A U.S. Needle Exchange Program Dramatically Reduces HIV Transmission
Investigators with the Yale University School of Organization and Management and the City of New Haven, Department of Health, worked to expand and evaluate a model needle exchange program in New Haven.
Needle exchange programs seek to reduce the spread of HIV via infected needles by providing intravenous (IV) drug users with clean syringes. In 1990, New Haven's local government mandated a demonstration needle exchange program along with an independent program evaluation.
- During the RWJF-funded period, the needle exchange program saw approximately 800 clients quarterly, and a total of more than 2,300 individuals.
- By the end of the funded period, the needle exchange program assisted over 1,000 clients to enter drug treatment programs.
- The investigators estimated that the needle exchange program reduced the risk of HIV transmission among program participants by one third.
- There was no evidence of an increase in drug use through injection as a result of this needle exchange.
- Based on estimates of population, rates of needle exchange, program costs, and predictions of future HIV infections, the researchers concluded that the program was cost-effective.
- Decriminalization of the purchase and possession of a syringe without a prescription resulted in a reduced demand for the needle exchange program.
The Robert Wood Johnson Foundation (RWJF) provided two grants to the Yale University School of Organization and Management totaling $208,132 from January 1992 to June 1992. RWJF provided a grant of $515,544 from June 1992 to May 1999 to the City of New Haven, Department of Health.
By 1987, over three-quarters of all AIDS cases in New Haven, Conn., resulted from IV drug use, either directly (through sexual contact with a user or through a shared syringe) or indirectly (from an infected mother to her fetus). In a 1987 survey, IV drug users in New Haven revealed that fear of arrest, scarcity of sterile needles, and the high cost of syringes significantly contributed to needle sharing.
To reduce the transmission of HIV through the sharing of these needles, New Haven's local government mandated a demonstration needle exchange program with an independent program evaluation. The needle exchange program, started in November 1990, employed a mobile van to visit several sites during its four-day-a-week operation.
Staff members exchanged sterile needles for used ones and distributed bleach, water bottles, condoms, and HIV literature. In addition, they gave clients drug treatment information and provided them with referral assistance.
These grants from RWJF supported the expansion of New Haven's model needle exchange program and its evaluation. The evaluation (ID#s 019227, 020049) provided an opportunity to demonstrate that needle exchange could be an effective HIV-infection reduction strategy without promoting drug use or increasing the number of IV drug users in the community.
The researchers believed that the needle exchange program would not increase the number of needles in circulation because users would be required to return a distributed needle at the same time they received a new one.
Instead, by providing users with an opportunity to exchange their used needles for clean ones, the researchers' goal was to reduce the amount of time each needle remained in circulation, reducing the likelihood that it would become contaminated with HIV. That, in turn, would reduce the number of contaminated needles in circulation.
The researchers developed a syringe tracking and testing system to assist in the evaluation of the program. They monitored the amount of time needles remained in circulation before being turned in, and they tested the needles for the presence of HIV proviral DNA. The evaluation also monitored client enrollment, demographics, and the number of participants entering drug treatment programs.
The evaluation used information from self-reported questionnaires, completed by each client at the time of enrollment and at follow-up. Along with client demographics, the questionnaire collected behavioral information such as how long a client had been injecting drugs, the frequency of drug injection, the frequency of syringe cleaning and sharing, the risks taken in sexual practice, and the use of condoms.
Concurrently with the evaluation, RWJF provided a grant to expand the program (ID# 019924). The expansion was meant to ensure that the evaluation would be examining a robust, fully functioning project.
The principal objectives were to: Increase the number of program staff to include outreach workers, a drug treatment coordinator, and a field manager. Purchase and outfit a second mobile van. Increase the number of sites covered and expand the program's hours of operation. Enhance health education, referral, and client follow-up.
The first year of the needle exchange program evaluation was completed by Yale University on a pro bono basis. Investigators also received a three-year, $1-million grant from the National Institute on Drug Abuse (NIDA) to fund program activities.
