BlaineThe use of contaminated needles to inject drugs is a main line to continuing the spread of bloodborne pathogens, including the viruses that cause AIDS and chronic hepatitis. The ravages of AIDS have become well understood by our society, but even as we make great strides forward in controlling the replication of the HIV virus in infected individuals, we have not been able to halt the spread of the virus through our population. Hepatitis viruses, especially HCV, loom on the horizon as an even greater chronic disease burden, with injection drug use, even once, a primary risk factor for infection. Of particular concern to health care workers is the prevalence of these viruses in the population as it translates into increased risk of infection from contaminated blood in the event of accidental exposure on the job.

Injection drug use is linked to almost one-third of all AIDS cases and one-half of hepatitis C cases. Seroprevalence rates of hepatitis B and hepatitis C among injection drug users can exceed 90 percent. At present there are no vaccines available for HIV or HCV, and virus transmission through injection drug use has a cascading effect into the population through other modes of spreading infection.

Prevention is our best weapon in combating the spread of these killer viruses. But what prevention methods are we willing to use?

The devastating consequences of injection drug use are certainly not limited to AIDS and hepatitis. Illegal drug use and the industry that fuels it are associated with crime, family disintegration, child neglect and neighborhood decay, with enormous health, social and economic costs. It is important to use all effective measures to prevent injection drug use.

Providing needles to drug users is not the kind of prevention measure that would intuitively seem to address the drug abuse problem. Many argue, however, that syringe exchange programs offer an effective means both of curtailing the spread of further disease, and of providing the kind of outreach that brings drug users into treatment programs.

Syringe exchange programs (SEPs) allow injection drug users (IDUs) to swap used needles for clean, uncontaminated ones, promoting the “one-time-only use of sterile syringes” supported by a comprehensive list of medical organizations and governmental bodies. At the same time, SEPs present an opportunity for referral to drug treatment programs, HIV/AIDS education and counseling, screening for tuberculosis, hepatitis B, hepatitis C and other infections, hepatitis B vaccination, and distribution of alcohol swabs to help prevent abscesses and other bacterial infections. Syringe exchange programs can be successful in reaching an otherwise unreachable population, and providing “teachable moments.” Studies show reduction in risk behavior attributed to SEPs as high as 80 percent, with estimates of a 30 percent or greater reduction of HIV in IDUs.

Providing syringes that are intended for use to inject illegal drugs is a concept that challenges our sense of right and wrong. At worst, it can be construed as the equivalent of providing the gun to commit a crime. At the least, it can send the mixed message that the crime may be tolerable. From a law enforcement perspective, the problems created by illegal drug use itself may be seen to supersede the problems created by the spread of HIV or HCV viruses. Further, law and drug enforcement agencies are more generally committed to a “zero tolerance” approach, heavily weighted with emotionalism and symbolism.

Do syringe exchange programs encourage more drug use? Or do they simply remove contaminated needles from circulation? Or do they go further, and provide very vulnerable members of our population access to much needed health care services, thus better protecting us all?

Studies reported by the Surgeon General, CDC and NIH, among others, have found that SEPs do not encourage use of illegal drugs, do not increase neighborhood disposal of used syringes (which are exchanged), and encourage entry into drug treatment programs with good success rates.

Data can sometimes be set aside, however, as the topic of syringe exchange remains one that pits a strict concern for public health against a strong concern for public symbolism.

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Ellen Blaine