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Delaware HIV Consortium
Policy Committee and Planning Council
September 2010
Needle Exchange Program White Paper:
Justification for Continuation and Expansion
of the Delaware Needle Exchange Program
Delaware HIV Consortium Policy Committee
Delaware Needle Exchange Program
White Paper
September 2010
I. Introduction
Problem Statement
Delaware is the second smallest state in the nation in terms of geographic size, yet its AIDS
incidence rate is among the highest in the nation (19.8 cases per 100,000 residents in 2008),
ranking consistently among the top ten each year in the rate of new AIDS cases per capita.
Further, recent data indicates that the frequency with which AIDS cases are being diagnosed in
Delaware is increasing in comparison with other states (10th in the nation in 2006; 6th in 2007).1
The majority of new and existing HIV cases in Delaware are attributable to needle sharing and/or
unprotected sexual contact with someone that has shared needles to inject drugs,2 with
Delaware’s HIV infection rate from injecting drug users (IDUs) more than twice the national
average.3
Needle exchange programs (NEPs)—also called syringe exchange programs (SEPs), syringe
access programs (SAPs), and syringe services programs (SSPs)—have become a mainstream
approach to substance abuse and HIV prevention in many countries for over twenty-five years.4
In 2006, the state of Delaware initiated a five-year pilot NEP in portions of the City of
Wilmington for two primary purposes: (1) preventing the transmission of blood-borne illnesses
including HIV and the hepatitis B virus; and (2) providing IDUs with referrals to appropriate
treatment and other health and social services programs.5
In three years of operation, Delaware’s NEP has been successful in meeting or exceeding the
majority of the goals established in its Implementation Plan and has become a key component of
the state’s HIV prevention and treatment strategy.6,7
Highlights of the program’s
accomplishments from inception through fiscal year 2010 (February 1, 2007 through June 30,
2010) include the following:
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1,864 rapid HIV screenings provided to NEP clients and community members
179 persons tested for HIV for the first time
16 persons newly diagnosed with HIV enrolled into medical care
11 formerly-diagnosed HIV-positive persons re-connected to medical care
130 NEP clients enrolled into substance abuse treatment programs
28.6% of clients reporting reduced needle sharing
As Delaware’s NEP nears its sunset date of February 2012, the Delaware HIV Consortium
Planning Council, the Consortium’s Policy Committee, and other supporters have made the
following recommendations for its continuation, grouped into three categories: capacity,
flexibility and funding. Expanded justifications and explanations for the recommendations are
provided on pages 9 and 10.
1
Recommendations for Delaware’s Pilot Needle Exchange Program (NEP)
1. Increase the NEP’s Capacity to Serve More People:
a. Move the NEP’s status from “pilot” to “permanent”.
b. Extend the NEP’s service area from “Wilmington” to “statewide”.
2. Enhance Flexibility to Respond to Community Needs:
a. Provide the Division of Public Health (DPH) and the NEP Oversight Committee with
the flexibility to approve new locations throughout the state, as evidenced and
justified by statistical need.
b. Provide DPH and the NEP Oversight Committee with the flexibility to approve
individualized NEP structures that are most responsive to the needs of participants
and varying local communities.
3. Secure Funding to Maintain and Expand Delaware’s NEP:
a. Continue state funding for the program.
b. Maintain and expand capacity to obtain any future federal funds released to support
this evidence-based and proven HIV prevention program.
II. Needle Exchange Overview
What is Needle Exchange?
