Study: Needle exchange policy prevented HIV

Lifting a ban on spending city money on needle exchanges for intravenous drug users prevented 120 new cases of HIV in two years in Washington, according to a new study that researchers hope can help other communities deal with a surge in addicts shooting up.

“Policy change makes a difference,” says Monica Ruiz of George Washington University, lead author of the research being published Thursday in the journal AIDS and Behavior. “While this study looks at (Washington), D.C., we’re seeing the same thing in Indiana,” which recently changed its policy to make needle exchanges legal in certain public health emergencies amid the state’s largest-ever HIV outbreak.

Needle exchanges, where addicts can trade dirty syringes for clean ones, have long been controversial. Proponents say the 220 or so across the nation effectively curb the spread of disease. But opponents argue that they enable addicts to keep using.

“My fundamental concern is that many of the needle exchanges aren’t going after the core problem, which is drug abuse,” says Kansas physician Eric Voth, who chairs the Institute on Global Drug Policy, a division of the Florida-based Drug Free America Foundation. “I call them needle handouts … What pressures are they exerting to get people into treatment?”

Congress first banned the use of federal funds for needle exchanges in 1988, and from 1998 to 2007, Washington wasn’t allowed to use its own money either because Congress oversees its budget. Other communities could, and did, use local funds to start exchanges.

The district’s health department did, too, as soon as the “D.C. ban” was lifted in late 2007. The program — which cost the department $650,000 a year in its first 24 months — offered clean syringes as well as HIV tests, free condoms and referrals to addiction treatment. During the D.C. ban, Ruiz says there was only one small donation-funded needle exchange program.

To quantify the effect of the policy change, Ruiz and her colleagues used a modeling technique to predict how many HIV infections would have occurred if the Washington ban had remained and came up with 296 cases. Then they looked at how many actually occurred in the two years after the ban was lifted, which was 176, yielding a difference of 120 “averted” cases, the study says.

Researchers also calculated the average lifetime cost of treating HIV in 120 people, which they estimate at about $44 million.

“Our study adds to the evidence that needle exchange programs not only work but are cost-effective investments in the battle against HIV,” says Ruiz, an assistant research professor of community health at George Washington's Milken Institute School of Public Health.

Jerome Adams, Indiana’s state health commissioner, agrees that exchanges “have been shown scientifically to slow the spread of infectious disease across time and across the country.” But he says they are only part of the answer. “I feel strongly that they only work because we used them as part of a comprehensive strategy” against a daunting problem.

By last count, Indiana’s outbreak included 177 confirmed HIV cases and four preliminary positive cases, most rooted in abuse of the powerful painkiller Opana. The epicenter of the outbreak is Austin, Ind., in Scott County, which, with a population of 4,200, has a higher incidence rate of HIV than any country in sub-Saharan Africa, according to Tom Frieden, director of the U.S. Centers for Disease Control and Prevention.The state and CDC responded to the outbreak with a one-stop shop offering HIV testing, substance abuse referrals and a temporary, county-run needle exchange.

A new Indiana law allows exchanges under certain circumstances when a community is wracked by an epidemic of HIV or hepatitis C. The approval process, designed to ensure community support, involves getting permission from county commissioners, who must hold a public hearing, adopt an emergency declaration, describe other unsuccessful actions that have been taken and ask Adams to declare an official public health emergency. State money can’t be used for the syringes, but can go toward related services, Adams says, while cities and towns, counties or non-profit groups buy the needles.

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. An exchange also began operating recently in Madison County, and another has been approved for Fayette County.

Ruiz says she was glad to see Indiana pass a law in response to its crisis. “That was the fastest I’ve seen any government move,” she says, adding that she’d also love to see the federal government lift its funding ban as well.

But Voth, a specialist in internal medicine, addiction and pain management, would like to see the ban stay in place because he views the exchanges as a waste of taxpayer money. “If you have a dollar, do you want to fund treatment? Or do you want to fund a needle,” he says. “There’s limited funding, and it should go toward prevention, first off, then treatment.”