Point-Counterpoint: Should We Implement Needle Exchange Programs for the Prevention of Hepatitis C Virus?

Of the approximately 12.7 to 16 million people who inject drugs (PWID) worldwide, an estimated 10 million individuals have hepatitis C virus (HCV), making it the most prevalent infectious disease in this population.¹ The United States federal government aims to reduce its nationwide incidence from 0.28 cases per 100,000 to 0.25 cases per 100,000, as stated in the Healthy People 2020 Objectives.²

A needle exchange program (NEP) is a harm reduction intervention — a set of practices aimed at reducing the consequences of drug abuse — that involves the provision of clean needles in exchange for used needles.² Most NEPs provide additional interventions for PWID and providers alike.^1,2

A joint venture of the World Health Organization (WHO) and the United Nations Program on HIV/AIDS (UNAIDS) has issued statements of support for comprehensive services in PWID for disease prevention, including NEPs, and the United Nations Office on Drugs and Crime (UNODC) has followed suit.³ Furthermore, the WHO Global Health Sector Strategy on Viral Hepatitis 2016-2021 cites harm reduction interventions in PWID, such as NEPs, as being critical to HCV prevention.³

However, implementation of NEPs in the United States and other countries has been a significant challenge, as many public officials and policymakers maintain steadfast opposition to these programs.^4-6

What are some key arguments against the implementation of needle exchange programs? 

First, community members and public officials alike have cited safety concerns regarding the inappropriate disposal of used syringes upon distribution of new syringes.⁴ Recent headlines are bringing attention to syringe litter problems in cities that actively distribute clean syringes, including San Francisco, California; Portland, Oregon; and Bloomington, Indiana.^7-9 However, such concerns are long-standing, especially with regard to the safety of children who may come across contaminated needs while playing in public places.⁴

Second, law enforcement officers have indicated that NEPs may interfere with their practice of searching suspects for probable cause of drug use or other illegal activity.⁴ For example, the presence of a syringe could normally be grounds for a search, but in cities that distribute syringes as part of Disease Prevention Demonstration Programs this practice may be disallowed.⁴

Third, critics question whether PWID have the necessary judgment to choose to participate in NEPs and bring its benefits to fruition.⁴ The moral value of harm reduction has also been called into question. “Opponents argue that…without risks and consequences, drug users would continue to behave in ways that are dangerous to themselves and detrimental to the community,” policy writer, Glenn Backes, and colleagues, explained in a manuscript published in the Journal of Urban Health.⁴

Advocates for Implementation of Needle Exchange Programs Respond

“[NEPs] are an important component of eliminating HCV without causing any negative unintended consequences,” Ricky Bluthenthal, PhD, professor, department of preventive medicine at University of Southern California’s Keck School of Medicine in Los Angeles, told Infectious Disease Advisor.  

Alex Wodak, MD, president of the Australian Drug Law Reform Foundation and emeritus consultant for the Alcohol and Drug Service at St. Vincent’s Hospital in Darlinghurst, New South Wales, Australia, concurred: “The combination of high intensity NEP and opioid substitution treatment is effective in reducing HCV.” 

Multiple studies have been conducted that support the use of NEPs to prevent transmission of infectious disease.^10-12 In a paper published in the Journal of Substance Abuse Treatment, Dr Heinzerling and his colleagues noted that NEPs can be an important source of preventive services for PWID, including HCV and HIV testing.¹³ Additional evidence suggests that NEPs may serve as a channel for substance abuse treatment.¹⁴

Dr Bluthenthal further noted, “Many of the concerns about [NEPs] have been disproven, including that they increase drug use among people who use them, increase crime in neighborhoods where they are located, and contribute to syringe litter.”

The results of a literature review published in Harm Reduction Journal demonstrated that NEPs have been effective in collecting used needles at an overall return rate of 90%.¹⁵ Subsequent studies have also disproved the claim that NEPs result in inappropriate disposal of contaminated syringes.^16-17

Dr Wodak commented, “[t]he USA was very slow to start NEPs and even slower to expand them to scale because of a pervasive puritanical and ideological War on Drugs mindset.” 

What do the data tell us?

