Delaware HIV Consortium
Policy Committee and Planning Council
September 2010
Needle Exchange Program White Paper:
Justification for Continuation and Expansion of the Delaware Needle Exchange Program

Delaware HIV Consortium Policy Committee
Delaware Needle Exchange Program
White Paper
September 2010
I.
Introduction
Problem Statement
Delaware is the second smallest state in the nation in terms of geographic size, yet its AIDS incidence rate is among the highest in the nation (19.8 cases per 100,000 residents in 2008), ranking consistently among the top ten each year in the rate of new AIDS cases per capita.
Further, recent data indicates that the frequency with which AIDS cases are being diagnosed in
Delaware is increasing in comparison with other states (10 th
in the nation in 2006; 6 th
in 2007).
1
The majority of new and existing HIV cases in Delaware are attributable to needle sharing and/or unprotected sexual contact with someone that has shared needles to inject drugs, 2 with
Delaware’s HIV infection rate from injecting drug users (IDUs) more than twice the national average.
3
Needle exchange programs (NEPs)—also called syringe exchange programs (SEPs), syringe access programs (SAPs), and syringe services programs (SSPs)—have become a mainstream approach to substance abuse and HIV prevention in many countries for over twenty-five years.
4
In 2006, the state of Delaware initiated a five-year pilot NEP in portions of the City of
Wilmington for two primary purposes: (1) preventing the transmission of blood-borne illnesses including HIV and the hepatitis B virus; and (2) providing IDUs with referrals to appropriate treatment and other health and social services programs.
5
In three years of operation, Delaware’s NEP has been successful in meeting or exceeding the majority of the goals established in its Implementation Plan and has become a key component of the state’s HIV prevention and treatment strategy.
6,7 Highlights of the program’s accomplishments from inception through fiscal year 2010 (February 1, 2007 through June 30,
2010) include the following:

1,864 rapid HIV screenings provided to NEP clients and community members

179 persons tested for HIV for the first time

16 persons newly diagnosed with HIV enrolled into medical care

11 formerly-diagnosed HIV-positive persons re-connected to medical care

130 NEP clients enrolled into substance abuse treatment programs

28.6% of clients reporting reduced needle sharing
As Delaware’s NEP nears its sunset date of February 2012, the Delaware HIV Consortium
Planning Council, the Consortium’s Policy Committee, and other supporters have made the following recommendations for its continuation, grouped into three categories: capacity, flexibility and funding. Expanded justifications and explanations for the recommendations are provided on pages 9 and 10.
1

Recommendations for Delaware’s Pilot Needle Exchange Program (NEP)
1.
Increase the NEP’s Capacity to Serve More People: a.
Move the NEP’s status from “pilot” to “permanent”. b.
Extend the NEP’s service area from “Wilmington” to “statewide”.
2.
Enhance Flexibility to Respond to Community Needs: a.
Provide the Division of Public Health (DPH) and the NEP Oversight Committee with the flexibility to approve new locations throughout the state, as evidenced and justified by statistical need. b.
Provide DPH and the NEP Oversight Committee with the flexibility to approve individualized NEP structures that are most responsive to the needs of participants and varying local communities.
3.
Secure Funding to Maintain and Expand Delaware’s NEP: a.
Continue state funding for the program. b.
Maintain and expand capacity to obtain any future federal funds released to support this evidence-based and proven HIV prevention program.
II.
Needle Exchange Overview
What is Needle Exchange?
Needle exchange (also known as syringe exchange, syringe access, and syringe services) refers to a “myriad of approaches geared towards ensuring that people who inject drugs have access to sterile syringes to prevent the transmission of HIV, viral hepatitis and other blood-borne pathogens”.
8
In the public health community, needle exchange is considered a harm reduction technique—a method of reducing health risks when eliminating them may not be possible. It is a mainstream approach to substance abuse and HIV prevention in many countries.
4
Most NEPs are part of comprehensive HIV prevention efforts that include counseling; testing; education; and referral to drug treatment services, mental health services, HIV counseling, HIV treatment, and traditional public health preventive and therapeutic services for other diseases and medical needs.
9-12 The American Foundation for AIDS Research (amfAR)—an international non-profit organization dedicated to the support of HIV/AIDS research, prevention, treatment, education, and advocacy—summarizes research findings on the beneficial effects of NEPs, which show that NEPs:

Are associated with reductions in the incidence of HIV, Hepatitis B, and Hepatitis C in the drug-using population and, by extension, their families and communities.