Needle exchange (also known as syringe exchange, syringe access, and syringe services) refers
to a “myriad of approaches geared towards ensuring that people who inject drugs have access to
sterile syringes to prevent the transmission of HIV, viral hepatitis and other blood-borne
pathogens”.8 In the public health community, needle exchange is considered a harm reduction
technique—a method of reducing health risks when eliminating them may not be possible. It is a
mainstream approach to substance abuse and HIV prevention in many countries.4
Most NEPs are part of comprehensive HIV prevention efforts that include counseling; testing;
education; and referral to drug treatment services, mental health services, HIV counseling, HIV
treatment, and traditional public health preventive and therapeutic services for other diseases and
medical needs.9-12 The American Foundation for AIDS Research (amfAR)—an international
non-profit organization dedicated to the support of HIV/AIDS research, prevention, treatment,
education, and advocacy—summarizes research findings on the beneficial effects of NEPs,
which show that NEPs:
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Are associated with reductions in the incidence of HIV, Hepatitis B, and Hepatitis C in
the drug-using population and, by extension, their families and communities.
Are associated with changes in injection and drug-related behavior among IDUs, thereby
reducing risk of infections and transmission to others.
Are a cost-effective and cost-saving strategy for reducing HIV transmission.
Reduce the circulation of contaminated injection equipment among IDUs and in the
community.4
Reduce needle stick injuries among police officers.13
2
General Structure:
NEPs vary in design and operation, with no one model working best for all communities.
Program settings can include storefronts, vans, sidewalk tables, and health clinics—any place
where IDUs gather—and hours of operation can vary from program to program.14 Whatever the
model, a study of “Best Practices” identified two key components necessary for the effectiveness
and success of all NEPs: flexibility and support.

Flexibility: Research shows that, to be most effective, NEPs should “match sound
operational characteristics with responsiveness to the unique features of their host
communities”.

Support: To be most successful, NEPs must have at least minimal support from their
communities’ respective governing bodies, plus the crucial support of a diverse group of
local stakeholders (public health departments, law enforcement, service organizations,
legal experts, grass roots organizations, and community leadership). The greater the
support, the greater the likelihood of effectiveness.15
Proof of Efficacy
NEPs have been operating in the United States (U.S.) for over 25 years, under the discretion of
state and local governments. Extensive studies in the U.S. and around the world have
demonstrated their effectiveness. A sampling of organizations and experts that have studied and
endorsed NEPs—and their findings—include the following:
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Over a 20-year period, at least 17 major reviews and assessments of NEPs by experts that
include the Centers for Disease Control (CDC), National Institutes of Health (NIH), the
Institute of Medicine, and the World Health Organization found that NEPs help reduce
the spread of HIV/AIDS without increasing drug use among existing IDUs or
encouraging the initiation of drug use.16
In 1997, the NIH Consensus Panel on HIV Prevention concluded that NEP studies show
a reduction in risk behaviors as high as 80% in IDUs, with estimates of a 30% or greater
reduction in HIV in IDUs.17
In 1998, Donna Shalala, U.S. Secretary of Health and Human Services, reported to
Congress that a review of scientific evidence indicated that NEPs "…can be an effective
component of a comprehensive strategy to prevent HIV and other blood-borne infectious
diseases..." and recommended lifting the ban against the use of federal funds for NEPs.18
Similarly, three former U.S. Surgeons General endorsed NEPs including U.S. Surgeon
General David Satcher who, in March 2000, conducted a review of all recent scientific
research for the Secretary of Health and Human Services and concluded, “After
reviewing all of the research to date, the senior scientists of the Department and I have
unanimously agreed that there is conclusive scientific evidence that syringe exchange
programs, as part of a comprehensive HIV prevention strategy, are an effective public
health intervention that reduces the transmission of HIV and does not encourage the use
of illegal drugs.”19
A 2007 CDC review of 185 NEPs in the U.S. and Puerto Rico concluded that NEPs
“…are helping protect IDUs and their communities from the spread of blood-borne
pathogens and are providing access to health services for a population at high risk.’’ 20
3
Facts About Needle Exchange Programs
The abundance of research on the effectiveness of NEPs, plus the experiences of Delaware’s
own NEP, dispel common myths associated with such programs.
Myth
There is no hard
evidence that NEPs
work.
NEPs do not reduce
HIV or other diseases.
NEPs increase drug
use among existing
IDUs.
NEPs promote
substance abuse.
