People who inject drugs risk contracting and transmitting bloodborne infections such as HIV, which can transmit through needle sharing. Needle exchange programs (NEPs) are community-based health programs aimed at preventing and curbing this spread.

NEPs — also called syringe exchange programs (SEPs) or needle and syringe programs (NSPs) — give people who use injectable drugs access to clean syringes and needles. They also safely dispose of used products.

The program also serves as a pathway to reach out to people currently using drugs and provide them with access to relevant services and programs, including HIV screening.

In 2020, 37.7 million people were living with HIV globally, according to the Joint United Nations (UN) Programme on HIV and AIDS (UNAIDS). Of these, 6.1 million were unaware that they had HIV. Despite this, there has been a 52% reduction in cases since the peak of the disease in 1997.

A similar decline in HIV infections occurred in the United States. The Centers for Disease Control and Prevention (CDC) estimated that there were 34,800 HIV infections in the U.S. in 2019, reflecting an 8% decline in cases from 2015 to 2019. The rate of annual HIV infections in the U.S. has also reduced by more than two-thirds since its height in the mid-1980s.

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NEPs aim to improve access to sterile syringes, needles, and other injection equipment for those who use injectable drugs. They were designed to eliminate the need to share unclean needles, thereby preventing disease outbreaks and reducing people’s risk of acquiring and transmitting diseases.

In addition, NEPs provide individuals with a range of other services. These often include:

  • training on how to manage an overdose
  • screening for sexually transmitted infections (STIs) and other diseases
  • care and treatment for infectious diseases, such as viral hepatitis and HIV
  • connecting people to substance use disorder treatment programs to help stop drug use
  • access to HIV prevention interventions, including pre-exposure prophylaxis (PrEP) and free condoms
  • referral to other services, such as counseling and psychosocial support

Although there is some debate over whether NEPs could potentially encourage drug use, research suggests that they do not increase illegal drug use or related crimes. On the other hand, syringe services programs (SSPs) have proven to reach injection drug users who are typically hidden and marginalized. In fact, a study found that first-time SSP users are more likely to stop using drugs and five times more likely to receive drug treatment than those who never use SSPs.

SSPs help reduce the number of deaths due to drug overdose by teaching individuals who inject drugs to recognize an overdose and administer naloxone, a drug that reverses opioid overdose. Most SSPs also provide people with overdose prevention kits.

It is important to note that one 2020 study found that many people using opioids do not accept or carry naloxone. However, in another 2020 study, people who had received substance abuse treatment were more likely to carry naloxone.

SSPs also provide care for people who have wounds and abscesses resulting from reusing syringes but are reluctant to seek medical care or go to the hospital. Proper needle disposal also protects first responders and the general public by reducing the presence of these needles in communities.

In the last decade, the opioid epidemic in the U.S. — specifically, the misuse of opioid pain relievers such as fentanyl and heroin — has continued to rise. In 2019 alone, about 1 million people in the U.S. reported using injectable drugs.

Globally, estimates based on the 2021 World Drug Report of the UN’s Office on Drugs and Crime suggest that more than 11 million people inject drugs, with half also living with hepatitis C.

This rise in injected drug use is associated with increasing drug overdose-related deaths to more than 166,000 deaths every year. In the U.S. alone, drug overdose caused 70,630 deaths in 2019, according to the CDC.

The misuse of injected drugs is also linked to unsafe injection practices, with people who inject drugs having a 22 times higher risk of having HIV. In 2016, 20% of HIV cases in men and 21% in women were associated with the use of injectable drugs.

About 416 SSP sites across different U.S. states are attempting to reduce the spread of these infections. A person can find their nearest one using the North American Syringe Exchange Network’s directory. Additionally, 86 other countries are currently hosting SEPs, according to the Global State of Harm Reduction 2020 report.

Several studies have demonstrated the effectiveness of NEPs in preventing the transmission of HIV and other diseases. A 2013 systematic review found that NSPs decrease the prevalence of infections with the hepatitis C virus and HIV. They also reduce the number of new cases of HIV.

A 2017 Cochrane study found that combining NSPs with opioid substitution therapy reduced hepatitis C transmission. A similar 2017 study concluded that using NEPs, either alone or in combination with other treatments, could potentially be a cost effective method of preventing HIV among people who use injectable drugs in the U.S.

A 2018 study found that having prison NSPs prevented HIV and viral hepatitis transmission. Other research found that NSPs are effective in reducing injecting risk behaviors and HIV transmission. Meanwhile, another study found that cities without NSPs have eightfold more improperly disposed syringes than cities with NSPs.

However, according to a 2021 study, the success of SSPs largely depends on various factors. These include:

  • program size
  • scope
  • whether they have a fixed or mobile site
  • program comprehensiveness
  • legality
  • community acceptance

An older study from 2008 measuring the effectiveness of a New York-based NSE program found that the program saved $325,000 for each HIV case averted and avoided between four and seven infections per 1,000 individuals.

Florida’s only syringe service program, IDEA Exchange, exchanges 3,000–5,000 syringes on a weekly basis and has enrolled more than 800 participants, performing in excess of 1,100 HIV and HCV tests combined since 2018.

A 2005 intervention program that Baltimore’s NEP network initiated found that providing case management intervention to users of injectable drugs effectively increased people’s enrollment into drug treatment programs.

The harm reduction approach has also produced success in other countries. One study attributed New Zealand’s low HIV infection rates to its NEPs, which started 30 years ago, much earlier than in other countries.

NSPs in Australia led to savings of 70–220 million Australian dollars in healthcare costs from 2000–2010. They also reduced the prevalence of HIV to less than 1% in people who inject drugs and cut syringe sharing from 70–90% to 17%.

By reducing needle sharing, needle exchange programs help reduce the spread of HIV and other infectious diseases. These programs also reduce the prevalence of substance use by providing people who inject drugs with access to helpful treatment and other services.

Many long-term studies have demonstrated the programs’ effectiveness. However, policies and community acceptance, among other factors, still affect the sustainability and effectiveness of NEPs.

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