Pubdate: Mon, 01 May 2006
Source: American Journal of Nursing (US)
Section: Vol. 106(5), PP 58-63
Copyright: 2006 Lippincott Williams & Wilkins
Contact:  http://www.ajnonline.com
Details: http://www.mapinc.org/media/4157
Authors: Holly Villarreal, BSN, RN and Catherine Fogg, MS, RN, ARNP
Note: Holly Villarreal is a medical-oncology nurse at Christus Santa 
Rosa Hospital in San Antonio, TX. Catherine Fogg is an assistant 
professor at Saint Anselm College and a part-time family NP at 
Merrimack Valley Assistance Program, a nonprofit agency focusing on 
HIV and AIDS prevention; both are in Manchester, NH. She is also a 
doctoral student in nursing at the University of Massachusetts-Lowell.
Note: Official Journal of the American Nursing Assoc. Submissions 
must be typed, under 400 words, and include name, address, and phone 
# or email address; incl. references for statistics or studies cited. 
May be edited for length/clarity.
Bookmark: http://www.mapinc.org/decrim.htm (Decrim/Legalization)
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)
Bookmark: http://www.mapinc.org/find?143 (Hepatitis)
Bookmark: http://www.mapinc.org/find?136 (Methadone)
Bookmark: http://www.mapinc.org/find?137 (Needle Exchange)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)
Bookmark: http://www.mapinc.org/youth.htm (Youth)

SYRINGE-EXCHANGE PROGRAMS AND HIV PREVENTION

If They're Effective, What's The Controversy?

Abstract

Overview: Injection drug users and their sexual partners and children 
represent an increasing proportion of Americans living with HIV or 
AIDS. Syringe-exchange programs (SEPs), which are based on the theory 
of harm reduction, are effective in preventing the transmission of 
HIV and other pathogens through injection drug use. Most programs 
also serve as gateways to other vital medical services. Yet SEPs 
remain controversial. This article describes the controversy, 
considers the evidence, and discusses the nursing implications.

It is indisputable that the HIV and AIDS epidemic has become a global 
health crisis. Through the end of 2005, an estimated 40.3 million 
people worldwide (including more than 1 million in North America) 
were living with HIV or AIDS, according to a report by the Joint 
United Nations Programme on HIV/AIDS and the World Health 
Organization. [1]  In this country (and some others, including 
Canada), injection drug users and their sexual partners and children 
represent an increasing proportion of this population. Regardless of 
how one feels about injection drug use, its role in HIV transmission 
makes it a pressing public health concern.

According to the Centers for Disease Control and Prevention (CDC), an 
estimated 26% of AIDS diagnoses among people age 13 or older through 
2003 are associated with exposure to injection drug use. [2]

Among women, 57% of all AIDS cases are so associated. [3]

(Although this article focuses on the association between injection 
drug use and HIV transmission, injection drug users are also at high 
risk for contracting hepatitis B and C, as well as parasitic and 
bacterial infections.)

There are several strategies that can prevent the spread of HIV and 
other pathogens through injection drug use. One such strategy, 
syringe-exchange programs (SEPs; also known as needle-exchange 
programs), remains controversial. Although estimates vary, in 2002 at 
least 148 SEPs were operating in the United States; collectively, 
they reported distributing 24.9 million syringes that year. [4]

Opponents of SEPs believe these programs are ineffective and may even 
encourage injection drug use; proponents believe SEPs can effectively 
reduce HIV transmission rates.

Theoretical Approaches: Prohibition And Harm Reduction

There are two main approaches to the problem of drug abuse in this 
country. The predominant strategy is commonly known as the war on 
drugs. The term reportedly was first used at a June 1971 press 
conference by President Richard Nixon, and the war has been raging since. [5]

It is an expensive one; in 2004 alone, the federal government poured 
almost $12.1 billion into the fight. [6]

Yet the 2004 National Survey on Drug Use and Health found that about 
8% of the population age 12 years or older reported current illicit 
drug use, a prevalence that has remained virtually unchanged for 
several years. [7]

The war on drugs relies heavily on criminal law enforcement and 
incarceration, strategies the Lancet 's editors have called a largely 
futile effort to stem the influx of drugs, one that results in the 
imprisonment of hundreds of thousands of offenders. [8]

This, despite the fact that study after study has shown that 
treatment and prevention help far more people at far less cost than 
do prohibitive and punitive measures. [8]

For example, a study commissioned by the Drug Policy Alliance found 
that states like New Jersey that increased their use of prison for 
drug offenses . . . did not experience less drug use than other 
states that made more moderate use of prison for drug offenders. [9]