Fact
NEPs are an effective public health intervention. Extensive studies
have shown the effectiveness of NEPs. As stated on page 3, U.S.
Surgeon General David Satcher conducted a review of all recent
scientific research in March 2000 for the Secretary of Health and
Human Services and concluded that “…the senior scientists of the
Department and I have unanimously agreed that there is conclusive
scientific evidence that syringe exchange programs, as part of a
comprehensive HIV prevention strategy, are an effective public
health intervention that reduces the transmission of HIV and does not
encourage the use of illegal drugs.”19 Regarding the effectiveness and
successes of Delaware’s NEP, see pages 7 and 8.
NEPs help reduce HIV and other diseases. NEPs are associated
with reductions in the incidence of HIV in the drug-using population
and, by extension, their families and communities.4 As stated earlier,
the NIH Consensus Panel on HIV Prevention concluded in 1997 that
NEP studies show estimates of a 30% or greater reduction in HIV
infection in IDUs.17 Another study—of IDUs in New York City
conducted between 1990 and 2002—showed HIV infections among
IDUs decreased 70%.21 A recent University of New South Wales
report showed that NEPs in Australia were directly linked to the
prevention of 32,000 cases of HIV infection and close to 100,000
cases of hepatitis C.22
NEPs do not increase drug use among existing IDUs; they help
get them into treatment. In the 1997 Consensus Statement cited
above, the NIH reported that “a preponderance of evidence shows
either no change or decreased drug use among persons who had
participated in NEPs.”17 Rather than increasing drug use among
IDUs, studies show that NEPs can have a positive effect in helping
them get into needed treatment. A study published in the Journal of
Urban Health in 1999 stated that “findings indicate that health care
providers and NEPs represent an important bridge to drug abuse
treatment for HIV-infected and uninfected IDUs. Creating and
sustaining these linkages may facilitate entry into drug abuse
treatment and serve the important public health goal of increasing the
number of drug users in treatment.”23
NEPs do not encourage the start of drug use. An amfAR
FactSheet summarizes extensive research that shows that NEPs do
not encourage the start of drug use in non-users,4 while the results of
a study of a San Francisco NEP over a five-year period indicated that
there was no significant increase in new or young injecting drug
4
Myth
Fact
users. Additionally, a CDC summary on NEPs stated, “Studies also
show that [NEPs] do not encourage drug use among [NEP]
participants or the recruitment of first-time drug users.”14
NEPs reduce risky behavior. Studies have shown that NEPs
actually reduce risky behaviors associated with sharing of needles and
NEP participants are “less prone to share, lend, borrow, or reuse a
used syringe when they have access (or reliable source) to obtain a
new and sterile syringe.”25 As stated earlier, the NIH Consensus
Panel on HIV Prevention concluded in 1997 that NEP studies show a
reduction in risk behaviors as high as 80% in IDUs.17 Delaware’s
own NEP participants reported a reduction of 28.6% in needle
sharing, as indicated on page 7.
NEPs do not increase crime in NEP communities. Studies have
been conducted that indicate that NEPs do not increase crime in the
neighborhoods in which they are located.26,27 Rather, they can benefit
the health and safety of a community by offering comprehensive
social services to needy community members.28,29
NEPs help keep communities safe. Studies have shown that NEPs
reduce the circulation of contaminated needles in the community by
educating users on the safe disposal of used needles.30,31 Delaware’s
NEP requires the issuance of individual Sharps Containers for safe
transportation and return of needles.32
NEPs are cost-effective. Numerous studies have shown NEPS to be
a cost-effective and cost-saving strategy for reducing HIV
transmission.4 The annual budget appropriation for Delaware’s NEP
is $230,500, while the lifetime cost of prescriptions and medical
treatment for one HIV-positive person—exclusive of supportive
services costs—is estimated to be as high as $618,000.33 Preventing
just one HIV infection per year through the NEP saves over
$618,000/person in potential treatment funding.
