Exploding Preconceptions About Needle Exchange Programs
The City of Baltimore's Needle Exchange Program purchased a mobile van to distribute clean needles to intravenous drug users to prevent the transmission of HIV, reduce AIDS deaths, and provide a way for addicts to obtain treatment.
- In the first 13 months of the program, some 3,400 addicts made 19,000 visits to the van to exchange more than 270,000 needles.
- Ninety drug treatment slots dedicated to the Needle Exchange Program served 200 clients each year.
- Data collected by the program showed a significant decrease in addict seroconversion rates (the change in status from HIV- to HIV+) and significant increases in safer drug behaviors among clients.
- A study by the Johns Hopkins School of Public Health indicated that the program reduced HIV transmission by almost 40 percent.
- The program generated significant interest both domestically and abroad, and has hosted 15 visiting delegations from such places as Japan, China, Africa, Canada, and the Netherlands.
The program is ongoing, has expanded to two vans, and serves a 5,300-addict population who exchange 500,000 needles a year.
The Robert Wood Johnson Foundation (RWJF) provided $50,000 in funding from August 1994 to July 1995 to support the project.
United States drug-abuse policy has consistently been polarized between the prevention and treatment of a medical problem, and punishment of criminal conduct. Moving outside this framework, Baltimore Mayor Kurt Schmoke's championing of medicalization of drugs and legalization of needle exchanges in order to reduce the collateral social problems that flow from drug abuse has been well received by state-level officials and the general public.
In 1993, the mayor's office and Baltimore's Abell Foundation reported two startling facts about the local population: AIDS was the number one cause of death for men and women ages 25 to 44, and, atypically, more than 70 percent of new AIDS cases were among intravenous drug users, their sex partners, and offspring.
The Mayor's Working Group on Drug Policy Reform then proposed that a needle exchange program be implemented, a proposal that met with approval of the governor, Maryland legislature, public health officials, and community groups.
The city's stated goals were to prevent the transmission of HIV, reduce AIDS deaths, and provide a way for addicts to obtain treatment for their drug addictions. The proposal was budgeted to exchange needles for 500 addicts for one year and included a three-year, million-dollar evaluation by The Johns Hopkins School of Hygiene and Public Health, funded by the National Institute on Drug Abuse (NIDA).
The City of Baltimore provided $160,000 in funds for a part of the project the Foundation declined to support. The Foundation had already funded the expansion and evaluation of the New Haven NEP in 1992 for three years (see Grant Results on ID#s 019924, 019227 and 020049).
RWJF supported the purchase of a mobile van to service NEP clients. Staffed by three people, the van visited high drug-use areas and provided the following services:
- dispensing needles and syringes, condoms, and educational pamphlets;
- HIV counseling and testing;
- TB skin testing and referral;
- syphilis serology and referral to clinics for sexually transmitted diseases (STD).
In addition, 90 drug treatment slots, funded by the City at a cost of $250,000, were dedicated to serve NEP clients.
After 13 months, 3,400 clients had made over 19,000 visits to exchange more than 270,000 needles. This met the program's goal to encourage use of sterile needles for the purpose of reducing HIV transmission. Furthermore, all 90 dedicated drug treatment slots were utilized, satisfying the goal of treatment referral and providing evidence of clients' willingness to seek treatment.
Continuing success after the grant period was reflected in the commissioner of health's report of July 17, 1996, that 4,565 clients made more than 36,600 visits to exchange 546,000 needles at two mobile offices during the first 22 months of the program. Between 325 and 550 new and return clients were served weekly and the 90 treatment slots served 200 patients per year. Measures to insure high reliability of the NEP data include:
- bar codes on new needles to match each client's assigned identification code in order to trace used needles to each respective client,
- follow-up HIV testing on clients.
Budgets for fiscal years 1996 and 1997 remained the same as in the original proposal to RWJF: $160,000 for the needle exchange with an additional $250,000 for drug treatment slots. While this grant helped to initiate the NEP (by providing funding to purchase a necessary piece of equipment), the program is now totally sustained by government funding.