Are associated with changes in injection and drug-related behavior among IDUs, thereby reducing risk of infections and transmission to others.

Are a cost-effective and cost-saving strategy for reducing HIV transmission.

Reduce the circulation of contaminated injection equipment among IDUs and in the community.
4

Reduce needle stick injuries among police officers.
13
2

General Structure:
NEPs vary in design and operation, with no one model working best for all communities.
Program settings can include storefronts, vans, sidewalk tables, and health clinics—any place where IDUs gather—and hours of operation can vary from program to program.
14
Whatever the model, a study of “Best Practices” identified two key components necessary for the effectiveness and success of all NEPs: flexibility and support.

Flexibility: Research shows that, to be most effective, NEPs should “match sound operational characteristics with responsiveness to the unique features of their host communities”.

Support: To be most successful, NEPs must have at least minimal support from their communities’ respective governing bodies, plus the crucial support of a diverse group of local stakeholders (public health departments, law enforcement, service organizations, legal experts, grass roots organizations, and community leadership). The greater the support, the greater the likelihood of effectiveness.
15
Proof of Efficacy
NEPs have been operating in the United States (U.S.) for over 25 years, under the discretion of state and local governments. Extensive studies in the U.S. and around the world have demonstrated their effectiveness. A sampling of organizations and experts that have studied and endorsed NEPs—and their findings—include the following:

Over a 20-year period, at least 17 major reviews and assessments of NEPs by experts that include the Centers for Disease Control (CDC), National Institutes of Health (NIH), the
Institute of Medicine, and the World Health Organization found that NEPs help reduce the spread of HIV/AIDS without increasing drug use among existing IDUs or encouraging the initiation of drug use.
16

In 1997, the NIH Consensus Panel on HIV Prevention concluded that NEP studies show a reduction in risk behaviors as high as 80% in IDUs, with estimates of a 30% or greater reduction in HIV in IDUs.
17

In 1998, Donna Shalala, U.S. Secretary of Health and Human Services, reported to
Congress that a review of scientific evidence indicated that NEPs "…can be an effective component of a comprehensive strategy to prevent HIV and other blood-borne infectious diseases..." and recommended lifting the ban against the use of federal funds for NEPs.
18

Similarly, three former U.S. Surgeons General endorsed NEPs including U.S. Surgeon
General David Satcher who, in March 2000, conducted a review of all recent scientific research for the Secretary of Health and Human Services and concluded, “After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs.” 19

A 2007 CDC review of 185 NEPs in the U.S. and Puerto Rico concluded that NEPs
“…are helping protect IDUs and their communities from the spread of blood-borne pathogens and are providing access to health services for a population at high risk.’’ 20
3

Facts About Needle Exchange Programs
The abundance of research on the effectiveness of NEPs, plus the experiences of Delaware’s own NEP, dispel common myths associated with such programs.
Myth
There is no hard evidence that NEPs work.
NEPs do not reduce
HIV or other diseases.
Fact
NEPs are an effective public health intervention.
Extensive studies have shown the effectiveness of NEPs. As stated on page 3, U.S.
Surgeon General David Satcher conducted a review of all recent scientific research in March 2000 for the Secretary of Health and
Human Services and concluded that “…the senior scientists of the
Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs.” 19
Regarding the effectiveness and successes of Delaware’s NEP, see pages 7 and 8.
NEPs help reduce HIV and other diseases.
NEPs are associated with reductions in the incidence of HIV in the drug-using population and, by extension, their families and communities.
4 As stated earlier, the NIH Consensus Panel on HIV Prevention concluded in 1997 that
NEP studies show estimates of a 30% or greater reduction in HIV infection in IDUs.
17
Another study—of IDUs in New York City conducted between 1990 and 2002—showed HIV infections among
IDUs decreased 70%.
21
A recent University of New South Wales report showed that NEPs in Australia were directly linked to the prevention of 32,000 cases of HIV infection and close to 100,000 cases of hepatitis C.
22
NEPs increase drug use among existing
IDUs .
NEPs promote substance abuse.
NEPs do not increase drug use among existing IDUs; they help get them into treatment. In the 1997 Consensus Statement cited above, the NIH reported that “a preponderance of evidence shows either no change or decreased drug use among persons who had participated in NEPs.” 17 Rather than increasing drug use among
IDUs, studies show that NEPs can have a positive effect in helping them get into needed treatment. A study published in the Journal of
Urban Health in 1999 stated that “findings indicate that health care providers and NEPs represent an important bridge to drug abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug abuse treatment and serve the important public health goal of increasing the number of drug users in treatment.” 23
NEPs do not encourage the start of drug use. An amfAR
FactSheet summarizes extensive research that shows that NEPs do not encourage the start of drug use in non-users,
4
while the results of a study of a San Francisco NEP over a five-year period indicated that there was no significant increase in new or young injecting drug
4