Delaware’s NEP is comprised of a strong partnership between
local law enforcement and DPH. Delaware’s Standing Operating
Procedures for the NEP mandate extensive and on-going outreach,
education, and coordination among all of the NEP program partners,
including DPH and the City of Wilmington Department of Public
Safety.32 Members of the Wilmington’s Public Safety Department are
supportive of the NEP as a result of strong, open lines of
communication and education. Wilmington Police have, in fact,
referred five IDUs to the NEP, a testament to their confidence in the
program’s mission.
24
NEPs increase risky
behavior.
NEPs increase crime
in their communities.
NEPs increase the
number of visible
contaminated needles
in the community.
NEPs are costly.
Law enforcement and
public health cannot
co-exist.
Nationwide Legislative Status
Currently, NEPs have received legislative approval in all states and territories of the U.S.
National statistics provide a stark picture of the relationship between injecting drug use and the
5
proliferation of HIV and other diseases throughout the country, as well as the need for NEPs to
help in the prevention of those diseases and the linkage of people to care. In the U.S.:
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8,000 people are reported newly infected with HIV annually through sharing
contaminated syringes.
1/3 of people with HIV in the U.S. were infected directly through injection drug use.
An estimated 61% of AIDS cases among women are due to injection drug use or the
result of sexual contact with someone who contracted HIV through injection drug use.
Over 50% of all AIDS cases attributed to injection drug use were African Americans,
while Latinos account for nearly 25%.
15,000 people are newly infected annually with Hepatitis C through sharing syringes and
other contaminated injection equipment, with IDUs generally becoming infected with
Hepatitis C within two years.34
In 2009, Congress lifted the ban on the use of federal funds for NEPs, and President Obama
signed the Consolidated Appropriations Act of 2010 on December 19 finalizing the action.
However, no federal funding has been allocated for any needle exchange program to date.
III.
Delaware’s Needle Exchange Program
Delaware’s History
As noted in the opening Problem Statement, Delaware is the second smallest state in the nation
in terms of geographic size, yet its AIDS incidence rate is among the highest in the nation (19.8
cases per 100,000 residents in 2008), ranking consistently among the top 10 each year in the rate
of new AIDS cases per capita. Further, recent data indicates that the frequency with which AIDS
cases are being diagnosed in Delaware is increasing in comparison with other states. Delaware
ranked 10th in the nation in 2006 and 6th in 2007.1 The majority of new and existing HIV cases
in Delaware are attributable to needle sharing and/or unprotected sexual contact with someone
that has shared needles to inject drugs,2 with Delaware’s HIV infection rate from IDU more than
twice the national average.3 The potential reductions in new HIV infections from a NEP,
therefore, is significant.
Delaware’s history in implementing a NEP extends back to 1996, when the Substance Abuse
Treatment Services Evaluation Task Force first recommended consideration be given to
exploring strategies to reduce HIV transmission through infected needles and syringes in the
Report to the Delaware Legislature. A draft NEP bill was submitted to the Delaware State
Legislature that year but was not passed. Each year thereafter it was re-written and re-submitted.
Finally, on June 30, 2006, the State Legislature approved implementation of a NEP, effective
through February 2012, codified under Title 29, Subchapter VIII.5 The code includes basic
provisions regarding the structure of the NEP, plus allows for the provision of traditional public
health preventive and therapeutic services for other sexually-transmitted diseases, tuberculosis,
family planning, pregnancy, prenatal care, and nutrition.
6
Program Structure
The State Division of Public Health (DPH) administers the NEP, supported by an Oversight
Committee of local stakeholders. Together they developed a multi-phased Implementation
Plan35 in accordance with the legislation. Under the plan, NEP:
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Is a mobile program, operating from a van;
Operates in focused zip code areas of Wilmington with the highest HIV risk prevalence
as noted by epidemiological data;
Includes a one-for-one needle exchange;
Allows no “by proxy” exchanges (No one can exchange for someone else.);
Includes outreach, engagement, counseling, and case management;
Collects data on syringes exchanged, treatment, behavior, and referrals at every instance
of exchange to assure the program remains on tract;
Provides HIV testing;
Makes referrals to facilities for treatment of substance abuse, mental health, HIV/AIDS,
and other diseases;
Makes referrals for services such as housing, food, and clothing.
