Editing Needle and syringe programmes (section)

== International experience ==
Programs providing sterile needles and syringes currently operate in 87 countries around the world.<ref>{{Cite web|title=Global State of Harm Reduction - 2021 Update|url=https://www.hri.global/global-state-of-harm-reduction-2021|access-date=2021-12-30|website=Harm Reduction International}}</ref> IA comprehensive 2004 study by the [[World Health Organization]] (WHO) found a "compelling case that NSPs substantially and cost effectively reduce the spread of HIV among IDUs and do so without evidence of exacerbating injecting drug use at either the individual or societal level."<ref name="Wodak20042">{{cite web|title=Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users|url=https://www.who.int/hiv/pub/prev_care/effectivenesssterileneedle.pdf|author1=Wodak, A.|author2=Cooney, A.|year=2004|publisher=World Health Organization|access-date=18 July 2013}}</ref> WHO's findings have also been supported by the [[American Medical Association]] (AMA), which in 2000 adopted a position strongly supporting NSPs when combined with addiction counseling.<ref>{{Cite journal|last1=Yoast|first1=R.|last2=Williams|first2=M. A.|last3=Deitchman|first3=S. D.|last4=Champion|first4=H. C.|year=2001|title=Report of the Council on Scientific Affairs|journal=Journal of Addictive Diseases|volume=20|issue=2|pages=15–40|doi=10.1300/J069v20n02_03|pmid=11318395|s2cid=23406146}}</ref><ref>{{Cite journal|last1=Stancliff|first1=S.|last2=Agins|first2=B.|last3=Rich|first3=J. D.|last4=Burris|first4=S.|year=2003|title=Syringe access for the prevention of blood borne infections among injection drug users|journal=BMC Public Health|volume=3|pages=37|doi=10.1186/1471-2458-3-37|pmc=317318|pmid=14633286 |doi-access=free}}</ref>

=== Australia ===
The Melbourne, Australia, inner-city suburbs of Richmond, and [[Abbotsford, New South Wales|Abbotsford]] are locations in which the use and dealing of heroin has been concentrated. The Burnet Institute research organisation completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. Between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the surrounding City of Yarra, an average of 1,550 syringes per month was collected from public syringe disposal bins in 2012. Paul Dietze stated, "We have tried different measures and the problem persists, so it's time to change our approach".<ref>{{cite news|title=Syringe machine push for addicts in Melbourne's heroin hot spots|url=http://www.theaustralian.com.au/news/syringe-machine-push-for-addicts-in-melbournes-heroin-hot-spots/story-e6frg6n6-1226646482548|access-date=20 May 2013|newspaper=The Australian|date=20 May 2013|author=Lucie Van Den Berg}}</ref>

On 28 May 2013, the Burnet Institute stated that it recommended 24-hour access to sterile injecting equipment in the Melbourne suburb of [[Footscray, Victoria|Footscray]] after the area's drug culture continued to grow after more than ten years of intense law enforcement efforts. The institute's research concluded that public injecting behaviour is frequent in the area and injecting paraphernalia has been found in carparks, parks, footpaths, and drives. Furthermore, people who inject drugs have broken into syringe disposal bins to reuse discarded equipment.<ref>{{cite news|title=Drug experts propose needle vending machines for Footscray|url=http://www.heraldsun.com.au/leader/west/drug-experts-propose-needle-vending-machines-for-footscray/comments-fngnvmj7-1226651497633|access-date=29 May 2013|newspaper=Herald Sun Maribyrnong Leader|date=28 May 2013|author=Bridie Byrne}}</ref>