- During the RWJF-funded period, the needle exchange program saw approximately 800 clients quarterly, and a total of more than 2,300 individuals. During these client encounters, needle exchange program staff provided information leading to behavior modification in addicts, including increased condom usage and cleaning of syringes. In addition, RWJF funds allowed the needle exchange program to hire additional outreach workers and other staff and purchase a second van, enabling staff to increase the program's number of targeted neighborhoods and hours of operation. A van operated by the Yale New Haven Hospital accompanied the needle exchange van to each site and offered treatment of less-complicated health complaints and referral to hospital system services.
- By the end of the funded period, the needle exchange program assisted over 1,000 clients to enter drug treatment programs. The addition of a full-time drug treatment coordinator increased the success of the needle exchange program by doubling the number of clients entering drug treatment (from an average of 14.4 persons per month to 28.8 persons per month).
- The investigators estimated that the needle exchange program reduced the risk of HIV transmission among program participants by one third. Prior to the start of the exchange program, 68 percent of needles found on the street and 93 percent of needles from drug shooting galleries had tested positive for HIV. Among needles obtained from program participants between 1990 and 1992, about 41 percent tested positive for the HIV virus. Based on the reduced prevalence of HIV-infected needles, the researchers estimated that the rate of new HIV infections among needle exchange participants would decline from 6 cases per 100 IV drug users per year to 4 cases per 100 a 33 percent reduction in the rate of new HIV infections. This estimate is based upon a model developed by the investigators, which relies solely on syringe testing and tracking data, rather than self-reported data, which may prove less reliable. Before the program began, New Haven had the state's highest number of reported AIDS cases. By 1996, New Haven was no longer the city with the highest number of reported AIDS cases in Connecticut.
- There was no evidence of an increase in drug use through injection as a result of this needle exchange. Decreased needle circulation time, rather than a change in participants' behavior from high-risk to low-risk behavior, appears to be responsible for the observed decrease in HIV prevalence. Data also indicated that exchange rates of needles increased over time; circulation times of needles decreased from an average of seven days to two to three days; and the level of infection in needles dropped, as needles spent progressively less time changing hands between possibly infected IV drug users.
- Based on estimates of population, rates of needle exchange, program costs, and predictions of future HIV infections, the researchers concluded that the program was cost-effective. Because of the high costs associated with treating HIV-positive individuals, even a tiny decrease in the fraction of infected needles circulating could potentially result in a significant reduction of health care expenditures. For example, the researchers estimated that 5 new cases of HIV were avoided during the first year of the program, and 20 during the second. With lifetime hospital costs then estimated at $50,000 to $100,000 per each new infection, the program was estimated to have saved $1 to $2 million in the first two years.
- Decriminalization of the purchase and possession of a syringe without a prescription resulted in a reduced demand for the needle exchange program. Connecticut law was amended in May 1992 to allow for the purchase of syringes without a prescription and the promotion of needle exchange programs statewide based on the New Haven model. During the three months prior to the Connecticut decriminalization, 164 clients joined the New Haven needle exchange program; during the three months after, only 80 clients joined, representing a 48 percent drop in enrollment. Although that drop was not as significant over the rest of the grant period, enrollment continued to decline over the remainder of the grant term.
The investigators published more than 30 articles in professional journals, including the New England Journal of Medicine and the Journal of the American Medical Association.
Project staff made presentations at numerous national and international conferences, including several international AIDS conferences, the American Public Health Association annual meeting, and meetings at the National Academy of Sciences and the Centers for Disease Control and Prevention.
The investigators were also interviewed on several local and national television stations, and appeared on the NBC "Today" show and the Discovery Channel's "Cronkite Report." The syringe tracking and testing research has been reported on in US News and World Report, the New York Times, and the Washington Post.
The General Accounting Office documented results of the program in a report to the House select committee on narcotics abuse and control. Within the research community, the evaluation won two prestigious awards the Franz Edelman Award for Management Science Achievement and the Frederick Lanchester Prize.
The director of the needle exchange program made presentations to several municipalities considering establishing their own needle exchange programs. In addition, the New Haven AIDS Division operated a Web site concerning the needle exchange program for almost a year. Program staff also produced a television program that aired on BET, Lifetime, E!, and MTV for 13 weeks. (See the Bibliography for a complete listing of publications and presentations.)
