Revisiting the Ban on Federal Funding for Syringe Exchange Programs
With HIV infection rates persisting at high levels in the United States, it’s time we faced the facts. Science and policy are disconnected. In the United States, the sharing of contaminated needles during injection drug use accounts for 7-14% of new HIV infections each year.1 Syringe exchange programs, which facilitate the trade of used syringes for free, sterile replacements, have been shown to substantially reduce the likelihood of HIV transmission through needle sharing.2 But in 2011, only two years after a landmark decision to allow federal funding for syringe exchange programs, the ban was renewed as the process of a political compromise on a general spending bill. Just as they did decades ago when the original ban was instated, public health officials continue to denounce the ban on federal funding for syringe exchange programs as a policy that is counter to what science tells us is a sensible and cost-effective public health strategy.
In 1988, during an escalating war on drugs, a ban on the use of federal funds for syringe exchange programs was instated due to the widely contested belief that such programs promote drug-using behavior. In 2009, public health officials praised Congress for lifting the 21-year ban. But by the time the ban was reinstated in 2011, the programs had become a negotiation asset used to bargain for a final budget. With a gridlocked government unable to finalize a spending bill for the upcoming fiscal year, the looming government shutdown forced compromises on both sides of the political divide. Republican leaders approved President Obama’s spending bill in exchange for a number of concessions, including the renewal of the ban on federal funding for syringe exchange programs.
The reinstatement of the ban ran contrary to countless studies on the efficacy of syringe exchange programs as HIV prevention strategies. Certainly, needle exchange programs are no cure-all for bloodborne diseases, and other routes of transmission that are untouched by these programs make up a much larger proportion of total HIV infections. However, one seminal study estimated that a federal needle exchange program could have reduced infections by 15-33% in the early stages of the AIDS epidemic.2 Every used syringe could potentially lead to new infections, and without federal funding for these programs, locally funded exchanges can cover only 3% of injections that occur every year.3
Critics of syringe exchange programs argue that they represent an implicit approval of drug-using behavior by the government and can lead to increases in drug use. But numerous studies have shown no connection between the presence of an exchange program and increases in injection drug use or promotion of needle-sharing behavior.4 In fact, one study on a syringe exchange program in San Francisco found that the presence of the program led to a decline in the median number of injections from 1.9 per day to 0.7 per day.5 This may be because many syringe exchange programs provide services that refer the largely disconnected population of injection drug users to drug rehabilitation clinics.
While some opponents of federal funding for exchange programs cite budgetary constraints, a cost-benefit analysis of needle exchange programs reveals that these programs would in fact save money by reducing long-term treatment costs for HIV. Hypothetical models predict that a full-coverage program that exchanges all used syringes in the United States would cost approximately $423 million but avert $1.3 billion in medical care and treatment costs.6 To put it simply, it can cost between $300,000 and $600,000 to treat an individual with HIV over a lifetime. A clean needle costs less than $1.7
There must be an honest reappraisal of the scientific evidence that demonstrates the costs and benefits of reversing the ban on federal funding for needle exchange programs. At the very least, syringe exchange programs, and the human lives that can be affected by them, should not be relegated to a role as bargaining chips on the political table.
CDC. HIV surveillance in injection drug users through 2010. 2012.
Lurie, Peter, and Ernest Drucker. “An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA.” The Lancet 349, no. 9052 (1997): 604-608.
Nguyen, Trang Q., et al. “Increasing investment in syringe exchange is cost-saving HIV prevention: modeling hypothetical syringe coverage levels in the United States.” Presentation, XIX International AIDS Conference, Washington, D.C., July 23, 2012.
Guydish, Joseph, Jesus Bucardo, Martin Young, William Woods, Olga Grinstead, and Wayne Clark. “Evaluating Needle Exchange: are there negative effects?.” Aids 7, no. 6 (1993): 871-876.
Watters, John K., Michelle J. Estilo, George L. Clark, and Jennifer Lorvick. “Syringe and needle exchange as HIV/AIDS prevention for injection drug users.” JAMA: the journal of the American Medical Association 271, no. 2 (1994): 115-120.
Holtgrave, David R., et al. “Cost and cost-effectiveness of increasing access to sterile syringes and needles as an HIV prevention intervention in the United States.” JAIDS Journal of Acquired Immune Deficiency Syndromes 18 (1998): S133.
Schackman, Bruce R., Kelly A. Gebo, Rochelle P. Walensky, Elena Losina, Tammy Muccio, Paul E. Sax, Milton C. Weinstein, George R. Seage III, Richard D. Moore, and Kenneth A. Freedberg. “The lifetime cost of current human immunodeficiency virus care in the United States.” Medical care 44, no. 11 (2006): 990-997.