Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy.

Abstract

Received for publication August 25, 2000, and accepted for publication August 22, 2001. Abbreviations: AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus. 1 Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. 2 Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY. 3 Chemical Dependency Research Institute, Beth Israel Medical Center, New York, NY. 4 Office of HIV/AIDS Policy, Office of the Secretary, US Department of Health and Human Services, Washington, DC. 5 Maryland State Senate, Annapolis, MD. 6 Public Citizen’s Health Research Group, Washington, DC. 7 National Association of People with AIDS, Washington, DC. Correspondence to Dr. David Vlahov, Center for Urban Epidemiologic Studies, The New York Academy of Medicine, 1216 Fifth Avenue, Room 553, New York, NY 10029 (e-mail: dvlahov@ nyam.org). Needle exchange programs provide a particularly compelling and informative example of the intersection between epidemiology and policy. The concept of needle exchange was developed and initially proposed on the basis of biologic plausibility: providing access to sterile needles and syringes (hereafter referred to as needles) should prevent parenteral transmission of human immunodeficiency virus (HIV) and other bloodborne pathogens, including hepatitis B and C. Nonetheless, various bans on the use of US federal funds for needle exchange program services have been in effect since 1988, limiting implementation and evaluation. The legislation included provisions that the ban on federal funding could be lifted only if the President of the United States or the US Surgeon General determined that needle exchange reduced the transmission of HIV infection and did not increase drug abuse. Indeed, the Secretary of the US Department of Health and Human Services did report in 1998 that the scientific evidence showed that needle exchange programs reduced HIV incidence and did not increase drug abuse. The Surgeon General reiterated this finding in 2000 (1). The administration decided, however, that federal funds would remain unavailable for needle exchange. During this policy stalemate at the federal level, the number of needle exchange programs has grown steadily, from none in 1987 to 160 programs operating in 39 states, the District of Columbia, and Puerto Rico in 1999 (2). In reviewing the history of needle exchange programs, a group was assembled to include perspectives from researchers, activists, and government to reflect on the role of epidemiologists in the development of needle exchange programs.