AFTER THE GRANT
The needle exchange program continues to operate. The loss of grant funds and city and state budget changes have led to the elimination of several staff positions. Staff members hope to develop a syringe disposal system and a home delivery program, and to expand the hours of operation at least one night a week into the early morning hours.
As a result of the research documenting evidence of the efficacy of the New Haven needle exchange program, other states have become interested in needle exchange programs. New needle exchange programs have begun in New York City, California, and Massachusetts.
Connecticut has expanded the program to include Bridgeport and Hartford.
Needle exchange programs continued to spread across the country. In 2007, New Jersey became the final state in the United States to adopt a needle exchange program.
GRANT DETAILS & CONTACT INFORMATION
Study of Needle Exchange Program's Effect on Reducing HIV Transmission
Yale University School of Organization and Management (New Haven, CT)
Dates: January 1992 to June 1992
- Evaluation of Model Needle Exchange Program
Amount: $ 159,315
Dates: May 1992 to April 1995
Edward Kaplan, Ph.D.
Expansion of Model Needle Exchange Program
City of New Haven, Department of Health (New Haven, CT)
Dates: June 1992 to May 1999
Matthew F. Lopes
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Eicher A, Eno R, Greaves S, Kamina A, Singh M, and Soni R. "The New Haven Needle Exchange Program as a Conduit to Drug Treatment. Community Research Project Report. New Haven, Conn.: Yale School of Medicine, Department of Epidemiology and Public Health, May 12, 1995.
Kaplan EH and Brandeau M (eds.). Modeling the AIDS Epidemic. New York, N.Y.: Raven Press, 1994.
United States General Accounting Office, Report to the Chairman, Select Committee on Narcotics Abuse and Control, House of Representatives. Needle Exchange Programs: Research Suggests Promise as an AIDS Prevention Strategy. GAO/HRD-93-60: 133, March 1993.
Anonymous. "Needle Exchange in New Haven." AIDS Information Exchange, The United States Conference of Mayors. 9: 116, 1992.
Caulkins J and Kaplan E. "AIDS Impact on the Number of Intravenous Drug Users." Interfaces, 21: 5063, 1991.
Heimer R, Kaplan EH, and Cadman E. "Prevalence of HIV-Infected Syringes During a Syringe-Exchange Program." New England Journal of Medicine, 327(26): 18831884, 1992.
Heimer R, Kaplan EH, Khoshnood K, Jariwala B, and Cadman EC. "Needle Exchange Decreases the Prevalence of HIV-1 Proviral DNA in Returned Syringes in New Haven, Connecticut." American Journal of Medicine, 95(2): 214220, 1993. Abstract available online.
Kaplan E. "A Method for Evaluating Needle Exchange Programs." Statistics in Medicine, 13: 21792187, 1994.
Kaplan E. "Economic Analysis of Needle Exchange." AIDS, 9(10): 11131119, 1995.
Kaplan E and Brandeau M. "AIDS Policy Modeling by Example." AIDS, 8(Suppl. 1): S333S340, 1994.
Kaplan E. "Evaluating needle-exchange programs via syringe tracking and testing (STT)." AIDS and Public Policy Journal, 6: 109115, 1991.
Kaplan E. "Federal Response to Needle Exchange Programs: Part II: B. Needle Exchange Research: The New Haven Experience." Pediatric AIDS and HIV Infection: Fetus to Adolescent, 4(2): 9296, 1993.
Kaplan E. "Let the Needles Do the Talking." Yale Management, 2: 1521, 1991.
Kaplan E. "Needle Exchange or Needless Exchange? The State of the Debate." Infectious Agents and Disease, 1(2): 9298, 1992. Abstract available online.
Kaplan E. "Needle Exchange Research: The New Haven Experience." Pediatric AIDS and HIV Infection, 4: 9296, 1993.
Kaplan E. "Needles That Kill: Modeling Human Immunodeficiency Virus Transmission via Shared Drug Injection Equipment in Shooting Galleries." Reviews of Infectious Diseases, 11(2): 289298, 1989 (Erratum, 11(4): 672, 1989). Abstract available online.
