug Users Network (TDN) has lobbied for the provision of sterile needles and syringes to IDUs participating in a US-sponsored clinical trial of tenofovir for HIV prevention in Thailand, where the HIV incidence among IDUs is 37-50%. The trial, sponsored by the US Centers for Disease Control and Prevention (CDC), is enrolling 1600 HIV-uninfected IDUs in Bangkok during the period from 2005-2007. IDUs will receive safe injecting education and access to methadone but not clean needles.
Needles and syringes are available for purchase at pharmacies but, according to Karyn Kaplan of TDN, the drug users her group talks with say that obtaining needles is not that easy. They cost about 12 cents each and many pharmacists refuse to sell needles to people they perceive as drug users. "The main issue, of course, is the criminalization of people who use drugs, rendering it highly unsafe to carry any drug paraphernalia, clean or not," says Kaplan. "Clearly, the US policies against needle exchange and harm reduction itself are hampering individuals' ability to protect themselves."
After unsuccessfully lobbying the CDC and the Thai Minister of Public Health, the TDN has taken their case to the Thailand National Human Rights Commission. Over the last three years Thai IDUs have been terrorized by a brutal anti-drug policy that has resulted in massive arrests and a reported 3000 extra-judicial killings. TDN has won a Global Fund grant to support involvement of drug users in the planning and implementation of harm reduction services and policy advocacy.
Since the US is not likely to begin funding needle and syringe programs in the near future, Beyrer suggests that an NGO could provide them. Providing syringes and needles in clinical trials will reduce the HIV transmission rate, so trial design will have to include enough participants to compensate for that reduction.
Barriers to access
Many researchers agree that the success of needle and syringe programs rests on easy availability. Down the street from Vancouver's safe injection facility, volunteers patrol the streets in the predawn hours passing out needles. This 'low threshold' approach makes it far easier to get needles than it would be at a health department or pharmacy that requires patients to sign forms and wait in line, says Dan Small. "Can you imagine a person living in the shadow of life, in active addiction, waiting 15 minutes for a needle?"
Users at the safe injection site have to register but proof of identification or form filling is not required. Patients are selected at random for participation in ongoing trials of the facility's efficacy. Already, several published papers demonstrate that the facility has lessened the number of needles littered in the community, reduced the number of addicts shooting up in doorways, prevented overdoses, and referred people for treatment. About 2500 IDUs are enrolled in an ongoing study to determine if the site is helping reduce the HIV seroconversion rate.
Despite these successes, the threat of closure has been hanging over the 'Hair Salon.' Happily, on September 1, 2006 Federal Health Minister Tony Clement announced that the Canadian government had "deferred the decision" on continuing the facility's operating exemption from the Controlled Drugs and Substances Act until December 31, 2007. During that time the supervised injection site will be allowed to continue operations and additional studies will be conducted on the effects on crime, prevention, and treatment.
Many questions remain about the best way to implement needle and syringe programs. Since it is impossible to ensure that every IDU uses a clean needle every time, researchers would like better information about the degree of coverage necessary to significantly reduce HIV transmission. Enhancing the ease of access to clean needles and syringes will help IDUs protect themselves and their partners, and perhaps help head off some of the world's burgeoning epidemics.
*Catherine Zandonella, MPH, is a freelance writer whose work has appeared in Nature and New Scientist.