In Drug Wars, an installment of the national public television show 
Frontline that aired in October 2000, almost every interviewed drug 
enforcement official agreed that current strategies needed to be revamped. [5]

According to the Lancet, only about one in four Americans who need 
treatment for substance abuse are in treatment programs. [8]

A recent study by McAuliffe and Dunn found treatment availability did 
not meet treatment need in 32 states; the largest gaps were found in 
southern and southwestern states. [10]

In U.S. prisons, where drug offenders constitute about 21% of the 
state and 63% of the federal prison population, the percentage 
receiving treatment is even lower. [11]

A 1997 Department of Justice survey among state and federal prisoners 
found, of those admitting to illicit drug use in the month before 
their offense, only 15% participated in drug treatment programs while 
incarcerated, down from almost 37% in 1991. [11]

Many treatment programs offer outpatient services or short-term stays 
only or require that clients be drug free on admission; others accept 
only self-paying clients or clients with private insurance, and few 
accept Medicaid or Medicare. (To locate a program in any state, visit 
the Substance Abuse and Mental Health Services Administration's 
treatment facility locator at http://dasis3.samhsa.gov .)

In the 1980s an approach based on the idea of harm reduction received 
increasing attention. As the Harm Reduction Coalition (HRC) ( 
www.harmreduction.org ), a nonprofit organization, describes it, this 
approach accepts that substance abuse exists and, instead of ignoring 
or condemning it, works toward minimizing its harmful effects. [12]

The injection drug user is seen as the primary agent of harm 
reduction; community and individual well-being, not cessation of drug 
use, are the criteria by which the success of an intervention is 
measured. As Edith Springer, a cofounder of the HRC's Harm Reduction 
Training Institute, recently put it, harm-reduction treatment models 
rely on a combination of respect for the customer, nonjudgmental 
stances, compassion, empathy, and practicality. [13]
This is in keeping with the ANA's Code of Ethics for Nurses with 
Interpretive Statements, which states that the nurse practices with 
compassion and respect for the inherent dignity, worth, and 
uniqueness of every individual, unrestricted by considerations of 
social or economic status, personal attributes, or the nature of 
health problems. [14]

Current harm-reduction strategies for injection drug users include 
SEPs, methadone clinics, condom distribution, free screening for HIV 
and other illnesses, treatment referrals, and counseling.

Are SEPs Effective?

Opponents of SEPs have contended that such programs do not reduce HIV 
transmission or injection-related risk behaviors. Some believe that 
SEPs actually lead to increased drug use by making syringes more 
readily available. Proponents of SEPs argue that they are effective 
in reducing HIV transmission and risk behaviors and do not lead to 
increased drug use. Most of the evidence appears to support the 
latter contentions.

According to the CDC, the one-time use of sterile syringes remains 
the most effective way to limit HIV transmission associated with 
injection drug use. [3]

Although some studies have found little or no reduction of HIV 
transmission in association with SEPs, [15,16] the majority of 
studies demonstrate significantly reduced rates of HIV transmission 
and injection-related risk behaviors (such as needle sharing or 
inconsistent use of bleach for cleaning syringes) among SEPs clients. 
For example, an analysis of New York State-approved SEPs found that 
during a 12-month period, an estimated 87 HIV infections were averted 
as a direct result of the use of SEPs. [17]

A literature review found strong support for the role of SEPs in 
reducing HIV transmission rates; in one study of 81 cities, the mean 
annual HIV seroprevalence rate decreased 5.8% in the 29 cities with 
SEPs, but increased 5.9% in the 52 cities without SEPs. [18]

A metaanalysis from 47 studies concluded that SEPs effectively 
reduced injection-related risk behaviors. [19]

A recent study on the long-term effects of SEPs found that 
injection-related risk behaviors did not increase among participants 
over a four-year period despite factors such as homelessness and 
depression. [20]

New HIV diagnoses in this country have been declining both overall 
and among injection drug users in recent years, [21, 22] and most 
experts attribute this in part to SEPs and other harm-reduction strategies.

SEPs also function as gateways to other medical services. A 2002 
survey conducted by Beth Israel Medical Center in New York City and 
the North American Syringe Exchange Network found that of the 126 
SEPs surveyed, 77% provided referrals to substance abuse treatment, 
72% provided on-site voluntary counseling and HIV testing, and more 
than two-thirds provided supplies such as bleach, alcohol pads, and 
male and female condoms. [4]

Many also provided screening for hepatitis and tuberculosis and 
offered on-site medical care. Moreover, many injection drug users who 
use SEPs will informally provide information about health maintenance 
and risk reduction to other drug users outside the exchange program. [23]

Injection drug users are more likely than nonusers to be homeless, 
mentally ill, unemployed, or a combination thereof, [24] and some 
SEPs offer assistance with social services.

