As of 2019, over 1.2 million Americans live with HIV . An estimated 7% of these patients used injection drugs such as heroin, a population consisting disproportionately of racial minorities. For instance, Black people made up 30% of injection drug users diagnosed with HIV in 2018, despite representing only around 13% of the population. The primary mechanism of HIV transmission in this case is the sharing of needles, which brings infected blood into contact with unaffected users . Another disease commonly spread through drug injection is hepatitis C, a virus that targets the liver and also travels through needle sharing [2,3]. In 2018, West Virginia researchers found that up to 40% of cases of hepatitis C may have resulted from drug injection . For over half of patients, an initially unthreatening infection develops into chronic disease, increasing the likelihood of cirrhosis and cancer .
In order to reduce the spread of these diseases, over 200 needle exchanges have opened across 33 states . These programs provide clean needles to drug users among other services such as education and rehabilitation programs, disease testing and even the distribution of condoms to prevent the spread of HIV through intercourse . Approximately 13% of people with HIV are unaware that they have contracted it; because those who inject drugs are estimated to do so around 1,000 times each year, by the time they develop symptoms, they likely have already shared needles with acquaintances [6,8]. Indeed, a study of Edmonton, Canada, found that 38% of needles used to inject drugs were shared between users.
The first needle exchanges opened in Europe in the 1980s, and the idea quickly spread to the
United States, despite federal hesitancy, among grassroots activists . The first official location, the Dave Purchase Project, opened in Tacoma in 1988 [4,11]. At around the same time, Congress passed laws withholding federal funding from these programs, a precedent that remained largely unchallenged until 2016. Even today, clinics cannot use federal money to purchase “injection equipment,” including needles, although they can apply it to other services, which most clinics certainly do. Though Dave Purchase died in 2013, his “project” runs to this day, offering contraceptives, naloxone, counseling and referrals to addiction specialists along with the needle exchange that initially distinguished them [5,12].
Despite political opposition, needle exchanges seem to work. As early as the 1990s and first part of the 2000s, the federal government commissioned seven studies, all of which published results favoring needle exchanges. These findings were later corroborated by investigations conducted on behalf of the United Nations and World Health Organization . Needle exchanges seem to universally reduce rates of hepatitis C and HIV transmission. The Tacoma program is thought to have reduced the risk of hepatitis transmission by as much as 60% since its opening. In addition, across the nation, urban needle exchanges have cut the spread of HIV by 5.8%, while cities without exchanges saw a 5.9% increase in cases per year . In Australia, needle exchanges have curbed the spread of HIV by 74% over a period of 10 years. Furthermore, these systems save money . The cost of HIV treatment can reach $400,000 over a single patient’s lifetime, while exchanges cost only $23 to $71 to run per user annually [1,10]. The prevention of a single case of HIV can save over $7,000 in a single year. A study of the Philadelphia needle exchanges found that they saved $2.4 billion over 10 years in preventing 10,592 cases of HIV. The aforementioned Australia project estimated savings of $5.50 for every dollar spent running the exchanges .
The most public effects of needle exchanges, perhaps, manifested in the wake of a severe outbreak of HIV in Scott County, Indiana in 2015 that was directly tied to drug injection. The virus infected 235 people, forcing then-governor Mike Pence to allocate state funding to a needle exchange in the area, despite personal reservations. However, the spread of the disease slowed markedly after the implementation of the program, with only one new case reported in the last year of the epidemic. A quarter of the patients at the nearby THRIVE drug rehabilitation center in 2020 were referred by the needle exchange clinic, demonstrating its ability to reach drug users and fight addiction in a way that general awareness campaigns do not seem able to do. Nonetheless, county commissioners voted two to one to close the program in 2021, with President Mike Jones asserting that it only promoted drug abuse . Nonetheless, according to “The St. Louis American,” no evidence has actually been published linking needle exchanges and elevated rates of either drug addiction or crime . Drug addiction actually seems to decrease, since more users end up in rehabilitation programs .
This year saw similar pushback in West Virginia, where representatives passed Senate Bill 334 mandating exchanges to ask for used needles and state IDs in exchange for clean ones. The law, signed on April 15, also requires exchanges to emphasize other means of combating drug use and associated infection in their public outreach [9,14]. Noncompliant organizations risked a $10,000 fine, a significant sum in a sector that relies heavily on local and private funding [8,9]. In response to a challenge by the state branch of the American Civil Liberties Union, District Judge Robert C. Chambers asserted that the law was constitutional, though its language was vague enough that, the plaintiffs argued, it could discourage clinics from continuing for fear of violating unclear stipulations . While certain programs closed in response to the decision, some counties, such as Kanawha, have voted to keep their needle exchanges open . Because these organizations are so reliant on local support, they likely will be able to continue into the near future, barring outright prohibition at the state or federal level. Perhaps, as their long-term benefits become more evident, this nation will become more hospitable to needle exchanges and their support of one of America’s most vulnerable populations.
Edited by: Alicia Yang
Illustrated by: Sophia Li