Needle exchanges, long credited with helping to slow the spread of infectious diseases by public health experts, have made inroads in recent years, even in states traditionally opposed to them.
A ban on federal funding for needle exchanges was lifted earlier this year. States including Ohio, Kentucky, and West Virginia have made it easier, or in some cases possible for the first time, for programs to operate. Even Vice President-elect Mike Pence, who resisted needle exchanges on moral grounds, repealed a ban on syringe exchanges as governor of Indiana when confronted with an HIV outbreak (albeit too slowly for many experts).
New data released by federal health officials Tuesday further demonstrated the value of needle exchanges, suggesting they had contributed to a major reduction in new HIV infections among people who inject drugs.
But the report also included some warnings. There aren’t enough needle exchanges or clean needles being supplied, and few drug users use only sterile syringes, researchers from the Centers for Disease Control and Prevention found. Plus, changes in the demography and geography of drug users suggest problems to come.
In particular, increased injected drug use among young white people, who also share needles more often than black or Hispanic drug users, “challenge[s] the decades of progress in HIV prevention” among drug users, the researchers found.
The concern stems in part from a ballooning opioid crisis and a recent surge in some places of hepatitis C infections, which are also associated with intravenous drug use and can foretell the spread of HIV.
Overall, the number of HIV diagnoses among people who inject drugs fell by 48 percent from 2008 to 2014, although the declines slowed in recent years, the researchers found. But when broken down by geography and race, the numbers show some worrisome trends.
Black and Hispanic drug users, whether they lived in cities or not, saw roughly 50 percent drops in HIV diagnoses over the time span.
But white drug users in urban areas only witnessed a 28 percent decline in diagnoses from 2008 to 2012 and no progress from 2012 to 2014. In suburban and rural areas, where a growing opioid epidemic has primarily taken hold, white drug users experienced a 28 percent drop in HIV diagnoses from 2008 to 2010 but no decline from 2010 to 2014.
In 2014, for the first time, a larger number of white drug users received an HIV diagnosis than drug users of any other race or ethnicity, the CDC found.
The CDC researchers also looked at the practice of drug users in 22 cities and found that differences in protective behavior could account in part for why black drug users saw greater drops in HIV cases than white drugs users.
Black drug users were less likely to share syringes than white drug users, and whites are making up an increasing share of new drug users. White people start injecting drugs when they are younger than black drug users and are less likely to seek clean syringes for all their injections.
While black and Hispanic drug users shared syringes less frequently from 2005 to 2015, the percentage of white drug users who shared needles did not change, the survey data showed.
Overall, only 1 out of 4 drug users get all of their syringes from a sterile source, the CDC found.
Part of the problem, the researchers said, is that exchanges do not provide as many clean syringes as people who use drugs need and that many places still do not have programs up and running. That challenge is particularly acute in rural areas, which are largely white and, the researchers said, “include some of the most vulnerable populations for injection drug use and injection drug-use related HIV outbreaks.”
Needle exchange programs do not just provide clean syringes. They often test for HIV and hepatitis B and C, distribute condoms or the antidote for opioid overdoses, and help those who want to enter substance abuse treatment find a program.
Public health experts who were not involved with the new report said it affirms the benefits needle exchange programs have shown in other places.
In Baltimore, which has had a needle exchange van for two decades, 63 percent of new HIV infections in 1994 came as a result of intravenous drug use. In 2015, only 8 percent of new infections were from shared injection tools.
“Programs like ours in Baltimore that do needle exchange are effective,” said Dr. Leana Wen, the city’s health commissioner. “We have seen the efficacy of programs that reach people where they are.”
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The question hanging in the air now is whether the putative safe injection site initiatives in cities like Seattle will be given a chance to demonstrate their value before a federal crackdown on harm prevention.
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