Yet, as Human Rights Watch recently reported, most states continue to 
restrict access to sterile syringes by enforcing 'drug paraphernalia' 
laws against needle-exchange program participants and regulating the 
purchase and sale of syringes in pharmacies. [25]

Although the CDC has given SEPs a central place in their HIV 
Prevention Strategic Plan, [26] many people remain unconvinced of 
their merit. Some of the main areas of ongoing discussion are outlined here.

Ethics

A common assertion is that a desired end, no matter how good, cannot 
justify the use of ethically reprehensible means. Accordingly, some 
opponents of SEPs contend that although such programs may result in 
reduced HIV transmission rates, providing sterile syringes 
facilitates injection drug use; therefore SEPs are ethically wrong.

But this argument is unsupported by evidence. No studies have shown 
that, lacking sterile syringes, injection drug users stop injecting; 
rather, they are likely to inject whether or not sterile syringes are 
available. As a participant in VanderWaal and colleagues' study said, 
I've seen guys pick up needles off the street. [27]

A study by Hagan and colleagues found that injection drug users who 
use an SEP were more likely to report reduced injection frequency or 
to stop injecting, and to remain in drug treatment, than those who 
did not. [28] New SEP clients were also five times more likely to 
enter drug treatment than those who had never used an SEP.

Another point of contention involves a fundamental tenet of the 
health care profession: the obligation to do no harm 
(nonmaleficence). Opponents of SEPs argue that health care workers 
who provide drug users with syringes, knowing they will be used to 
inject drugs, violate that tenet. But proponents of SEPs point out 
that there is another fundamental tenet to consider-the obligation to 
do good (beneficence). They argue that health care professionals have 
a responsibility to protect the public health; and by reducing the 
transmission of HIV and other infectious diseases, SEPs serve that end.

Public Perceptions And Fears

Federal government funding for SEPs has often been withheld on the 
grounds that the public will perceive such funding as official 
sanction of illicit drug use. Just say no has been the government's 
message for years. But is it ethical for the government to fail to 
support SEPs (and thus fail to prevent many cases of HIV transmission 
on the basis of public misperception)?

Residents often fear that if an SEP opens in their neighborhood, it 
will bring with it increased crime. It's well known that drug abuse 
and drug trafficking are often linked with community devastation, 
manifesting in high rates of unemployment, homelessness, and crime. 
But several studies have demonstrated that neighborhood crime rates 
do not rise after an SEP opens. [18, 29, 30]   Nor does the presence 
of an SEP increase the number of discarded syringes found in its 
vicinity. [31, 32]

Strong opposition to the harm-reduction approach has sometimes come 
from black community leaders. Blacks have been disproportionately 
affected by the HIV and AIDS epidemic; in 2003 the rate of new AIDS 
diagnoses in blacks was nearly 10 times that in whites and three 
times that in Hispanics. [33]

In a study that explored barriers to HIV prevention among 
predominantly black injection drug users, VanderWaal and colleagues 
stated that many black leaders view SEPs as quick-fix, low-budget 
substitutes for much needed drug user treatment programs and economic 
support. [27]

As one black elected official reportedly stated, I cannot condone my 
government telling communities ravaged by twin epidemics of drugs and 
AIDS that clean needles are the best we can do for you. [34]

And at worst, VanderWaal and colleagues stated, SEPs are seen as an 
attempt [by] the white power establishment to weaken or eliminate the 
black population by supporting continued drug use. [27]

As they note, given the exploitation of black communities by past 
public health initiatives (such as the Tuskegee Syphilis Study), that 
distrust isn't completely unjustified. VanderWaal and colleagues 
conclude that it underscores the importance of providing reliable, 
readily accessible harm-reduction services, including SEPs. In the 
face of opposition, they recommend working with community members and 
tailoring services and education to the needs of that community.

Implications For Nursing

The International Council of Nurses'Code of Ethics for Nurses speaks 
of the nurse's responsibility for initiating and supporting action to 
meet the health and social needs of the public, in particular those 
of vulnerable populations, a category that includes injection drug users. [35]

In its position statement on needle exchange and HIV, the ANA states, 
nurses support the availability of needle exchange programs [that] 
include adherence to public health and infection control guidelines, 
access for referral to treatment and rehabilitation services, and 
education about the transmission of HIV disease. [36]

Nurses need to identify pragmatic and effective strategies for 
working with injection drug users. Areas of focus should include 
provision of care, advocacy, and program development.