A study commissioned by the Australian Government revealed that for every [[Australian dollar|A$]]1 invested in NSPs in Australia, $4 was saved in direct healthcare costs,<ref name="ROI">{{cite web |date=2009 |title=Evaluating the cost-effectiveness of needle and syringe programs in Australia |url=https://www.acon.org.au/wp-content/uploads/2015/04/Evaluating-the-cost-effectiveness-of-NSP-in-Australia-2009.pdf |url-status=live |archive-url=https://web.archive.org/web/20230323160725/https://www.acon.org.au/wp-content/uploads/2015/04/Evaluating-the-cost-effectiveness-of-NSP-in-Australia-2009.pdf |archive-date=23 March 2023 |access-date=4 April 2023 |website=ancon.org.au |publisher=Australian Department of Health and Aging}}</ref> and if productivity and economic benefits are included, the programs returned a staggering $27 for every $1 invested. The study notes that over a longer time horizon than that considered (10 years) the cost-benefit ratio grows even further. In terms of infections averted and lives saved, the study finds that, between 2000 and 2009, 32,000 HIV infections and 96,667 hepatitis C infections were averted, and approximately 140,000 [[disability-adjusted life year]]s were gained.<ref name="ROI"/>

=== United Kingdom ===
{{expand section|date=April 2014}}

From the 1980s, [[Maggie Telfer]] from the Bristol Drugs Project advocated for needle exchanges to be established in the United Kingdom.<ref>{{cite news |last1=Ayres |first1=Rachel |title=Maggie Telfer obituary |url=https://www.theguardian.com/politics/2023/apr/21/maggie-telfer-obituary |website=[[The Guardian]] |date=21 April 2023 |access-date=23 April 2023}}</ref> The British public body, the [[National Institute for Health and Care Excellence]] (NICE), introduced a recommendation in April 2014 due to an increase in the number of young people who inject [[steroid]]s at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services were not advised for people under 18, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programmes. In the updated guidance, NICE recommended the provision of specialist services for "rapidly increasing numbers of steroid users", and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.<ref>{{cite news|title=NICE: Needle exchanges should supply safe equipment to under-18 steroid users|url=https://www.independent.co.uk/life-style/health-and-families/health-news/nice-needle-exchanges-should-supply-safe-equipment-to-under18-steroid-users-9247087.html |archive-url=https://ghostarchive.org/archive/20220618/https://www.independent.co.uk/life-style/health-and-families/health-news/nice-needle-exchanges-should-supply-safe-equipment-to-under18-steroid-users-9247087.html |archive-date=2022-06-18 |url-access=subscription |url-status=live|access-date=9 April 2014|newspaper=The Independent|date=9 April 2014|author=Charlie Cooper}}</ref>

=== United States ===
The first program in the United States to be operated at public expenses was established in [[Tacoma, Washington]] in November 1988.<ref>{{Cite book |last1=DiClemente |first1=Ralph J. |url=https://books.google.com/books?id=WzqzwiHUVtIC&pg=PA216 |title=Preventing AIDS: Theories and Methods of Behavioral Interventions |last2=Peterson |first2=John L. |date=1994-03-31 |publisher=Springer Science & Business Media |isbn=978-0-306-44606-1 |language=en}}</ref><ref>{{Cite journal |last1=Sherman |first1=Susan G. |last2=Purchase |first2=Dave |date=2001-04-01 |title=Point Defiance: a case study of the United States' first public needle exchange in Tacoma, Washington |url=https://linkinghub.elsevier.com/retrieve/pii/S0955395900000748 |journal=International Journal of Drug Policy |volume=12 |issue=1 |pages=45–57 |doi=10.1016/S0955-3959(00)00074-8 |pmid=11275503 |issn=0955-3959|url-access=subscription }}</ref> The [[Centers for Disease Control and Prevention]] and the [[National Institutes of Health]] confirm that needle exchange is an effective strategy for the prevention of HIV.<ref name="United States 2005" /><ref name="United States 2002">{{cite journal |pmid=12407572 |journal=Hepatology |date=November 2002 |volume=36|issue=5 Suppl 1|pages=S3–20 |title=National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002--June 10–12, 2002 |doi=10.1002/hep.1840360703 |last1=National Institutes Of |first1=Health|doi-access=free}}</ref> The NIH estimated in 2002 that in the United States, 15–20% of injection drug users have HIV and at least 70% have hepatitis C.<ref name="United States 2002" /> The [[Centers for Disease Control]] (CDC) reports one-fifth of all new HIV infections and the vast majority of hepatitis C infections are the result of injection drug use.<ref name="United States 2005">{{cite journal |title=Update:Syringe Exchange Programs |date=15 July 2005 |volume=54 |issue=27 |pages=673–6 |journal=MMWR Morb Mortal Wkly Rep |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5427a1.htm |pmid=16015218 |author1=Centers for Disease Control and Prevention (CDC)}}</ref> [[United States Department of Health and Human Services]] reports 7%, or 2,400 cases of HIV infections in 2018 were among drug users.<ref>{{Cite web|date=2020-06-30|title=U.S. Statistics|url=https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics|access-date=2020-10-10|website=HIV.gov}}</ref>

