Testimony Regarding Needle Exchange Programs in Texas

May 14, 2007 before the Texas House of Representatives Committee on Public Health
April 12, 2007 before the Texas Senate Health and Human Services Committee

Peter Lurie, M.D., M.P.H.
Deputy Director
Public Citizen's Health Research Group

Thank you for the opportunity to discuss with the Committee the scientific issues that underpin SB 308, which would allow municipalities to establish needle exchange programs using private or local funding.  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 this bill is in the very mainstream of public health practice.  This summer, both Delaware and New Jersey passed laws allowing needle exchange programs, which leaves Texas increasingly isolated in its reluctance to provide access to sterile syringes for high-risk populations.

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.  However, every single federally funded comprehensive review of needle exchanges has endorsed the programs as being effective, even in the absence of perfect evidence:  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; the U.S. Conference of Mayors; and the International Red Cross and Red Crescent Society.

In our 1993 study and in subsequent articles, we cited several 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.
  • 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.

In an article published in The Lancet in March 1997, 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 had they begun operating as early as 1987, when Australia began its programs.  For this hearing, I have adapted that method to estimate the number of HIV infections that could be prevented by needle exchange programs in Texas (see attached figure).  Using data obtained from the Texas Department of State Health Services and very conservative assumptions, I calculated that, if the programs begin next year and grow at the rate they did in Australia, between 199 and 438 HIV infections could be prevented in just Bexar, Dallas, El Paso, Harris, Tarrant and Travis counties by 2020 (see attached figure).  It is estimated that it costs $385,200 to treat each HIV infection over a lifetime, so as much as $169 million in medical treatment costs can be averted, to say nothing of the human suffering each HIV infection represents.  Since annual needle exchange program budgets in the U.S. are typically well below $1 million, even in large cities, these programs are likely to save far more than they would cost.  From the state of Texas’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. 

I understand some remain concerned that needle exchange programs may create unintended consequences.  Yet, in the 30 years that the programs have been operating and examined, there is no evidence that this has been 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 crime rates in their vicinities. More recently, researchers have described the strong connections between needle exchange programs and drug addiction treatment providers.

Legislators can also rest assured that this bill will not lead to an increase in the overall discarding of syringes.  Because the bill permits the provision of only as many syringes as are returned by drug users, it is literally mathematically impossible to increase syringe discarding.  Indeed, the bill can be thought of as a “bottle bill” for used syringes, providing drug users with a strong incentive to gather up previously discarded syringes in order to obtain new ones.

There is no such thing as a panacea in HIV prevention.  But a basic mantra in public health is that we must tailor our efforts to reach all sectors of the at-risk community, not insist upon a one-size-fits-all approach.  While we know abstinence from injection drug use is the best way to avoid injection drug use-related HIV, those who are not abstinent are at risk of contracting HIV and other blood-borne infections such as hepatitis B and C, and are at risk of spreading them to others, including children and non-injectors.  

For preventing disease due to drug injection, one therefore has to tailor one’s approach to everyone on the spectrum from complete abstinence to frequent injection.  Those who are abstinent need to be reinforced in that behavior, but those who do inject are also entitled to comprehensive public health services.  For such people, the international standard is referral to drug treatment, when appropriate and possible, and the provision of sterile syringes for those who continue to inject.  In addition, drug injectors should have access to HIV counseling and testing, social services and condoms to prevent sexual transmission of HIV.  Many needle exchange programs offer all of these services, and have been shown repeatedly to attract the most at-risk populations of injection drug users. 

Needle exchange programs do not represent a surrender in the war on drugs.  They represent a recognition that, whether we like it or not, some people do continue to inject, and that such people are entitled to public health services like everyone else in this country.  Reductions in the prevalence of HIV among drug users benefit the whole society, as drug users are then less likely to spread the infection to their sex partners or children.  By integrating syringe availability programs with drug treatment and prevention programs, we are most likely to reduce the terrible burden of HIV infection for all residents of Texas.

Figure: HIV Infections Preventable by Needle Exchange Programs in Six Texas Counties, 2007-2015

HIV Infections Preventable by Needle Exchange Programs in Six Texas Counties, 2007-2015