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HIV Transmission in Intravenous Drug Users and the Effectiveness of

Needle Exchange Programs in the United States
By Mathew Ciesla
Introduction

The use of intravenous drugs (ID) is a large and continually growing issue within the

United States. These drugs, which include morphine, cocaine, methamphetamines, and heroin are

injected directly into the circulatory system via a syringe. Perhaps the most widely known of

these is heroin; An opioid made from morphine which is extracted from the seeds of poppy

plants (NIDA, 2021a). There are several risk factors associated with ID use ranging from

collapsed veins, overdoses, and the spread of sexually transmitted diseases or infections

(STD/STI). In an effort to combat the spread of STDs through the ID user populations, needle

exchange programs (NEP) have been operating in many cities across the country. In addition to

providing clean needles, these programs frequently offer counseling and rehabilitation services

as well. It is the purpose of this case study to investigate the impact that NEPs have had on the

spread of STDs, specifically HIV in ID using populations.

Heroin Use and HIV Risk

According to the National Survey on Drug Use and Health (NSDUH), between the years

2002 and 2018 there was a 201% increase in heroin use in the United States (SAMHSA, 2017,

2019). In 2002, there were ~214,000 reported heroin users. By the year 2018, that number had

risen to ~646,000 (SAMHSA, 2019). The largest number of users being in the category of 18-25

years old (SAMHSA, 2017). Heroin itself is a highly addictive opioid which when taken, binds

to the mu-opioid receptors in the brain resulting in a surge of pleasurable feelings often referred

to as a “rush”. This is also accompanied with the sensation of heavy limbs, flushing of the skin,
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and dry mouth (NIDA, 2021b). However, long term use of heroin has many negative side effects.

These include necrotizing fasciitis at injection sites, deep vein thrombosis (DVT), tolerance

increase, subacute bacterial endocarditis (SABE), STDs, and overdoses (Cornford & Close,

2016).

With regard to STDs, users of IDs are highly susceptible to HIV infection. This is a

compounding result due to the cost of the drug itself and the cost of the equipment needed to

inject (e.g., needles and syringes). Therefore, many ID users in lower socioeconomic levels will

share or reuse needles, increasing their risk of contracting HIV. Indeed, Abdala, Reyes, Carney,

and Heimer (2000) showed that the HIV-1 virus can continue to be infectious inside of a syringe

for up to 42 days at 4°C (39.2° F) and up to 21 days at 20°C (68°F). This makes the likelihood of

HIV transmission through shared needles, incredibly high. In the year 2019, there were ~36,337

new cases of HIV reported in the United States. Of those, 2,480 (6.8%) were attributed to the use

of IDs (CDC, 2019). In fact, users of IDs are 22 more times like to contract HIV, than non-users

(UNAIDS, 2018). Laws which have attempted to criminalize the use of heroin and other IDs

have failed, leading to riskier and more subversive use of the drugs. According to Bluthenthal,

Lorvicks, Kral, Erringer, and Kahn (1999), due to criminalization laws, users are up to 2 times

more likely to share needles and other drug paraphernalia. It has also led to users being less

likely to seek testing, care, and rehabilitation services, increasing the risk of HIV exposure and

transmission.

Needle Exchange and Syringe Service Programs

In recent years, the United States has seen a rise in needle exchange or syringe service

programs (NEP or SSP). Intravenous drug users bring in their used needles and are provided new

needles in exchange under the concept that this will help alleviate the spread of HIV. The first
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known NEP in the US began with a student at Yale University distributing sterile needles to

users in New Haven, Connecticut, in 1983. To date, there are approximately 200 NEPs operating

in 33 states and the District of Columbia (NASEN, 2021). There are two main models of NEPs:

one for one (1:1) and secondary syringe exchanges (SSE). The 1:1 system operates in exactly the

way it sounds. Users bring in a needle and receive a sterile needle in return. The SSE, however,

utilizes ID users to collect and hand out sterile needles within their community, rather than a

centralized exchange location. Due to criminalization, users may be less likely to come to

centralized location due to fear of being arrested. Therefore, the SSE model has been shown to

effectively provide risk-reduction and rehabilitation services (Snead et al., 2003). In addition to

exchanging needles, NEPs also offer a range of care services including testing of STDs,

vaccines, distribution of sexual health materials, counseling, and rehabilitation services (Arzt,

2021).