Provision Of Care

In addition to educating injection drug users on HIV prevention and 
risk reduction, nurses can inform them about SEPs and other community 
resources. The needs and experiences of the individual should be 
considered. For example, some people may be unable to read or 
understand English; others may not trust the verbiage of national 
prevention campaigns or of professionals whom they may view as 
sterile entities largely out of touch with their needs and struggles. [27]

Handing out brochures and pamphlets is not enough. Nurses must be 
able to communicate effectively and comfortably with clients who, for 
example, may be experiencing withdrawal symptoms or are not adhering 
to a treatment plan. Participating in a professional workshop or 
continuing education program on injection drug use may be useful. 
Family Drug Support, an Australian nonprofit organization, offers a 
fact sheet on communicating with drug users that may assist health 
care professionals as well as family members: 
www.fds.org.au/pdf/factsheet18 cwdu.pdf . Educating clients and 
providing referrals to SEPs and other resources can also indirectly 
foster informal communication and support networks among drug users.

Nurses who work with SEPs can help clients to access other services 
available at the exchange site. Some SEPs provide lists of emergency 
shelters, referrals, and food and clothing donations. In areas 
without SEPs, other harm-reduction programs such as HIV-prevention 
programs may provide nurses with similar opportunities. For example, 
in New Hampshire, where one of us (Fogg) resides, SEPs are currently 
unavailable. Her community-outreach work has included identifying 
pharmacies that will sell needles without a prescription and 
informing injection drug users where to purchase them.

Advocacy

In order to achieve policy change, nurses may need to educate the 
general public and public leaders regarding the efficacy of SEPs in 
decreasing the transmission of HIV and other infectious pathogens. 
Collaboration with other health care professionals and policymakers 
can add clout. In April 1989, Seattle became one of the first U.S. 
cities to legally adopt an SEP, largely because of the joint efforts 
of local health care workers and public health officials.[37]

Some people may be unable to read or understand English. Handing out 
brochures and pamphlets is not enough.

By becoming familiar with state laws and regulations, nurses can 
serve as resources for the public and work toward legislative change. 
According to a summary of state law concerning nonprescription access 
to sterile syringes ( www.temple.edu/lawschool/phrhcs/otc.htm ), 13 
states and the District of Columbia have affirmatively authorized 
SEPs, and 11 states have fully or partially deregulated syringe sales. [38]

Moreover, the retail sale of syringes to an injection drug user-even 
when the seller know[s] of the intended use-is clearly legal in 22 
states and has reasonable claim to legality in 22 others; only in 
eight states and the District of Columbia are such sales clearly illegal. [38]

In support of SEPs, the CDC recommends the collaborative review of 
the public health impact of repealing drug paraphernalia laws with 
regard to syringe possession, as well as community-based discussion 
of SEPs and their role in preventing HIV transmission. [39]

Both actions would benefit from nurses' involvement.

There has been a ban on federal funding for SEPs since 1988. [37]

Nurses should advocate the lifting of this ban. In conducting its war 
on drugs, the federal government has consistently spent more on law 
enforcement and interdiction than on treatment and prevention. Of the 
$12.1 billion spent in 2004, 55.5% went to law enforcement and 
interdiction efforts, while 44.5% went to treatment and prevention efforts. [6]

Public officials should be encouraged to redirect more antidrug money 
into improving and expanding drug treatment programs.

Program Development

Many states have limited rehabilitative services for injection drug 
users. For example, in 1998 Rich and colleagues surveyed patients 
enrolled in one of the two state-funded detoxification facilities in 
Rhode Island. [40]

Although both facilities offered medical and counseling services, the 
longest stay permitted was seven days, and the average length of stay 
was just four and a half days. Twenty-nine percent of patients left 
before completing treatment; only 53% of those who completed it left 
with an aftercare referral plan. [40]

New models of treatment and detoxification programs are needed. Bed 
shortages aren't the only reason more substance abusers aren't in 
treatment. Many drug users, realizing one week of treatment will be 
inadequate to help them overcome long-term addiction, don't want to 
enroll in seven-day programs. Some programs aren't equipped to accept 
people with certain disabilities. Nurses can collaborate with other 
health care professionals to develop and run treatment programs that 
can more realistically meet the needs of long-term drug users.

Nurses can support the development of comprehensive educational 
programs for nurses and other health professionals regarding drug 
abuse and related health concerns such as risk behaviors, the 
harm-reduction approach, and effective treatment and prevention 
modalities. Being able to interact effectively with injection drug 
users and helping them to set realistic, attainable goals are essential skills.

Eventually, more effective, less controversial approaches to the 
problem of HIV transmission associated with injection drug use may 
emerge. Until then, SEPs and other harm-reduction strategies remain 
the best approach to curbing the adverse health effects of injection drug use.

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