Successes
Delaware’s NEP has been extremely effective. Within affected communities, there have been
exceptionally high levels of cooperation and support of the program and no negative publicity or
reactions. Client participation has increased steadily as a result of the distribution of printed
materials and presentations to community groups, police officers, City Council, and various
other partners, with referrals coming from all partners, including local law enforcement. The
program maintains extensive records on both NEP participants and community residents who use
services on the NEP van. While current statistics exceed goals in almost all categories of
performance, DPH estimates that it will not be until year four or five that a direct link between
the pilot NEP and HIV/AIDS reduction can be shown conclusively in Delaware.
The successes of the pilot NEP—in numbers and design— are documented below, from program
inception through the end of state fiscal year 2010 (February 2007 - June 30, 2010), as follows:
Successes from February 1, 2007 through June 30, 2010
General Programmatic Successes:
Clients enrolled
829
Needles exchanged and incinerated
54,000+
HIV and Other Disease Prevention Services:
Rapid HIV screenings provided to NEP
390
clients
Rapid HIV screenings provided to
1,864
community members not in NEP
People tested for the first time for HIV
179
People newly diagnosed with HIV and
16 (9 NEP clients, 7 community members)
enrolled into care
NEP clients reporting reduced needle
28.6% versus 15% goal
sharing
7
Successes from February 1, 2007 through June 30, 2010
NEP clients enrolled in substance abuse
63% (130 of 206 referred)
treatment programs
HIV-infected individuals who were re11
connected with HIV treatment services
Design Successes
Model Program Design
Delaware’s NEP operates differently from
many other NEPs while using the best features
of some of them.
Effective Administration and Oversight
DPH administers the NEP, in cooperation with
an Oversight Committee inclusive of key
partners in the program.
Professional Operational Management
The NEP is operated currently by treatment
professionals with expertise and close working
relationships with other local treatment
programs, enabling streamlined referrals to
higher levels of care.
Partnerships
The NEP partners with City of Wilmington
Public Safety Department, Christiana Care
Health Services, grassroots community
organizations, local non-profits, Division of
Substance Abuse and Mental Health, and the
faith community.
Enrollment in Treatment
The NEP refers clients directly to drug and
medical treatment programs—not simply crisis
services.
Community Engagement
The NEP uses the Indigenous Leader Outreach
Model to engage and retain community
involvement in support and services.
Membership Recruitment
The NEP employs a model social networking
strategy, which encourages membership of
participants: 65% of all clients (454) were
referred by other clients (versus 20% goal)
Positive Relationship With Law
The program nurtures a positive relationship
Enforcement
with local law enforcement through on-going
reporting, updating, and education.
Law
enforcement itself has referred five people to
the program.
Safety of Law Enforcement Personnel
NEP supplies needle-resistant gloves to law
enforcement personnel to help reduce needle
stick injuries.
Cost Effectiveness
NEPS have been shown to be a cost-effective and cost-saving strategy for reducing HIV
transmission.4 The lifetime cost of prescriptions and medical treatment for one HIV-positive
person—exclusive of supportive services costs—is estimated to be as high as $618,000.33 The
8
cost of preventing HIV infection among one of the highest at-risk populations in Delaware
through NEPs is substantially less—approximately $230,500 annually for the current NEP.
Conservatively allowing that connecting to treatment each of the 16 persons who found they
were HIV-infected as a result of NEP testing prevents just one additional person being infected,
the program potentially has saved $9,888,000 in prescription and medical treatment funding—
exclusive of supportive services costs. These savings do not include the potential savings from
all other persons who reduced their risky behavior for becoming infected or transmitting HIV, as
well as other blood-borne diseases, as a result of NEP services. It is evident from these figures
that NEPs are a cost effective prevention measure in the fight against blood-borne illnesses
transmitted through injecting drug use.