Myth
NEPs increase risky behavior.
Fact users.
24
Additionally, a CDC summary on NEPs stated, “Studies also show that [NEPs] do not encourage drug use among [NEP] participants or the recruitment of first-time drug users.” 14
NEPs reduce risky behavior. Studies have shown that NEPs actually reduce risky behaviors associated with sharing of needles and
NEP participants are “less prone to share, lend, borrow, or reuse a used syringe when they have access (or reliable source) to obtain a new and sterile syringe.” 25
As stated earlier, the NIH Consensus
Panel on HIV Prevention concluded in 1997 that NEP studies show a reduction in risk behaviors as high as 80% in IDUs.
17
Delaware’s own NEP participants reported a reduction of 28.6% in needle sharing, as indicated on page 7.
NEPs increase crime in their communities.
NEPs increase the number of visible contaminated needles in the community.
NEPs do not increase crime in NEP communities.
Studies have been conducted that indicate that NEPs do not increase crime in the neighborhoods in which they are located.
26,27
Rather, they can benefit the health and safety of a community by offering comprehensive social services to needy community members.
28,29
NEPs help keep communities safe. Studies have shown that NEPs reduce the circulation of contaminated needles in the community by educating users on the safe disposal of used needles.
30,31 Delaware’s
NEP requires the issuance of individual Sharps Containers for safe transportation and return of needles.
32
NEPs are costly.
Law enforcement and public health cannot co-exist.
NEPs are cost-effective. Numerous studies have shown NEPS to be a cost-effective and cost-saving strategy for reducing HIV transmission.
4
The annual budget appropriation for Delaware’s NEP is $230,500, while the lifetime cost of prescriptions and medical treatment for one HIV-positive person—exclusive of supportive services costs—is estimated to be as high as $618,000.
33
Preventing just one HIV infection per year through the NEP saves over
$618,000/person in potential treatment funding.
Delaware’s NEP is comprised of a strong partnership between local law enforcement and DPH.
Delaware’s Standing Operating
Procedures for the NEP mandate extensive and on-going outreach, education, and coordination among all of the NEP program partners, including DPH and the City of Wilmington Department of Public
Safety.
32 Members of the Wilmington’s Public Safety Department are supportive of the NEP as a result of strong, open lines of communication and education. Wilmington Police have, in fact, referred five IDUs to the NEP, a testament to their confidence in the program’s mission.
Nationwide Legislative Status
Currently, NEPs have received legislative approval in all states and territories of the U.S.
National statistics provide a stark picture of the relationship between injecting drug use and the
5

proliferation of HIV and other diseases throughout the country, as well as the need for NEPs to help in the prevention of those diseases and the linkage of people to care. In the U.S.:

8,000 people are reported newly infected with HIV annually through sharing contaminated syringes.

1/3 of people with HIV in the U.S. were infected directly through injection drug use.

An estimated 61% of AIDS cases among women are due to injection drug use or the result of sexual contact with someone who contracted HIV through injection drug use.

Over 50% of all AIDS cases attributed to injection drug use were African Americans, while Latinos account for nearly 25%.

15,000 people are newly infected annually with Hepatitis C through sharing syringes and other contaminated injection equipment, with IDUs generally becoming infected with
Hepatitis C within two years.
34
In 2009, Congress lifted the ban on the use of federal funds for NEPs, and President Obama signed the Consolidated Appropriations Act of 2010 on December 19 finalizing the action .
However, no federal funding has been allocated for any needle exchange program to date.
III.
Delaware’s Needle Exchange Program
Delaware’s History
As noted in the opening Problem Statement, Delaware is the second smallest state in the nation in terms of geographic size, yet its AIDS incidence rate is among the highest in the nation (19.8 cases per 100,000 residents in 2008), ranking consistently among the top 10 each year in the rate of new AIDS cases per capita. Further, recent data indicates that the frequency with which AIDS cases are being diagnosed in Delaware is increasing in comparison with other states. Delaware ranked 10 th
in the nation in 2006 and 6 th
in 2007.
1
The majority of new and existing HIV cases in Delaware are attributable to needle sharing and/or unprotected sexual contact with someone that has shared needles to inject drugs,
2
with Delaware’s HIV infection rate from IDU more than twice the national average.
3
The potential reductions in new HIV infections from a NEP, therefore, is significant.
Delaware’s history in implementing a NEP extends back to 1996, when the Substance Abuse
Treatment Services Evaluation Task Force first recommended consideration be given to exploring strategies to reduce HIV transmission through infected needles and syringes in the
Report to the Delaware Legislature . A draft NEP bill was submitted to the Delaware State
Legislature that year but was not passed. Each year thereafter it was re-written and re-submitted.
Finally, on June 30, 2006, the State Legislature approved implementation of a NEP, effective through February 2012, codified under Title 29, Subchapter VIII.
5
The code includes basic provisions regarding the structure of the NEP, plus allows for the provision of traditional public health preventive and therapeutic services for other sexually-transmitted diseases, tuberculosis, family planning, pregnancy, prenatal care, and nutrition.
6

