Testimony of Peter Lurie, M.D., M.P.H.
Deputy Director, Public Citizen’s Health Research Group
before the New Jersey Senate Health, Human Services and Senior Citizens Committee
Thank you for the opportunity to discuss with the Committee the scientific issues that underpin S494, which would allow municipalities to establish needle exchange programs using private or local funding, and S823, which would permit limited pharmacy sales of syringes without a prescription. As the Principal Investigator of a 700-page report to the Centers for Disease Control and Prevention and the author of over a dozen peer-reviewed articles on sterile syringe access in the U.S. and abroad, let me assure you that these bills are in the very mainstream of public health practice. Every single federally funded comprehensive review of needle exchanges has endorsed the programs as effective: the General Accounting Office; the Office of Technology Assessment; the Centers for Disease Control and Prevention; the University of California, San Francisco (our study); the National Institutes of Health; and the National Academy of Sciences (twice). The programs have been endorsed by such mainstream organizations as the U.S. Department of Health and Human Services; the American Medical Association; the American Bar Association; the American Public Health Association; the American Academy of Pediatrics; the World Health Organization; and the U.S. Conference of Mayors. Indeed, at present it is New Jersey that is the exception: in every other state, laws either have long permitted the operation of needle exchange programs or actions have been taken legislatively to permit the programs.
Proving that needle exchange programs reduce the number of new HIV infections is no easy task. Impediments include the need for very large and lengthy studies, ethical and practical obstacles to randomization and the illegal nature of drug use itself, making it difficult to locate and follow injection drug users. All the reviews cited above have thus concluded that needle exchanges are effective even in the absence of perfect evidence. For example, in our 1993 study, we cited several indirect lines of evidence supporting the effectiveness of the programs in reducing new HIV infections:
- Needle exchange is based on a sound and accepted public health principle: for diseases spread by objects (as opposed to people), one seeks to remove the object (the potentially contaminated syringe) from circulation. This is analogous to mosquito eradication to prevent West Nile Virus infection.
- There is clear evidence that needle exchange programs are associated with reductions in drug-related risk behavior, in some cases in comparison with control groups, which should translate into decreased HIV infection rates.
- One study showed a reduction in hepatitis B and C infections, which are spread similarly to HIV.
- Multiple mathematical models using different approaches consistently estimate substantial decreases in HIV transmission rates.
For these reasons, we felt comfortable concluding that it was “likely” that needle exchange programs reduce the rate of new HIV infections. Since our study was published in 1993, further evidence has accumulated:
- Needle exchange programs have proved successful in referring injection drug users to drug treatment, potentially ending any drug-related risk for HIV.
- Several studies conducted at a city-wide level (so-called ecological studies, distinct from studies that evaluate actual individuals) have associated needle exchanges with stable or even declining prevalences of HIV infection.
I understand that we all would prefer a “smoking gun” study that proved beyond all doubt that needle exchanges are effective. But that has never been the standard for endorsing HIV prevention interventions. There is not a single behavioral HIV intervention that has been proved effective in reducing the number of new HIV infections in a randomized, controlled trial: not condoms, not bleach for disinfecting syringes, not blood screening, not drug treatment, not counseling and testing, not posters, not outreach, etc., etc. Indeed the only HIV prevention interventions that have been proved effective in that manner are those in which the intervention is literally in the hands of the researcher so he or she can decide who will get the intervention and who will not: antiretroviral drugs (to prevent mother-to-infant HIV transmission), antibiotics (to treat sexually transmitted infections and thus reduce HIV infection), and surgery (circumcision). Indeed, it is the inherent nature of drug-related HIV risk – the circulation and sharing of contaminated syringes – that is beyond the researcher’s control and thus makes randomization infeasible. For all other interventions, we have relied either upon common sense (if we eliminate HIV-infected units of blood, we can eliminate transfusion-related HIV), laboratory evidence (if HIV can’t get out of the condom, it can’t infect someone) or studies showing impacts upon HIV-risk behaviors (e.g., counseling and testing) to justify our support for these programs. For needle exchange programs, we have done all three (and much more). A program should not rise or fall on a single study. When a pattern of evidence demonstrating needle exchange program effectiveness emerges from a variety of very differently designed studies, we can feel confident in concluding that the programs are indeed effective.
If we accept, as most HIV prevention experts do, that needle exchanges can reduce the number of HIV infections (in an article in The Lancet, we estimated that by the year 2000, up to 20,000 U.S. HIV infections among injection drug users, their sex partners and their children could have been prevented by needle exchange programs), it still remains theoretically possible that some adverse consequence of the programs could outweigh that benefit. Yet, there is no evidence that this is the case. The most obvious concern is that needle exchanges would increase the amount of drug use. But our study, using multiple lines of investigation, yielded no evidence that needle exchange programs increase the amount of injection by program clients (most evidence points to no change or a decrease), recruit young people into drug use or change community levels of drug use. Subsequent investigations (and all the reviews listed above) have corroborated these conclusions and have also found no association between the programs and increased crime rates in their vicinities.
There is no such thing as a panacea in HIV prevention. But experience suggests two major lessons. First, we must tailor our efforts to reach all sectors of the at-risk community, not insist upon a one-size-fits-all approach. This means reaching out to drug users who cannot or will not stop injecting drugs in the near future. It also means having an array of outlets for such persons to obtain syringes; both needle exchanges and pharmacy availability are critical, because they have been shown repeatedly to reach different populations of injection drug users. It is noteworthy that, from the state of New Jersey’s perspective, there are literally no costs for the programs envisioned by these bills, but the state is likely to reap the benefits in decreases in costs to treat patients infected with HIV. Second, HIV prevention programs have the most success when they are embedded in a comprehensive approach to HIV prevention. By integrating syringe availability programs with drug treatment and prevention programs, we are most likely to reduce the terrible burden of HIV infection.