Kaplan E. "Operational Modeling of Needle Exchange Programs." Needle Exchange and Bleach Distribution Programs. National Research Council: Panel on Behavioral and Social Sciences and Education. National Academy Press, Washington, D.C., 202249, 1994.
Kaplan E. "Probability Models of Needle Exchange." Operations Research, 43: 558569, 1995.
Kaplan E and Heimer R. "A Circulation Theory of Needle Exchange." AIDS, 8(5): 567574, 1994.
Kaplan E and Heimer R. "A Model-Based Estimate of HIV Infectivity via Needle Sharing." Journal of Acquired Immune Deficiency Syndromes, 5(11): 11161118, 1992. Abstract available online.
Kaplan E and Heimer R. "HIV Incidence Among Needle Exchange Participants: Estimates from Syringe Tracking and Testing Data." Journal of Acquired Immune Deficiency Syndromes, 7(2): 182189, 1994. Abstract available online.
Kaplan E and Heimer R. "HIV Incidence Among New Haven Needle Exchange Participants: Updated Estimates from Syringe Tracking and Testing Data." Journal of Acquired Immune Deficiency Syndromes, 10: 175176, 1995.
Kaplan E and Heimer R. "HIV Prevalence Among Intravenous Drug Users: Model-Based Estimates from New Haven's Legal Needle Exchange." Journal of Acquired Immune Deficiency Syndromes, 5(2): 163169, 1992. Abstract available online.
Kaplan E and Heimer R. "What Happened to HIV Transmission Among Drug Injectors in New Haven?" Change: New Directions for Statistics and Computing, 6(2): 914, 1993.
Kaplan E and O'Keefe E. "Let the Needles Do the Talking! Evaluating the New Haven Needle Exchange." Interfaces, 23(1): 726, 1993. (Abstract appears in "Abstracts of the Marschak Colloquium at UCLA." Mathematical Social Sciences, 26: 99101, 1993.)
Kaplan E and Soloshatz D. "How Many Drug Injectors Are There in New Haven? Answers from AIDS Data." Mathematical and Computer Modeling, 17: 109115, 1993.
Kaplan E, Heimer R, and Lopes M. "Needle Exchange Hastens Entry into Drug Treatment." Journal of the American Medical Association, 271(23): 18251826, 1994.
Kaplan E, Heimer R, Khoshnood K, Stephens P, and Jariwala-Freeman B. "Evaluating a Needle Exchange Program: Models for Testing HIV-1 Risk Reduction." International Journal of Drug Policy, 7: 123129, 1996
Kaplan E, Heimer R, Meyers S, and Cadman E. "Detection by Polymerase Chain Reaction of Human Immunodeficiency Virus Type 1 Proviral DNA Sequences in Needles of Injecting Drug Users." Journal of Infectious Diseases, 165(4): 781782, 1992.
Kaplan E, Heimer R, Myers S, Liu D, and Cadman HD. "HIV DNA and Antibodies in Syringes from Injecting Drug Users: A Comparison of Detection Techniques." AIDS, 7: 925931, 1993.
Kaplan E, Heimer R, O'Keefe E, Khoshnood K, and Altice F. "Three Years of Needle Exchange in New Haven: What Have We Learned?" AIDS and Public Policy Journal, 9: 5974, 1994.
Kaplan E, Khoshnood K, and Heimer R. "A Decline in HIV-Infected Needles Returned to New Haven's Needle Exchange Program: Client Shift or Needle Exchange?" American Journal of Public Health, 84(12): 19911994, 1994. Abstract available online.
Khoshnood K, Kaplan EH, and Heimer R. "'Dropouts' or 'Drop-ins?' Client Retention and Participation in New Haven's Needle Exchange Program." Public Health Reports, 110(4): 462466, 1995. Abstract available online.
O'Keefe E. "Altering public policy on needle exchange: the Connecticut experience." AIDS and Public Policy Journal, 6: 159164, 1991.
Brochures and Fact Sheets
"Community Health Care Van Project: Youth Health Connection!" New Haven Department of Health.
"VII International Conference on AIDS," 1991, Florence, Italy.