Current research has yielded mixed results regarding the efficacy of NEPs in HCV prevention. “NEPs are more effective for slowing the spread of HIV than for HCV,” Dr. Wodak told Infectious Disease Advisor. “First, HCV is far more infectious than HIV by blood-blood spread. Second, HCV prevalence among people who inject drugs was already extremely high when NSPs began to be established for HIV starting from 1980.”

Ricardo Fernandes, MD, PhD, of the Center for Evidence-Based Medicine and the Collaborating Centre of the IberoAmerican Cochrane Network-Cochrane Portugal, Faculty of Medicine, University of Lisbon, and colleagues corroborate this information through their meta-analysis published in BMC Public Health, showing that NEP was in fact more effective in reducing HIV transmission than HCV transmission.¹ Findings have been mixed regarding the efficacy of NEPs in HCV.²

Researchers point to study design as a driver of uncertain results rather than an assertion that such programming is ineffective to HCV prevention.²

Concluding Remarks

Although NEPs remain a contentious issue, their implementation may continue to progress. To garner additional support for harm reduction programming, further research is warranted not just into the efficacy of these programs², but also into the dynamics of syringe distribution and disposal, as well as legal issues surrounding this process.⁴

References

1. Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs – An overview of systematic reviews. BMC Public Health. 2017;17(1):309. 
2. Davis SM, Daily S, Kristjansson AL, et al. Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: a systematic review with meta-analysis. Harm Reduct J. 2017;14(1):25. 
3. Larney S, Peacock A, Leung J, et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.  Lancet Glob Health. 2017;5(12):e1208-e1220. 
4. Backes G, Rose VJ. Primary and secondary analysis of local elected officials’ decision to support or oppose pharmacy sale of syringes in California. J Urban Health.  2010;87(4):553-560. 
5. Des Jarlais DC. Research, politics, and needle exchange. Am J Public Health.  2000;90(9):1392-1394. 
6. Moss AR. Epidemiology and the politics of needle exchange. Am J Public Health.  2000;90(9):1385-1387. 
7. Matier P, Ross A. Those needles littering the streets?  The city gave them out. San Francisco Chronicle. May 9, 2018. http://www.sfchronicle.com/bayarea/matier-ross/article/Those-needles-littering-the-streets-The-city-12898656.php. Accessed June 28, 2018.
8. Budnick, N. Used syringes litter Portland as needle exchanges grow. Portland Tribune. March 8, 2018.  http://www.portlandtribune.com/pt/9-news/389032-279230-used-syringes-litterportland-as-needleexchanges-grow. Accessed June 28, 2018. 
9. Bull, H. Bloomington neighbors say syringes litter the streets.CBS 4 Indy. June 7, 2018. http://cbs4indy.com/2018/06/07/bloomington-neighbors-concerned-over-syringes. Accessed July 9, 2018. 
10. Des Jarlais DC, Fisher DG, Newman JC, et al. Providing hepatitis B vaccination to injection drug users: Referral to health clinics vs. on-site vaccination at a syringe exchange program. Am J Public Health. 2001;91:1791-1792. 
11. Perlman DC, Perkins MP, Solomon N, et al. Tuberculosis screening at a syringe exchange program. Am J Public Health. 1997;87:862-863.
12. Stancliff S, Salomon N, Perlman DC, et al. Provision of influenza and pneumococcal vaccines to injection drug users at a syringe exchange. J Acquir Immune Defic Syndr. 2000;18:263-265.
13. Heinzerling KG, Kral AH, Flynn NM, et al. Human immunodeficiency virus and hepatitis C virus testing services at syringe exchange programs:Availability and outcomes. J Subst Abuse Treat. 2007;32(4):423-429. 
14. Heimer R. Can syringe exchange serve as a conduit to substance abuse treatment?  J Subst Abuse Treat. 1998;15(3):183-191.
15. Ksobiech K. Return rates for needle exchange programs: a common criticism answered. Harm Reduct J. 2004;1(1):2. 
16. Bluthenthal RN, Anderson R, Flynn NM, et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. 
17. Tookes HE, Kral AH, Wenger LD, et al. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug Alcohol Depend. 2012;123(1-3):255-259.