IV.
Closing Recommendations for Delaware’s NEP
Since its implementation in February 2007, Delaware’s pilot NEP has become a key component
of the state’s HIV prevention and treatment strategy and effectively met its purposes as outlined
in the Delaware Code. With the sunset date of the pilot program nearing—February 2012—it is
critical that the program be re-authorized so that its benefits can continue into the future. At the
same time, modifications to the program are recommended in response to an evolving epidemic
and as a result of the experiences gathered during the pilot program period. Recommendations
for its continuance are grouped into three categories: capacity, flexibility and funding:
Recommendations for Delaware’s Pilot Needle Exchange Program
1. Increase the NEP’s Capacity to Serve More People:
a. Move the NEP’s status from “pilot” to “permanent”. Change Delaware Code Title
29, Subchapter VIII, removing references to “pilot” and making the program
“permanent” to assure that the NEP continues into the future.
b. Extend the NEP’s service area from “Wilmington” to “statewide”.
Statistics
maintained by the Division of Public Health (DPH) provide a picture of the evolving
nature of the HIV epidemic in Delaware. Areas of need regarding IDUs are not
confined to the portions of the City of Wilmington currently approved for a NEP. As
the epidemic further evolves, areas of need may shift with time.
2. Enhance Flexibility to Respond to Community Needs:
a. Provide DPH and the NEP Oversight Committee with the flexibility to approve new
locations throughout the state, as evidenced and justified by statistical need.
Approving the NEP as a statewide program is the first step in reaching other locations
of need, as justified by sound epidemiological data. DPH has proven an effective
administrator of the current NEP, is the administrator of federal HIV/AIDS dollars in
the state, and maintains statistics on the disease and information on emerging trends.
Providing DPH with the flexibility to approve NEP sites—with the approval of the
Oversight Committee and in conformance with the program’s Standard Operating
9
Procedures (SOP)—will assure successful implementation and operation of other
program sites within new partner communities.
b. Provide DPH and the NEP Oversight Committee with the flexibility to approve
individualized NEP structures that are most responsive to the needs of participants
and varying local communities. NEPs vary in design and operation with no one
model working best for all communities. They are most successful, however, when
they match good operational practices with the features of the community in which
they operate. In a report published in 2009 and submitted to the CDC, a group of
nationally-recognized NEP experts met to achieve consensus on the characteristics of
NEPs that maximize their effectiveness and to highlight best practices. Delaware’s
NEP contains many of the suggested best practice approaches. It also contains several
approaches the experts recommended avoiding because they limit effectiveness.
These include the following: (a) enforcing a mandated exchange ratio, such as “onefor-one”; (2) disallowing by-proxy exchange (allowing someone else to exchange
needles for another); and (3) limiting location and hours of operation.15 While these
three practices may or may not need inclusion in any particular NEP established in
Delaware, it is important that flexibility be provided to DPH to assure that the design
of a NEP satisfies the needs and concerns of a community, as well as program
participants. As with recommendation 2a, providing DPH with flexibility of program
design—with the approval of the Oversight Committee and in conformance with the
program’s SOP—will assure successful implementation and operation of new
program sites.
3. Funding:
a. Continue state funding for the NEP. The state of Delaware has supported the NEP
program through its budget process. In December 2009, the federal government
approved the use of federal dollars for NEPs but made no funding available to date
and may not make any available in the future. At the same time, the availability of
state dollars for the program assures that—should federal funding be budgeted along
the lines of a Medicaid-type program that requires cost-sharing allocations—
Delaware will be in a position to accept such federal dollars. The NEP has become a
key part of Delaware’s HIV prevention and treatment efforts. It is critical that state
dollars remain in place to continue the program.
b. Maintain and expand capacity to obtain any future federal funds released to support
this evidence-based and proven HIV prevention program. Again, although no federal
dollars are available to date, it is important to maintain current funding and expand
the capacity of the existing program to assure that Delaware can access federal dollars
when and if they become available.