- Edward H. Kaplan, Elaine O'Keefe, and Robert Heimer. "Evaluating the New Haven Needle Exchange Program (needle exchange program), in Final Program and Abstracts of the VII International Conference on AIDS. Florence, Italy (abstract WC 3286), 1991.
"Let the Needles Do the Talking!" Rand Corporation, Santa Monica, Calif., February 1991.
UCLA Social Statistics Seminar, February 1991.
Harvard Decision Sciences Colloquium, April 1991.
Yale AIDS Colloquium, April 1991.
Mixing Conference, University of Michigan, June 1991.
Evaluating the New Haven Needle Exchange Program, New York City Department (Commissioner) of Health, August 1991.
Medical Grand Rounds, Yale Medical School, August 1991.
Robert Wood Johnson Clinical Scholars Program®, Yale Medical School, October 1991.
Harvard School of Public Health, AIDS Institute and Department of Health Policy and Management, November 1991.
Massachusetts Institute of Technology, Operations Research Center, November 1991.
San Francisco Treatment Research Unit, University of California, San Francisco, November 1991.
Yale University Women's Organization, November 1991.
Combined HIV Rounds and Division of HIV/AIDS Research Seminar, United States Centers for Disease Control, December 1991.
The Robert Wood Johnson Foundation, December 1991.
Oral presentation by Edward Kaplan, in Needle and Syringe Availability and Exchange for HIV Prevention. Menlo Park, 1992.
Martin Luther King Day Symposium, Yale Medical School, January 1992.
Statistics Seminar, Yale Department of Statistics, February 1992.
Joint SIMS/NIDA Conference on AIDS Modeling, Blaubeuren, Germany, March 1992.
21st Franz Edelman Award Competition, Orlando, Fla., April 1992.
Health Psychology Seminar, Yale Department of Psychology, April 1992.
"VIII International Conference on AIDS," July 1992, Amsterdam, the Netherlands.
- Edward H. Kaplan and Robert Heimer. "Needle Exchange Lowers HIV Incidence in New Haven," in Final Program and Abstracts of the VIII International Conference on AIDS. Amsterdam, the Netherlands (abstract WeC 1092), 1992.
Imperial College, London, England, July 1992.
Netherlands National Institute of Public Health, Bilthoven, the Netherlands, July 1992.
College on the Practice of Management Science, Williams College, Williamstown, Mass., August 1992.
Yale AIDS Colloquium Series, Yale University, New Haven, Conn., September 1992.
Heller School, Brandeis University, Waltham, Mass., October 1992.
Marschak Symposium, UCLA, Los Angeles, Calif., October 1992.
AIDS and Society, Biology Department, Yale University, New Haven, Conn., November 1992.
Drug Policy Foundation, Washington, D.C., November 1992.
Joint ORSA/TIMS Meeting, San Francisco, Calif., November 1992.
Yale University Medical School, Substance Abuse Treatment Unit, New Haven, Conn., November 1992.
Kaiser Foundation, Palo Alto, Calif., December 1992.
APT Foundation, New Haven, Conn., January 1993.
University of Toronto, Ontario, Canada, January 1993.
North American Syringe Exchange Conference, Boston, Mass., February 1993.
Hill Health Center, New Haven, Conn., March 1993.
Rennselaer Polytechnic Institute, Decision Sciences Department, Troy, N.Y., April 1993.
Villanova University, Villanova, Pa., April 1993.
Wharton School, University of Pennsylvania, Philadelphia, Pa., April 1993.
"IXth International Conference on AIDS," June 1993, Berlin, Germany.
- Robert Heimer et al. "A comparison of techniques for detecting HIV-1 in syringes returned to a needle exchange program (needle exchange program)," in Final Program and Abstracts of the IX International Conference on AIDS. Berlin, Germany, 1993. (Abstract PO-C31-3297)
- Kaven Khoshnood and Robert Heimer. "Detection of hepatitis B virus (HBV) DNA in syringes of infecting drug users in the city of New Haven's needle exchange program (needle exchange program)." New Haven, Conn. (Abstract PO-C15-2960)
- Frederick L. Altice et al. "Provision of health care and HIV counseling and testing for clients of the New Haven needle exchange program." New Haven, Conn. (Abstract PO-D17-3927)
"Circulation Theory of Needle Exchange: Societal Institute for Mathematical Sciences/National Institute on Drug Abuse Conference on Quantitative Methods in AIDS," Blaubeuren, Germany, June 1993.