[[Portland, Oregon]], was the first city in nation to expend public funds on a NSP which opened in 1989.<ref>{{Cite news|url=https://www.bizjournals.com/portland/news/2018/03/15/a-legal-site-in-portland-to-inject-heroin-elected.html|title=A legal site in Portland to inject heroin? Elected officials, advocates explore the idea|last=Hayes|first=Elizabeth|date=May 15, 2018|work=Portland Business Journal|access-date=April 28, 2019}}</ref> It is also one of the longest running programme in the country.<ref name=":0">{{Cite news|url=https://pamplinmedia.com/pt/9-news/354711-234196-spike-in-discarded-syringes-littering-portland|title=Spike in discarded syringes littering Portland|last=Hewitt|first=Lindsey|date=April 18, 2017|work=Portland Tribune|access-date=April 27, 2019|quote=Multnomah County will give up to 10 syringes to an individual who has none to exchange.}}</ref> Despite the word "exchange" in the programme name, the Portland needle exchange operated by [[Multnomah County, Oregon|Multnomah County]] hands out syringes to addicts who do not present any to exchange.<ref name=":0" /> The exchange programme reports 70% of their users are transients who experience "homelessness or unstable housing"<ref>{{Cite web|url=https://multco.us/hiv-and-std-services/questions-about-syringe-exchange|title=Questions about Syringe Exchange|date=2018-01-30|website=Multnomah County|access-date=2019-04-28}}</ref> It was reported that during the fiscal year 2015–2016, the county dispensed 2,478,362 syringes and received 2,394,460, a shortage of 83,902 needles.<ref name=":0" /> In 2016, it was reported that the [[Cleveland]] needle exchange program sees "mostly white suburban kids ages 18 to 25".<ref>{{Cite web|author=<!--Staff writer(s); no by-line.-->|title=Needle exchange program sees mostly white suburban kids ages 18 to 25|url=https://www.cleveland19.com/story/32057159/needle-exchange-program-aims-to-stop-spread-of-disease|access-date=2020-09-29|website=Cleveland 19|date=25 May 2016 }}</ref>

==== San Francisco ====
Since the full sanction of syringe exchange programs (SEP) by then-Mayor [[Frank Jordan]] in 1993, the San Francisco Department of Public Health has been responsible for the management of syringe access and the proposed disposal of these devices in the city. This sanction, which was originally executed as a state of emergency to address the HIV epidemic, allowed SEPs to provide sterile syringes, take back used devices, and operate as a service for health education to support individuals struggling with [[substance use disorder]]s. Since then, it was approximated that from July 1, 2017, to December 31, 2017, only 1,672,000 out of the 3,030,000 distributed needles (60%) were returned to the designated sites.<ref name="sfw">{{Cite news|url=http://www.sfweekly.com/news/s-f-pins-down-its-needle-problem/|title=S.F. Pins Down Its Needle Problem - April 25, 2018 - SF Weekly|date=2018-04-25|work=SF Weekly|access-date=2018-11-02}}</ref> In April 2018, acting Mayor [[Mark Farrell (politician)|Mark Farrell]] allocated $750,000 towards the removal of abandoned needles littering the streets of San Francisco.<ref name="sfw" />

