Washington, D.C. has a higher AIDS diagnosis rate than any U.S. state, with about 2.4 percent of residents living with HIV/AIDS. About one in six of those cases is directly linked to injection drug use.
But until 2007, there was a federal ban on using D.C.’s municipal funds for needle exchange programs, an outreach technique that reduces disease spread and can channel vital health and addiction services to drug users. When Congress lifted the ban, public health scientists were eager to see if needle exchanges would stem the tide of new HIV cases in the district.
Thanks to a new study that followed the first two years of such needle exchange programs in D.C., the verdict is in: By funding the exchanges, lawmakers helped avert at least 120 new HIV cases in the District in the first 24 months, saving an estimated $44 million in lifetime costs for HIV/AIDS care. The findings, published in the journal AIDS and Behavior, add to an extensive line of research confirming the effectiveness of harm-reduction strategies, which have already been endorsed by many major medical organizations, including the Infectious Diseases Society of America (IDSA) and the HIV Medicine Association (HIVMA).
“Our study adds to the evidence that needle exchange programs not only work but are cost-effective investments in the battle against HIV,” said lead researcher Dr. Monica Ruiz of George Washington University’s Milken Institute School of Public Health.
Currently, only 16 states and Washington, D.C. explicitly authorize needle exchange programs, according to April 2015 data from LawAtlas. A funding ban implemented in 1998 prohibits the use of federal dollars to establish needle exchange programs, limiting what states can do. But research consistently shows that providing clean needles to drug users reduces infectious disease and, despite claims to the contrary, doesn’t “encourage” drug addiction.
“A lot of policymakers are caught up in that belief system without looking at the evidence,” said Ruiz. But, she said, this latest study provides clear evidence that setting aside such biases in favor of evidence-based policies can save lives — and help reduce an unnecessary health care burden.
How needle exchanges work
Injection drug users have a higher risk of contracting blood-borne diseases like HIV and hepatitis B and C because the disease can be transferred from an infected person to a new person if they use the same needle or other paraphernalia (e.g., cotton, spoons). In the U.S., injection drug users represent eight percent of all new HIV infections and 16 percent of new hepatitis B infections. Globally, about 90 percent of all new hepatitis C infections are linked to injection drug use.
Cleaning needles and other drug paraphernalia does not completely remove these pathogens. That’s why new, sterile syringes are the safest way to inject drugs and prevent disease transmission.
Past research from other areas of the country has linked access to clean syringes to huge reductions in both hepatitis B and C infections and HIV infections. In addition to providing access to clean equipment, experts say, these programs are important points of contact where medical personnel can refer drug users to other services that may help address addiction and health. According to the North American Syringe Exchange Network, nearly 90 percent of needle exchange programs offer HIV testing and counseling, 80 percent provide referrals for drug and mental health treatment, and nearly 70 percent distribute medications and resources to prevent drug overdoses and deaths.
Analyzing D.C.’s program
For the study, Ruiz used a statistical model to predict how many injection drug-associated HIV cases D.C. residents would have acquired if the district’s needle exchange program had never been created.
In that scenario, D.C. would have seen a total of 296 injection drug-related HIV cases in the first two years. In actuality, cases totaled only 176, which means that at least 120 people avoided HIV infection as a result of the needle exchange policy, according to the researcher’s calculations.
In addition to saving 120 people from contracting HIV, the program, which cost the city $1.3 million over two years, saved an estimated $44.3 million in lifetime HIV costs those 120 patients would likely have incurred. It also opened the door for public health workers to reach at-risk people with other interventions, like distributing condoms and HIV tests. And it connected 321 people to substance abuse treatment, confirming previous studies that have shown an increased likelihood of treatment-seeking among individuals enrolled in needle exchange programs.
Ruiz’s analysis is unique, because while other research has measured the effects of a needle exchange program before and after it was implemented, her study assesses the impact of how policy, and investing local funds, changed the rates of new HIV contractions in D.C. The District did have an independently funded needle exchange program before Congress lifted the ban on using municipal money, but once the ban was lifted, D.C. was able to invest a lot more to enhance and expand its services.
The human cost of not having a needle exchange program became clear in Indiana’s Scott County, which saw an explosion of HIV cases tied to intravenous drug use. The small county, which has just under 24,000 residents, had never seen more than five HIV cases a year, but in 2015 that number is so far up to 177. In response to the crisis — and despite a long-held stand against needle exchange programs — Gov. Mike Pence (R) established temporary service in the county.
Since Scott County started its exchange, hundreds of people been tested for HIV and Hep C, 40 have been referred to inpatient drug treatment and 20 have been referred to outpatient treatment, according to Jerome Adams, Indiana’s state health commissioner. An exchange also began operating recently in Madison County, and another has been approved for Fayette County.
Ruiz praised Gov. Pence for his leadership on the issue, as well as his ability to set aside his personal bias in favor of evidence-based programs that have been shown to prevent the spread of HIV. She called on other politicians to do the same, urging Congress to do their part by lifting the ban on federal funds for needle exchange programs in all 50 states.
The time to act is now, experts say. Waiting until an outbreak has already erupted can spell disaster, says Dr. Steffanie A. Strathdee, an infectious disease epidemiologist and Associate Dean of Global Health Sciences at the University of California, San Diego.
“HIV outbreaks among injection-drug users can escalate quickly,” Dr. Strathdee told the New England Journal of Medicine in a July 2015 interview. “The literature is rife with examples from North America, Southeast and Central Asia, and Eastern Europe, where HIV prevalence among injection-drug users had been below 5% for decades but leapt to 80% or higher within a year owing to continuing high-risk behaviors in the absence of adequate HIV prevention and access to treatment.”