V.
Annotated Bibilography (Attached)
10
References
1. Delaware Division of Public Health. 2008 Delaware HIV/AIDS Surveillance Report. 2008:1.
2. Delaware Department of Health and Social Services. Delaware Department of Health and Social
Services Legislative Proposal Form SFY 2011. 2010:2.
3. Delaware Division of Public Health. Needle Exchange and Community Outreach, Questions and
answer about the need in Delaware. October 2009:1.
4. amfAR AIDS Research. Fact Sheet No. 1, Revised November 2007. The Effectiveness of Harm
Reduction in Preventing the Transmission of HIV/AIDS. Available at http://www.amfar.org/
uploadedFiles/In_the_Community/Publications/The%20effectiveness%20of%20 harm%20reduction. pdf.
5. Title 29 DE Code. Chapter 79.Department of Health and Social Services, Subchapter VIII Sterile
Needle and Syringe Exchange Pilot Program for Prevention of AIDS and Other Diseases [Subject to
sunset according to the term of Subsection 7997 of this title . Subsection 7992 (a)(b).
6. Delaware Division of Public Health. 2009 End-of-Year Report-Delaware 5-Year Pilot Needle
Exchange Program. 2009:2-10.
7. Delaware HIV Consortium Planning Council and Delaware Division of Public Health. 2010-2014
Comprehensive HIV Prevention Plan and Statewide Coordinated Statement of Need. 2009:3-101.
8. National Alliance of State & Territorial AIDS Directors. Health Department Role in Expanding
Syringe Access:1.
9. New York State AIDS Advisory Council. Report on Needle Exchange Programs and Deregulation of
Needles and Syringes.1996. Available at: http://www.health.state.ny/us/diseases/aids/workgroups/aac
/docs/needleexchangeprograms.pdf.
10. Wodak A, Cooney A. Effectiveness of Sterile Needle and Syringe Programs. Int J Drug Policy. 2005;
16s:S31-S44.
11. Strathdee SA, Patrick DM, Currie SL, et al. Needle Exchange is not Enough: Lessons from the
Vancouver Injecting Drug Use Study. AIDS. 1997; 11(8):F59-65.
12. Des Jarlais DC, Perlis T, Arasteh K, Torian LV, Beatrice S, Milliken J, Mildvan D, Yancvitz S.
Friedman SR. HIV Incidence among Injection Drug Users in New York City, 1990 to 2002. Use of
Serologic Test Algorithm to Assess Expansion of HIV Prevention Services. Am J Public Health. 2005;
95(8): 1439-44.
13. amfAR AIDS Research. FactSheet Public Safety, Law Enforcement, and Syringe Exchange, January
2010. Available at http://www.amfar.org/uploadedFiles/In_the_Community/Publications/factsheetJan
2010.pdf.
14. Centers for Disease Control. Syringe Exchange Programs December 2005. Available at:
http://cdc/gov/idu/facts/aed_idu_syr.pdf.
15. Bluthenthal, R, Clear A, Des Jarlais D, Friedman S, Grove D, Hagan H, Heimer R, Heller D, Kral, A,
Sherman S, Tolbert R. Results of A Consensus Meeting. Recommended Best Practices for Effective
Syringe Exchange Programs in the United States. 2010: 4, 17, 26.
16. Syringe Exchange Programs: Frequently Asked Questions. Updated June 2009. Available at:
http://saveneedleexchange.org/syringe_exchange_faq/.
17. National Institutes of Health. Consensus Development Statement. Interventions to prevent HIV risk
behaviors. February 11-13, 1997:7-8.
18. Shalala, DE. Needle Exchange Programs in America: Review of Published Studies and Ongoing
Research. Report to the Committee on Appropriations for the Departments of Labor, Health and Human
Services, Educations and Related Agencies. February 18, 1997.