==== General characteristics ====
As of 2011, at least 221 programmes operated in the US.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16">{{cite journal |vauthors=Green TC, Martin E, Bowman S, Mann M, Beletsky L |title=Life After the Ban: An Assessment of US Syringe Exchange Programs' Attitudes About and Early Experiences with Federal Funding|journal=Am. J. Public Health |volume=102 |issue=5 |pages=e9–e16 |year=2012 |doi=10.2105/AJPH.2011.300595|pmid=22420810|pmc=3484785}}</ref> Most (91%) were legally authorized to operate; 38.2% were managed by their local health authorities.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/><ref name="Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. 2009 1441–6">{{cite journal |vauthors=Des Jarlais DC, McKnight C, Goldblatt C, Purchase D |title=Doing harm reduction better: syringe exchange in the United States. |journal=Addiction |url=http://www.nasen.org/site_media/files/nasec2010/ddj_2009DoingHarmReductionBetterSEPintheUS.pdf |access-date=2012-07-05 |volume=104 |issue=9 |pages=1441–6 |year=2009 |doi=10.1111/j.1360-0443.2008.02465.x |pmid=19215605 |archive-url=https://web.archive.org/web/20110929103921/http://www.nasen.org/site_media/files/nasec2010/ddj_2009DoingHarmReductionBetterSEPintheUS.pdf |archive-date=2011-09-29 |url-status=dead}}</ref> The CDC reported in 1993 that the most significant expenses for the NSPs is personnel cost, which reports it represents 66% of the budget.<ref>{{Cite web|title=The Public Health Impact of Needle Exchange Programs in the United States and Abroad Summary, Conclusions and Recommendations|url=https://stacks.cdc.gov/view/cdc/11203/cdc_11203_DS1.pdf?|date=1993|website=CDC}}</ref>

More than 36 million syringes were distributed annually, mostly through large urban programmes operating a stationary site.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/> More generally, US NEPs distribute syringes through a variety of methods including mobile vans, delivery services and backpack/pedestrian routes<ref name="Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. 2009 1441–6"/> that include secondary (peer-to-peer) exchange.

==== Funding ====

In the United States, a ban on federal funding for needle exchange programs began in 1988, when republican North Carolina Senator [[Jesse Helms]] led Congress to enact a prohibition on the use of federal funds to encourage drug abuse.<ref name=":5">{{Cite journal|last=Weinmeyer|first=Richard|date=2016-03-01|title=Needle Exchange Programs' Status in US Politics|url=https://journalofethics.ama-assn.org/article/needle-exchange-programs-status-us-politics/2016-03|journal=AMA Journal of Ethics|volume=18|issue=3|pages=252–257|doi=10.1001/journalofethics.2016.18.3.hlaw1-1603|pmid=27002996 |issn=2376-6980|doi-access=free}}</ref> The ban was briefly lifted in 2009, reinstated in 2010, and partially lifted again in 2015. Currently, federal funds can still not be used for the purchase of needles and syringes or other injecting paraphernalia by needle exchange programs, though can be used for training and other program support in the case of a declared public health emergency.<ref name="Davis C, Beletsky L 2009">{{Cite journal|last1=Davis|first1=C. S.|last2=Beletsky|first2=L.|year=2009|title=Bundling occupational safety with harm reduction information as a feasible method for improving police receptiveness to syringe access programs: Evidence from three U.S. Cities|journal=Harm Reduction Journal|volume=6|pages=16|doi=10.1186/1477-7517-6-16|pmc=2716314|pmid=19602236 |doi-access=free}}</ref><ref name=":5" /><ref>{{Cite web|date=2019-07-08|title=Federal Funding for Syringe Services Programs|url=https://www.cdc.gov/ssp/ssp-funding.html|access-date=2020-08-23|website=cdc.gov}}</ref> In the time between 2010 and 2011 when no ban was in place, at least three programmes were able to obtain federal funds and two-thirds reported planning to pursue such funding.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/> A 1997 study estimated that while the funding ban was in effect, it "may have led to HIV infection among thousands of IDUs, their sexual partners, and their children."<ref>{{cite journal|last1=Lurie|first1=P|last2=Drucker|first2=E|title=An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA.|journal=The Lancet |date=1 March 1997|volume=349|issue=9052|pages=604–8|pmid=9057732|doi=10.1016/S0140-6736(96)05439-6|s2cid=37080993}}</ref> US NEPs continue to be funded through a mixture of state and local government funds, supplemented by private donations.<ref name="Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. 2009 1441–6"/> The funding ban was effectively lifted for every aspect of the exchanges except the needles themselves in the omnibus spending bill passed in December 2015 and signed by President Obama. This change was first suggested by Kentucky Republicans [[Hal Rogers]] and [[Mitch McConnell]], according to their spokespeople.<ref>{{cite web | url=https://www.usatoday.com/story/news/nation/2016/01/07/funding-ban-needle-exchanges-effectively-lifted/78420894/ | title=Funding ban on needle exchanges effectively lifted | work=USA Today | date=7 January 2016 | access-date=25 January 2016 | author=Ungar, Laura}}</ref>

