Research has shown that needle exchange programs can effectively lower the risk of HIV transmission among injection drug users. In 1988, Congress passed legislation prohibiting the use of federal funding for any activities associated with needle exchange. While states and localities were able to use their own revenue to fund such programs, in 1998, the United States Congress passed legislation prohibiting the District of Columbia from using its municipal revenue to fund these programs. Until Congress lifted the ban in 2007, these policies limited access to needle exchange in the city.
A Big Impact
“Following the policy change in Washington, DC, it was important to determine whether or not it was going to make a difference,” says Monica S. Ruiz, PhD, MPH. “Clinicians need to know the impact of this policy change on people’s ability to access services.”
For a study published in AIDS and Behavior, Dr. Ruiz and colleagues used existing surveillance data from the Department of Health in Washington, DC from September 1996 through December 2011 to project the impact of needle exchange access on the number of new HIV cases associated with injection drug use (IDU). “We used mathematical modeling to estimate the number of infections there would have been without the policy change in order to see if there was a significant difference between that and the number of cases that actually occurred,” Dr. Ruiz explains. “Interrupted time series analyses were used to control for other factors, such as HIV-focused educational campaigns.”
The investigators estimated that about 120 infections were averted as a result of the policy change. In the 2 years following the change, 176 IDU-associated HIV cases were reported in Washington, DC, compared with 296 cases that would have emerged had the policy remained in place, as predicted by the model used in the study. “That’s a 70% decrease in newly diagnosed IDU-associated HIV cases in just 2 years,” says Dr. Ruiz. “Whereas the number of new cases was relatively stable in the months prior to the policy change, we observed an obvious decrease with implementation of the policy [Table]. Our findings show that needle exchange programs help save lives.”
Dr. Ruiz and colleagues also concluded that the needle exchange program was cost effective. “The CDC estimates lifetime HIV care costs to be about $380,000 per person, a figure that doesn’t even include treatment of comorbidities,” adds Dr. Ruiz. “If we multiply this cost by the 120 prevented HIV infections, the total cost savings from the needle exchange program were $45.6 million. Most of these costs would likely be accounted for by tax-payer money because many people in the study got their healthcare coverage through the Washington, DC health exchange or Medicare.” Even after subtracting the operating costs for the first 2 years of supporting the needle exchange network that arose as a result of the policy change, the net savings were $44 million.
“Our findings have national significance, especially with the recently observed resurgence in IDU-associated HIV cases, including outbreaks in Indiana, Kentucky, and West Virginia,” says Dr. Ruiz. “These are different populations than the one we studied because they live in suburban and rural areas. That said, our findings suggest that needle exchange programs are necessary everywhere that people have HIV and/or use injection drugs. With these simple, cost-effective programs, the number of new IDU-associated HIV cases and healthcare spending dollars can be reduced.”
Dr. Ruiz adds that needle exchange programs can also reduce the transmission of hepatitis C and its associated costs. These programs serve as linkages to care for injection drug users, with or without HIV, who require medical and social support, social services, mental healthcare, and addiction treatment, among other services.
“Needle exchange programs are a link to the healthcare system that many patients may not feel comfortable accessing through other means because of the stigma associated with IDU and HIV,” says Dr. Ruiz. “The legislation that has passed since our study has essentially lifted the ban on federal funding for personnel costs and outreach services. Federal funding still can’t be use for purchasing syringes, but those costs are relatively low. Our finding that these programs work and are cost effective—in light of this recent national policy change—adds to the argument that needle exchange programs need to be supported as part of a nation-wide strategy to fight HIV infection, especially among drug-using populations.”
Start the Conversation
The study findings highlight the importance of starting a conversation about drug use with patients, regardless of whether they have HIV, according to Dr. Ruiz. “Many patients won’t bring it up because it’s a stigmatized, sensitive topic,” she says. “Clinicians should make sure their patients who may be using drugs know where to access prevention services like needle exchanges. When identified, they should be directed to counseling and addiction treatment. Overall, it’s crucial that clinicians ask about drug use without judgement. It’s imperative to get patients the help they need, not necessarily what we think they need.”
Ruiz M, O’Rourke A, Allen S. Impact evaluation of a policy intervention for HIV prevention in Washington, DC. AIDS Behav. 2016;20:22-28. Available at http://link.springer.com/article/10.1007/s10461-015-1143-6/fulltext.html.
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