19. U.S. Department of Health and Human Services (HHS). Evidence-Based Findings on the Efficacy of
Syringe Exchange Programs: An Analysis for the Assistant Secretary for Health and Surgeon General of
the Scientific Research Completed since April 1988. Washington, D.C.: U.S. Department of Health and
Human Services; 2000.
20. Centers for Disease Control. 2007 review of 185 NEPs in the U.S. and Puerto Rico. Available at http:
11
//www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a4.htm.
21. Des Jarlais, et al.. HIV incidence among injection drug users in New York City, 1990 to 2002.
AJPH.2005;95(8):1439-1444.
22. Kwon J; Iversen, J, Maher L, Law M. Wilson D. The Impact of Needle and Syringe Programs on
HIV and HCV Transmissions in Injecting Drug Users in Australia: A Model-Based Analysis. 2008.
23. Strathdee SA, Celentano DD Shah N, Lyles C, Stambolis VA, Macalino G, Nelson K and Vlahov D.
(1999). Needle-exchange attendance and health care utilization promote entry into detoxification.Journal
of Health Issue: Volume 76, vol. 4, P:448-460, Springer Boston
24. Watters J, Estilo J, Clark G, Lorvick J. Syringe and Needle Exchange as HIV/AIDS Prevention for
Injection Drug Users. JAMA 1994:271(2):115-120.
25. Martinez JB. Narrative: Science-based literature on Syringe Exchange Programs (SEPS) 1996-2007.
October 9, 2007.
26. Marx MA, Crape B, Bookmeyer RS, Junge B, Latkin C, Vlahov D, Strathdee SA. Trends in Crime
and the Introduction of a Needle Exchange Program. AM J Public Health. 2000; 90(12):1933-1936.
27. Center of Innovative Public Policies, Inc. April 2001. Needle Exchange Programs: Is Baltimore a
Bust?
28. Heimer R, Khoshnood K, Bigg D, Guydish J, Junge B. 1998. Syringe use and reuse: Effects of
syringe exchange programs in four cities. Journal of Acquired Immune Deficiency Syndromes and
Human Retrovirology 18 (Supplement 1): S37-S44.
29. Hogan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. 2000.Reduced injection
frequency and increased entry and retention in drug treatment associated with needle-exchange
participation in Seattle drug injectors.Journal of Substance Abuse Treatment 19(3):247-252.
30. Doherty MC, et al. Discarded Needles Do Not Increase Soon After the Opening of a Needle Exchange
Program. American Journal of Epidemiology 1997;145(8):730-737.
31. Kaplan EH, Heimer R.A Circulation Theory of Needle Exchange. AIDS. 1994;8(5):567-574.
32. Delaware Pilot Needle Exchange Program. Standard Operating Procedures.
33. Schackman, BR et al. (2006). The Lifetime Cost of Current Human Immunodeficiency Virus Care in
the United States. Medical Care, 44,11:990-997. Results: From the time of entering HIV care, per person
projected life expectancy is 24.2 years, discounted lifetime cost is $385,200,and undiscounted cost is
$618,900 for adults who initiate ART with CD4 cell count _350/_L. Seventy-three percent of the cost is
antiretroviral medications, 13% inpatient care, 9% outpatient care, and 5% other HIV-related medications
and laboratory costs. For patients who initiate ART with CD4 cell count _200/_L, projected life
expectancy is 22.5 years, discounted lifetime cost is $354,100 and undiscounted cost is $567,000. Results
are sensitive to drug manufacturers’ discounts, ART efficacy, and use of enfuvirtide for salvage. If costs
are discounted to the time of infection, the discounted lifetime cost is $303,100.
34.Harm Reduction Coalition. Statistics available at http://www.harmreduction.org/article.php?list=type
&type=49.
35. Division of Public Health. Pilot Needle Exchange Program Implementation Plan.
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