For decades, public health experts have known that syringe exchange programs reduce the spread of certain viral infections — like H.I.V., hepatitis B and hepatitis C — by removing contaminated syringes from circulation.
They have known that programs using sterile injection equipment are both safe and save money.
And yet they are rarely seen in the United States.
Evidence abounds that they work. A study of the first American program — started in the Tacoma, Wash., area in 1988 — found that use of the exchange was associated with a greater than 60 percent reduction in the risk of contracting hepatitis B or C. Another study of over 1,600 injection drug users in New York found that those who didn’t use a syringe exchange in the early 1990s were more than three times as likely to contract H.I.V.
Syringe exchange programs do more than improve health. Because they are so effective and far cheaper than the lifetime cost of treating H.I.V., hepatitis B or hepatitis C, they save taxpayers money. A cost-effectiveness analysis published in 2014 replicated the findings of others that came before it: A dollar invested in syringe exchange programs saves at least six dollars in avoided costs associated with H.I.V. alone.
The most frequently expressed concerns about the programs are that they promote drug use and raise crime levels. But according to many studies, that isn’t so. Instead, they are associated with increased participation in treatment programs.
Syringe exchange programs “reduce not only infectious disease but also create an opportunity for people to get the care and provide a transition into treatment for people in the community,” said Michael Botticelli, director of the federal Office of National Drug Control Policy, at an event sponsored by the Chamber of Commerce of northern Kentucky, a region hit hard by illegal drug use.
In the 1990s and early 2000s, seven evidence reviews for federal government agencies reaffirmed that syringe exchanges were effective, safe and cost-effective. Since then, numerous other studies of programs have replicated these results, including a systematic review by the World Health Organization and another by the United Nations. These include examination of exchange programs outside the United States, such as those in Canada and Australia.
Syringe exchanges are endorsed by the 2015 National H.I.V./AIDS Strategy for the United States and the 2012 President’s Emergency Plan for AIDS Relief Blueprint. The American Medical Association says they work.
With all this evidence and the official endorsements, you’d think the government would generously fund syringe exchanges. But just as the first program opened in 1988, Congress prohibited federal funding for any such programs. With the exception of a few years, that moratorium held until this year. Though federal funds may now be used to support syringe exchanges, they still may not be used to buy injection equipment.
Although most states and local governments limit or prohibit syringe exchange programs, some restrictions have been lifted, offering additional opportunities to study their effects. For example, in 2008, the District of Columbia’s syringe exchange funding ban was lifted, and several programs began offering harm reduction and exchange services. One study found that the funding ban’s lift was associated with a 70 percent drop in new H.I.V. cases tied to injection drug use.
“Policies that limit syringe access are not in the best interest of public health,” said Sean Allen, an infectious disease and public health researcher at Johns Hopkins University and a co-author of the study. “Syringe services programs can prevent new H.I.V. infections, but they need to be accessible to work.”
Today, injection drug use — notably, of heroin — is on the rise and has led to outbreaks of H.I.V. in some communities. In response, some leaders, like Gov. Mike Pence of Indiana, the Republican vice-presidential nominee, have reversed course and embraced the programs.
Today, only about 200 syringe exchange programs are operating in 33 states. In many areas where they could do a lot of good, resistance to them remains strong.