==== Legal aspects ====
Many states criminalized needle possession without a prescription, arresting people as they left underground needle exchange efforts.<ref>{{cite journal |vauthors=Case P, Meehan T, Jones TS |title=Arrests and incarceration of injection drug users for syringe possession in Massachusetts: implications for HIV prevention |journal=J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. |volume=18 |pages=S71–5 |year=1998 |issue=Suppl 1 |pmid=9663627 |doi=10.1097/00042560-199802001-00013|doi-access=free}}</ref> In some jurisdictions, such as New York, needle exchange activists challenged the laws in court, with judges ruling that their actions were justified by a "necessity defense" which permits breaking of a law to prevent an imminent harm.<ref>{{Cite news|last=Sullivan|first=Ronald|date=1991-06-26|title=Needle-Exchangers Had Right to Break Law, Judge Rules|work=The New York Times|url=https://www.nytimes.com/1991/06/26/nyregion/needle-exchangers-had-right-to-break-law-judge-rules.html|access-date=2021-12-30|issn=0362-4331}}</ref> In other jurisdictions where syringe possession without a prescription remained illegal, physician-based prescription programmes have shown promise.<ref>{{cite journal |author1=GE Macalino |author2=D Dhawan Sachdev |author3=JD Rich |author4=C Becker |author5=LJ Tan |author6=L Beletsky |author7=S Burris. |title=A national physician survey on prescribing syringes as an HIV prevention measure. |journal=Substance Abuse Treatment, Prevention, and Policy|volume=4 |issue=1 |year=2009 |doi=10.1186/1747-597X-4-13 |pages=13 |pmid=19505336 |pmc=2700789 |doi-access=free}}</ref> Epidemiological research demonstrating that syringe access programmes are both effective and cost-effective helped to change state and local NEP-operation laws, as well as the status of syringe possession more broadly.<ref name="S Burris, D Finucane, H Gallagher, and J Grace 1996 1161–6">{{cite journal |author1=S Burris |author2=D Finucane |author3=H Gallagher |author4=J Grace |title=The legal strategies used in operating syringe exchange programs in the United States. |journal=Am. J. Public Health |volume=86 |year=1996 |pmc=1380633 |pmid=8712281 |issue=8 |pages=1161–6 |doi=10.2105/ajph.86.8_pt_1.1161}}</ref> For example, between 1989 and 1992, three exchanges in [[New York City]] tagged syringes to help demonstrate rates of return prior to the legalization of the approach.<ref>{{Cite book|last1=Programs|first1=National Research Council (US) and Institute of Medicine (US) Panel on Needle Exchange and Bleach Distribution|url=https://www.ncbi.nlm.nih.gov/books/NBK232350/|title=Needle Exchange and Bleach Distribution Programs in the United States|last2=Normand|first2=Jacques|last3=Vlahov|first3=David|last4=Moses|first4=Lincoln E.|date=1995|publisher=National Academies Press (US)}}</ref>

