No Place to Sit

This month I’ve been working on a research paper looking at needle syringe exchange (NSE) programs and whether or not they were cost effective. I finished the paper last week, and have been meaning to write to you all about it, but have been busy finishing up psych rotation in nursing school. Today however, some exciting news has come out, Governor Jerry Brown has signed into law two pieces of legislation: SB 41 and AB 604. Both bills work to move the power of regulating syringe exchange from the municipal level to the state level, thereby making the way California approaches syringe exchange more uniform. SB 41 will make it legal for pharmacies to sell syringes to people without a prescription anywhere in California; and AB 604 will move the power to establish NSE from local jurisdiction to the California Department of Public Health.

This is especially exciting for me because I worked on a project to gather signatures in support of these bills for a class on hepatitis. People are understandably reticent to remove power from local governments, but in this case it makes a lot of sense, because it’s hard for any local official to come out on the side of NSE and not get attacked for it. Public health issues should be taken out of the political arena where getting reelected matters more than the health and safety of the electorate.

However, I’m not popping open a bottle of bubbly just yet. When I started researching the issue of the cost-effectiveness of NSE I could only find scholarly articles that supported the thesis that they are indeed cost effective; it seemed like an open and shut case. I was elated. I love being right, I especially love being super duper right. I kept looking though, because my paper required at least one article that refuted my stance. I tried finding the sources the people who were squarely against NSE were quoting. It was a circular goose chase with no one reputable leading. I read over the papers I had in favor of NSE and realized that the evidence for the cost-effectiveness of NSEs all depended on them preventing transmission of HIV. The idea is that the money saved in not having to pay for a person’s HIV care will more than cover the cost of the NSE program. All of the papers I read showed this to be the case, however they also all acknowledged that they were unable to know for certain how many cases of HIV these programs were preventing. The problem is you can’t do a randomized controlled study to determine the efficacy of NSE; what are you going to do- withhold clean needles from a given population? If there is an NSE in an area the influx of needles related to it will affect users who don’t use the program just by nature of there being more clean needles in circulation.

With this new understanding I looked for papers that judged the efficacy of the programs at preventing HIV transmission instead of cost-effectiveness. I found an article that reviewed the reviews of NSE programs. What they found was that researchers tended to explain away data that didn’t support the effectiveness of NSE. I understand this, it comes from the mental pain caused by data not supporting common sense. Sharing needles is the main mode of transmission among IV drug users (IDUs), ergo, if you give them clean needles transmission rates will go down. It’s not rocket science; unfortunately, as with most things dealing with human behavior, it’s actually more complicated than rocket science. The review found that there was evidence to support the efficacy of NSE in preventing HIV transmission, but it was tentative. They also found that there was insufficient evidence to support the efficacy of NSE in preventing HCV, which isn’t surprising if you consider how much easier  it is to transmit HCV than HIV.

The review wasn’t able to take into account comparisons of different programs, it was looking at general efficacy, and in NSE all programs are not equal. They learned this in Vancouver, Canada, home of North America’s first supervised injection facility, and home to an epic battle against high rates of HIV among IDUs. Looking at Vancouver over the past 13 years or so you can see that just starting NSE wasn’t enough, they were not able to significantly reduce dangerous behavior, such as needle sharing, until they they made clean needles readily available and easily accessible. They did away with the one for one policy (a literal exchange) and just gave people how many needles they said they needed and made collection a separate event. In effect, they had to saturate Vancouver in order to significantly affect behavior.

So this is why I’m not popping the bubbly just yet. I’m afraid that when the state comes in they either won’t do enough, or the local governments will undermine the programs where they are not wanted. This will lead to insufficient programs that will add more evidence to the idea that NSE is ineffective.

However, a bright (?) spot in all of this is that HIV related costs are so incredibly high that you only need NSE to be minimally effective in order to render the programs cost-effective, and that is why all the articles come to the conclusion that NSE is cost-effective.

(Un-cited (sorry it’s not graded and I’m not adding citations) References:

Belani, H. K., Muennig, P. A. (2008) Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New York City. Journal of HIV/AIDS &Social Services, 7(3), 229-240.

Buchner, C., Kerr, T., Montaner, J., Small, W., Wood, E., Zhang, R. (2010) Syringe sharing and HIV incidence among injection drug users and incresed access to sterile syringes. American Journal of Public Health, 100(8), 1449-1454.

Goldberg, D., Hickman, M., Hutchinson, S., Kimber, J., Palmateer, N., Rhodes, T. (2009) Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews. Addiction, 105, 844-859.

Pinkerton, S. (2010) Is Vancouver Canada’s supervised injection facility cost-saving? Addiction, 105, 1429-1436.