Despite evidence that needle-exchange programs are a low-cost, effective way to prevent the spread of infectious disease like HIV and hepatitis, such programs remain underused, federal health officials said last week.
According to a report issued by the Centers for Disease Control and Prevention, 1 in 3 individuals who inject illegal drugs said they had shared a needle within the past year. Even fewer reported getting all of their syringes from sterile source, whether an exchange program, hospital or pharmacy.
Public health authorities have documented how an increase in the prescribing of prescription opioid painkillers, such as oxycontin, has lead to a rise in the use of heroin. With more individuals injecting drugs, officials now fear a shadow increase in the number of new HIV and hepatitis C cases.
“Opiates are threatening the progress that we have made fighting HIV in this country,” CDC Director Dr. Tom Frieden said in a press conference last week. “We risk stalling or reversing decades of progress in HIV prevention.”
Nationally, HIV infections among individuals who inject drugs dropped by 27 percent from 2008 to 2012, but progress has plateaued ever since.
The CDC data shows stark differences by race and ethnicity, with an increasing percentage of African Americans and Latinos using clean needles. But the percentage of white Americans in urban areas sharing needles is almost unchanged over the past decade, from 45 percent in 2005 to 43 percent in 2015. The percentage of whites who got all their syringes from a sterile source declined slightly from 24 percent to 22 percent over those same years.
The data is based on interviews with drug users conducted in 22 large cities throughout the U.S. CDC officials said the situation may be even worse in rural areas where access to clean needles is lower, and falling well short of demand.
“That is showing up here,” said Susan McCreedy, HIV program coordinator for the Deschutes County Public Health Department. “We’re seeing a lot more people coming for the exchange. We’re seeing a lot more people having problems with opioid and heroin use and meth and reporting problems.”
Deschutes County has run a needle-exchange program out of its offices on the east side of Bend for more than a decade, but recently found demand for clean syringes was greater in the downtown area. In May, the county began distributing clean needles at the United Methodist Church downtown every Wednesday in a partnership with Mosaic Medical. The church provides an array of services to a largely homeless population, and Mosaic provides medical care and clean needles out of a mobile health van.
The health department is still compiling its data on the exchange program, but Laurie Hubbard, a communicable disease nurse who works in Deschutes County’s needle exchange program, estimated that moving downtown has tripled the number of needles exchanged. In 2015, Deschutes County Health Services distributed 11,550 sterile syringes in 426 individual client visits. On Nov. 30, the mobile van handed out 25 syringe kits, each containing 20 clean needles, its highest single day total ever.
Both Jefferson and Crook counties have considered starting needle-exchange programs, but lack the funding to do so.
“We simply don’t have the resources or staff to appropriately support a program,” said Michael Baker, health services director for Jefferson County Public Health.
The county is exploring options including finding local partners or collaborating on a regional model that could be self-sustaining. The North American Syringe Exchange Network lists only nine exchange programs in Oregon, mostly located in the larger cities in the state.
Hubbard said the health department would like to grow its program, expanding it to more locations to help overcome the transportation challenges faced by many drug users. But the program has already stretched its limited funding to its limits.
Additional funding could not only provide more needles, but increase the number of sharps containers that could be placed around the region, helping to keep contaminated needles off community streets, out of parks and playgrounds and out of standard trash receptacles.
“There is still a misperception out there that it enables drug use,” Hubbard said. “There’s research that it does not do that, and there’s research that it connects people to services. What we are enabling people to do is to take care of themselves.”
More than needles
Needle-exchange programs become a point of contact with drug users where health officials can connect them with substance abuse treatment and other health services. The Deschutes County program provides vouchers for HIV or hepatitis C testing, or for vaccines against hepatitis A and B, tetanus or pneumonia. The county is also considering whether it can provide them with naloxone, a medication that reverses the effects of opioids and prevents overdoses.
Sharing needles exposes individuals to microscopic droplets of blood that could contain bloodborne viruses. But reusing needles, even without sharing, increases the risk for infections and abscesses as the needles dull. County officials recently learned that IV drug users are particularly concerned about losing access to their veins due to an infection, and are using that concern to promote needle-exchange. The health department changed its messaging from “Clean needles save lives” to “Clean needles save veins.”
Hubbard said the stigma around drug use also remains a major barrier. Drug users are wary of interacting with government agencies.
“In some of my interactions with the people who inject, they express surprise that they are not being judged, lectured to, or lobbied around their drug use,” she said. “This is part of what drives harm reduction: providing humane, compassionate services to people who want to reduce their risks of disease or injury.”
Research has also shown that every dollar invested in a needle-exchange program saves $8 in downstream health care costs.
“(Syringe services programs) recognize that we have to deal with the world and the problems of the world as they are, and not as we wish they were,” Frieden said. “We wish drug use were far less common than it is. But in fact, it is common and sadly, it has been increasing.”
The public health goal is for people who inject drugs to live long enough to stop using drugs and not get HIV or other infections while they’re injecting.
“Needle exchange programs help accomplish both goals,” Frieden said.
Public health officials remain concerned that the lack of needle-exchange programs could lead to another localized HIV outbreak, like the one experienced in Scott County, Indiana. There some 181 individuals in a close network sharing needles contracted HIV. Indiana state law bans needle-exchange programs.
In Deschutes County, hepatitis C remains a more common risk among drug users than HIV. But McCreedy said that HIV could easily be spread in the same way.
“We’ve been very lucky. We just haven’t gotten people with HIV infection in our syringe-using community,” McCreedy said. “But the minute that happens, we could be Indiana.”
— Reporter: 541-617-7814, firstname.lastname@example.org