By 2012, legal syringe exchange programmes existed in at least 35 states.<ref name="Green TC, Martin E, Bowman S, Mann M, Beletsky, L 2012 e9-e16"/> In some settings, syringe possession and purchase is decriminalized, while in others, authorized NEP clients are exempt from certain drug paraphernalia laws.<ref name="Beletsky L, Grau LE, White E, Bowman S, Heimer R. 2011">{{cite journal |vauthors=Beletsky L, Grau LE, White E, Bowman S, Heimer R |title=The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs. |journal=Addiction |volume=106 |issue=2 |year=2011 |doi=10.1111/j.1360-0443.2010.03149.x |pmid=21054615 |pmc=3088513 |pages=357–365}}</ref> However, despite the legal changes, gaps between the formal law and environment mean that many programmes continue to face law enforcement interference<ref name="Beletsky L, Burris S, Macalino GE. 2005 267–274">{{cite journal |vauthors=Beletsky L, Burris S, Macalino GE |title=Attitudes of Police Officers Towards Syringe Access, Occupational Needle-Sticks, and Drug Use: A Qualitative Study of One City Police Department in the United States. |journal=International Journal of Drug Policy |ssrn=872756|volume=16 |issue=4 |pages=267–274 |year=2005 |doi=10.1016/j.drugpo.2005.01.009|s2cid=57946984}}</ref> and covert programmes continue to exist within the U.S.<ref>{{cite journal |author=Lune, H |date=December 2002 |title=Weathering the Storm: Non-profit Organization Survival Strategies in a Hostile Climate |journal=Nonprofit and Voluntary Sector Quarterly |volume=31 |issue=4 |pages=463–83 |doi=10.1177/0899764002238096|s2cid=145472945}}</ref>

Colorado allows covert syringe exchange programmes to operate. Current Colorado laws leave room for interpretation over the requirement of a prescription to purchase syringes. Based on such laws, the majority of pharmacies do not sell syringes without a prescription and police arrest people who possess syringes without a prescription.<ref>[http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102187404.html]{{dead link|date=March 2012}}</ref> Boulder County health department reports between January 2012 and March 2012, the group received over 45,000 dirty needles and distributed around 45,200 sterile syringes.<ref>{{cite web |url=http://www.bouldercounty.org/health/hpe/STI/exchange.htm |archive-url=https://web.archive.org/web/20080606023305/http://www.bouldercounty.org/health/hpe/STI/exchange.htm |url-status=dead |archive-date=6 June 2008 |title=Boulder County Public Health |publisher=Bouldercounty.org |access-date=14 March 2012}}</ref>

As of 2017, NSPs are illegal in 15 states.<ref name=":4">{{Cite web|last=Lopez|first=German|date=2018-06-22|title=Needle exchanges have been proved to work against opioid addiction. They're banned in 15 states.|url=https://www.vox.com/science-and-health/2018/6/22/17493030/needle-exchanges-ban-state-map|access-date=2020-10-10|website=Vox}}</ref> NSPs are prohibited by local regulations in cities in [[Orange County, California]],<ref>{{Cite web|title=Court order all but bans mobile needle exchange program in Costa Mesa, other O.C. cities|url=https://www.latimes.com/socal/daily-pilot/news/story/2019-10-25/court-order-all-but-bans-mobile-needle-exchange-program-in-costa-mesa-other-o-c-cities|date=2019-10-26|website=Daily Pilot|access-date=2020-05-24}}</ref> even though it is not disallowed by state law in California.<ref name=":4" />