Program Structure
The State Division of Public Health (DPH) administers the NEP, supported by an Oversight
Committee of local stakeholders. Together they developed a multi-phased Implementation
Plan
35
in accordance with the legislation. Under the plan, NEP:

Is a mobile program, operating from a van;

Operates in focused zip code areas of Wilmington with the highest HIV risk prevalence as noted by epidemiological data;

Includes a one-for-one needle exchange;
 Allows no “by proxy” exchanges (No one can exchange for someone else.);

Includes outreach, engagement, counseling, and case management;

Collects data on syringes exchanged, treatment, behavior, and referrals at every instance of exchange to assure the program remains on tract;

Provides HIV testing;

Makes referrals to facilities for treatment of substance abuse, mental health, HIV/AIDS, and other diseases;

Makes referrals for services such as housing, food, and clothing.
Successes
Delaware’s NEP has been extremely effective. Within affected communities, there have been exceptionally high levels of cooperation and support of the program and no negative publicity or reactions. Client participation has increased steadily as a result of the distribution of printed materials and presentations to community groups, police officers, City Council, and various other partners, with referrals coming from all partners, including local law enforcement. The program maintains extensive records on both NEP participants and community residents who use services on the NEP van. While current statistics exceed goals in almost all categories of performance, DPH estimates that it will not be until year four or five that a direct link between the pilot NEP and HIV/AIDS reduction can be shown conclusively in Delaware.
The successes of the pilot NEP—in numbers and design— are documented below, from program inception through the end of state fiscal year 2010 (February 2007 - June 30, 2010), as follows:
Successes from February 1, 2007 through June 30, 2010
General Programmatic Successes:
Clients enrolled
Needles exchanged and incinerated
829
54,000+
HIV and Other Disease Prevention Services:
Rapid HIV screenings provided to NEP 390 clients
Rapid HIV screenings provided to 1,864 community members not in NEP
People tested for the first time for HIV 179
People newly diagnosed with HIV and enrolled into care
NEP clients reporting reduced needle sharing
16 (9 NEP clients, 7 community members)
28.6% versus 15% goal
7

Successes from February 1, 2007 through June 30, 2010
NEP clients enrolled in substance abuse 63% (130 of 206 referred) treatment programs
HIV-infected individuals who were reconnected with HIV treatment services
11
Design Successes
Model Program Design
Effective Administration and Oversight DPH administers the NEP, in cooperation with an Oversight Committee inclusive of key partners in the program.
Professional Operational Management
Delaware’s NEP operates differently from many other NEPs while using the best features of some of them.
The NEP is operated currently by treatment professionals with expertise and close working relationships with other local treatment programs, enabling streamlined referrals to higher levels of care.
Partnerships The NEP partners with City of Wilmington
Public Safety Department, Christiana Care
Health Services, grassroots community organizations, local non-profits, Division of
Substance Abuse and Mental Health, and the faith community.
Enrollment in Treatment
Community Engagement
The NEP refers clients directly to drug and medical treatment programs—not simply crisis services.
The NEP uses the Indigenous Leader Outreach
Model to engage and retain community involvement in support and services.
Membership Recruitment
Positive Relationship With Law
Enforcement
The NEP employs a model social networking strategy, which encourages membership of participants: 65% of all clients (454) were referred by other clients (versus 20% goal)
The program nurtures a positive relationship with local law enforcement through on-going reporting, updating, and education. Law enforcement itself has referred five people to
Safety of Law Enforcement Personnel the program.
NEP supplies needle-resistant gloves to law enforcement personnel to help reduce needle stick injuries.
Cost Effectiveness
NEPS have been shown to be a cost-effective and cost-saving strategy for reducing HIV transmission.
4 The lifetime cost of prescriptions and medical treatment for one HIV-positive person—exclusive of supportive services costs—is estimated to be as high as $618,000.
33
The
8