- There has been a significant decrease in the seroconversion rate (change from HIV- to HIV+) of IDUs enrolled in the Baltimore NEP, thus signaling a reduction in the spread of HIV as a result of the NEP.
- Free needle exchanges do not contribute to increased drug usage by intravenous drug users (IDUs), which would increase the risk of HIV transmission. While this mirrors the earlier New Haven findings, this is not an issue that is settled in the literature or in conventional opinion.
- Needle exchange programs are a cost-effective preventative approach to the AIDS crisis. Including the cost of the dedicated treatment slots, the Baltimore program costs about $410,000 a year. Because the client population is largely Medicaid eligible or uninsured, the NEP need only prevent the spread of HIV to four clients to make the program cost-effective to taxpayers who pay the $102,000 average cost to treat adult AIDS patients from diagnosis to death.
- The program did not make it easier for youngsters to get needles. The average age of clients was 39 years and only two clients were under age 19.
- NEP clients tend to be "harder core" addicts than previously studied Baltimore addict populations, yet their rate of successful retention in treatment programs matches that of patients who were not referred by the program. This held true in spite of findings that NEP clients are significantly less likely to have been in treatment before and that they have significantly more medical problems.
- Approximately one-half of enrolled clients became active exchangers, returning on average every two weeks to exchange an average of 14 needles and syringes at each visit.
- After enrolling in the program, clients reported significant drops in unsafe drug behaviors: sharing needles, cookers, and cotton swabs. While 63 percent of clients reported the source of needles as the "street" before the initiation of the program, this dropped to 39 percent for clients enrolled for two weeks. A significant number of clients reported injecting themselves in their home instead of in "drug houses" or on the "street." The average circulation time of client's needles dropped by 33 percent. While these findings are based upon client reports, which can be unreliable, the Baltimore NEP uses scientifically sophisticated verification procedures. For instance, needles and client ID cards are bar coded to match clients to needles.
- The program served as a much-needed point of access to health care for addicts who had no other resources. If a client tested positive for HIV or TB, the client was referred to clinics for care and/or family planning.
- The community accepted the program and the police were cooperative. The program was essentially self-policed by the clients served. Communities were involved in the NEP planning initially and were asked whether they wanted the program to serve their neighborhood: seven communities applied. To date, police have only been called to respond to one incident.
- The program did not result in an increase in discarded needles in the areas served, according to a study which compared discarded needle rates at program sites and other high drug-use areas.
The Baltimore NEP has been the subject of frequent print and television news reports, including local broadcasts, national broadcasts (e.g., ABC), and foreign broadcasts (including Japan).
The commissioner of health testifies twice yearly before the Maryland legislature about NEP and his other programs. Nationally, the commissioner and other NEP representatives have published articles, given speeches, and made presentations at numerous conferences, including the XI International Conference on AIDS in Vancouver (July 1996) and a past National Conference of Mayors (October 1994).
The program fields many calls and has hosted 15 visiting delegations, both domestic and international, from such places as Japan, China, Africa, Canada, and the Netherlands. The commissioner reported that he expects a professional journal (either New England Journal of Medicine or The Journal of the American Medical Association) to publish an article soon announcing a "significant decrease in the seroconversion of IDUs enrolled" in the Baltimore NEP.
AFTER THE GRANT
Since this grant was made, the Baltimore NEP has expanded to a staff of six distributing 500,000 needles to 5,300 clients a year from two mobile vans which visit six sites in the city. Upon completion some time in 1997, the results of the three-year Johns Hopkins evaluation will be disseminated and are predicted to further document the benefits of needle exchange programs.
GRANT DETAILS & CONTACT INFORMATION
Implementation of a Pilot Needle Exchange Program
City of Baltimore Department of Health (Baltimore, MD)
Dates: August 1994 to July 1995
Peter Beilenson, M.D., M.P.H., Commissioner of Health
Report prepared by: John H. Petito
Reviewed by: Molly McKaughan
Program Officer: Paul S. Jellinek