Despite the many services that NEPs provide, there are some who argue that there are

potentially more negative side effects to both the local community and users that they service.

Some of these negative effects include lowering the perception of the danger that ID use causes,

an increase in discarded needles thereby increasing safety hazards to the community, and also

sending the message of “approval” from governmental entities (NRC & USIM, 1995). In fact, as

of 2016, it is prohibited for NEPs to be supported using federal funds (Weinmeyer, 2016). Due to

the controversial nature of NEPs, many studies have been done attempting to evaluate their

effectiveness. These studies range from new HIV infection rates, negative consequences of the

NEPs, as well as ID users who take part in the programs and are rehabilitated. The next section

of this case study will attempt to unify some of these findings and make a determination.
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By the Numbers: The Effectiveness of NEPs in the United States

The first and perhaps largest issue to be addressed is the infection and transmissions rates

of HIV in communities which provide NEP resources. Exchange programs claim that their

services are vital in helping reduce the spread of HIV in ID users and the numbers agree. A 2003

simulation study in the Journal of Urban Health forecasted the spread of HIV in ID users both

with and without access to NEPs. Their simulation showed that without NEP access, the rates of

transmission were as high as 90.2 per 100 individuals. Conversely, regular NEP attendance

resulted in a peak at 21.8 per 100 individuals, a 76% decrease (Radboud, Boily, Rajeswaran,

O'Shaughnessy, & Schechter, 2003). Studies of empirical data also support the effectiveness of

NEPs in reducing the spread of HIV (Cornford & Close, 2016; Packham, 2019; UNAIDS, 2018).

A systemic review of the New York State NEP showed a decrease in HIV prevalence from 50%

in 1990 to 17% in 2002 (CDC, 2016). In fact, it is estimated that NEPs have reduced the spread

of HIV in the US by one third to two fifths (NIH, 1997).

Other questions regarding NEPs such as crime rates, increased ID use, and cost must also

be addressed. However, to date there is no evidence which suggests an increase in any of the

aforementioned activities. Crime rates in and around exchange points have shown no significant

increases from before the exchange opening (Marx et al., 2000; NHRC, 2006). There is also no

evidence that heroin or other ID use increases with access to an NEP (Arzt, 2021; NRC & USIM,

1995). With regard to funding costs, NEPs are shown to reduce total government spending on

HIV and rehabilitation treatment. From a national perspective, for every dollar spent on

exchange programs, $7.58 are returned (Nguyen, Weir, Des Jarlais, Pinkerton, & Holtgrave,

2014). An analysis of the New York State program showed a return of $1,300 to $3,000 per

individual through rehabilitation, disease treatment, and individual societal contribution (Belani
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& Muennig, 2008). Additionally, individuals who participate in NEPs are nearly 5 times more

likely to succeed in drug rehabilitation and treatment programs, than individuals who do not

(Brooner et al., 1998). This naturally increases the lifespan of the individual, making them a

more productive member of society long-term.

Conclusion

The purpose of this case study was to review the effectiveness of needle exchange

programs in preventing the transmission of HIV in intravenous drug users. With the use of

intravenous drugs on the rise in the United States, interventions such as exchange programs are

vital to minimizing the risks of HIV to their users. Though, some would argue that exchange

programs present more harm than good through increasing risk-taking behavior, costing taxpayer

money, and further increasing the use of intravenous drugs. However, based upon the evidence

presented herein, it can be concluded that needle exchange programs are indeed highly effective

at reducing the rates of HIV in user populations. It has also shown that concerns regarding

exchange programs are unfounded with no data showing direct correlation to crime rates, drug

use, or high government costs. Rather, the addition of exchange programs to a community show

a general reduction in governmental costs related to disease treatment and drug use. Overall, the

establishment and funding of needle exchange programs should have a higher priority within

local, state, and federal governments to assist in the reduction in HIV rates and drug use in their

communities.
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