National Institute on Drug Abuse Research and Practice Conference, Washington, D.C., July 1993.
National Academy of Sciences, Washington, D.C., September 1993.
Presentation to members of city government, City of San Juan, Puerto Rico, September 1417, 1993.
American Public Health Association, San Francisco, Calif., October 1993.
Department of Biology, Yale University, New Haven, Conn., October 1993.
Drug Policy Foundation, Washington, D.C., November 1993.
Presentation on New Haven needle exchange program to graduate students, University of New Haven, New Haven, Conn., November 1993.
ORSA/TIMS Conference, Phoenix, Ariz., November 1993.
Risk Analysis Seminar, Harvard School of Public Health, Cambridge, Mass., November 1993.
Yale School of Organization and Management, New Haven, Conn., November 1993.
National Needle Exchange Conference, Santa Cruz, Calif., February 1994. Presentation by project staff about the New Haven needle exchange program.
Hebrew University Hadassah Medical Center Braun School of Public Health, Jerusalem, Israel: HIV incidence among needle exchange participants, April 4, 1994; operational modeling of needle exchange programs, March 15, 1994.
Osservatorio Epidemiologico, Regione Lazio, Rome, Italy: Operational modeling of needle exchange programs, March 29, 1994.
Ben Gurion University of the Negev, Beersheba, Israel, May 1994.
Israel Statistical Association, June 1994.
OSIRIS Operations Research Society of Israel, June 1994.
Department of Statistics, Yale University, New Haven, Conn., October 1994.
Matthew F. Lopes, Jr. "New Haven Needle Exchange Program," at the Rochester, N.Y., Medical Society Meeting, February 1995.
Congressional Seminar, Drug Policy Foundation, Washington, D.C., March 1995.
3rd Conference on Retroviruses and Opportunistic Infections, Washington, D.C., January 31, 1996.
Matthew F. Lopes, Jr. "New Haven Needle Exchange Program," at the Springfield, Mass., Aldermanic Meeting, February 1996.
"First Annual INFORMS Lecture of the UK Operational Research Society: Probability Models of Needle Exchange, 38th National Meeting of the UK Operational Research Society," at the University of Warwick, Warwick, U.K., September 4, 1996.
Matthew F. Lopes, Jr. "New Haven Needle Exchange Program," at the Detroit, Mich., City Hall Aldermanic Meeting, October 1996.
"Hebrew University of Jerusalem, Department of Statistics: Probability Modeling of Needle Exchange Programs,"May 8, 1997.
World Wide Web Sites
www.datebookmag.com/nhh provided information about the New Haven needle exchange program, describing services offered by AIDS Division and providing contact numbers. The site was operational from June 1996 until May 1997.
Comcast Cable Television, "Building a Healthier New Haven," an AIDS Division Promotion, 13-week telecasts on BET, Lifetime, E!, and MTV beginning December 31, 1997.
"Needle Exchange Gets Grant" in The Westport News, June 5, 1992.
"Needle Exchange Gets Lots Of Attention" in The Hartford Courant, June 24, 1992.
"Needle-Exchange Hiring Sparks Sick-Out" in The New Haven Register, September 4, 1992.
Yale Daily News, interview with staff, November 26, 1994.
"New Haven Department of Health," in Datebook magazine, 19(8): 1820, 1996.
Mayor of New Haven's monthly television program, a segment on New Haven needle exchange program, March 1994.
"The Mayor's Show," WNUV-TV, Baltimore, Md., February 1995.
Walter Cronkite and Sanford Socolow. The Cronkite Report, "The Drug Dilemma: War or Peace?" The Discovery Channel, June 20, 1995.
Report prepared by: Fran Karo
Report prepared by: Patricia Patrizi
Reviewed by: Marian Bass
Reviewed by: Robert Crum
Reviewed by: Richard Camer
Program Officer: Paul Jellinek