cost of preventing HIV infection among one of the highest at-risk populations in Delaware through NEPs is substantially less—approximately $230,500 annually for the current NEP.
Conservatively allowing that connecting to treatment each of the 16 persons who found they were HIV-infected as a result of NEP testing prevents just one additional person being infected, the program potentially has saved $9,888,000 in prescription and medical treatment funding— exclusive of supportive services costs. These savings do not include the potential savings from all other persons who reduced their risky behavior for becoming infected or transmitting HIV, as well as other blood-borne diseases, as a result of NEP services. It is evident from these figures that NEPs are a cost effective prevention measure in the fight against blood-borne illnesses transmitted through injecting drug use.
IV.
Closing Recommendations for Delaware’s NEP
Since its implementation in February 2007, Delaware’s pilot NEP has become a key component of the state’s HIV prevention and treatment strategy and effectively met its purposes as outlined in the Delaware Code. With the sunset date of the pilot program nearing—February 2012—it is critical that the program be re-authorized so that its benefits can continue into the future. At the same time, modifications to the program are recommended in response to an evolving epidemic and as a result of the experiences gathered during the pilot program period. Recommendations for its continuance are grouped into three categories: capacity, flexibility and funding:
Recommendations for Delaware’s Pilot Needle Exchange Program
1.
Increase the NEP’s Capacity to Serve More People: a.
Move the NEP’s status from “pilot” to “permanent”. Change Delaware Code Title
29, Subchapter VIII, removing references to “pilot” and making the program
“permanent” to assure that the NEP continues into the future. b.
Extend the NEP’s service area from “Wilmington” to “statewide”.
Statistics maintained by the Division of Public Health (DPH) provide a picture of the evolving nature of the HIV epidemic in Delaware. Areas of need regarding IDUs are not confined to the portions of the City of Wilmington currently approved for a NEP. As the epidemic further evolves, areas of need may shift with time.
2.
Enhance Flexibility to Respond to Community Needs: a.
Provide DPH and the NEP Oversight Committee with the flexibility to approve new locations throughout the state, as evidenced and justified by statistical need.
Approving the NEP as a statewide program is the first step in reaching other locations of need, as justified by sound epidemiological data. DPH has proven an effective administrator of the current NEP, is the administrator of federal HIV/AIDS dollars in the state, and maintains statistics on the disease and information on emerging trends.
Providing DPH with the flexibility to approve NEP sites—with the approval of the
Oversight Committee and in conformance with the program’s Standard Operating
9

V.
Procedures (SOP)—will assure successful implementation and operation of other program sites within new partner communities. b.
Provide DPH and the NEP Oversight Committee with the flexibility to approve individualized NEP structures that are most responsive to the needs of participants and varying local communities. NEPs vary in design and operation with no one model working best for all communities. They are most successful, however, when they match good operational practices with the features of the community in which they operate. In a report published in 2009 and submitted to the CDC, a group of nationally-recognized NEP experts met to achieve consensus on the characteristics of
NEPs that maximize their effectiveness and to highlight best practices. Delaware’s
NEP contains many of the suggested best practice approaches. It also contains several approaches the experts recommended avoiding because they limit effectiveness.
These include the following: (a) enforcing a mandated exchange ratio, such as “onefor-one”; (2) disallowing by-proxy exchange (allowing someone else to exchange needles for another); and (3) limiting location and hours of operation.
15 While these three practices may or may not need inclusion in any particular NEP established in
Delaware, it is important that flexibility be provided to DPH to assure that the design of a NEP satisfies the needs and concerns of a community, as well as program participants. As with recommendation 2a, providing DPH with flexibility of program design—with the approval of the Oversight Committee and in conformance with the program’s SOP—will assure successful implementation and operation of new program sites.
3.
Funding: a.
Continue state funding for the NEP. The state of Delaware has supported the NEP program through its budget process. In December 2009, the federal government approved the use of federal dollars for NEPs but made no funding available to date and may not make any available in the future. At the same time, the availability of state dollars for the program assures that—should federal funding be budgeted along the lines of a Medicaid-type program that requires cost-sharing allocations—
Delaware will be in a position to accept such federal dollars. The NEP has become a key part of Delaware’s HIV prevention and treatment efforts. It is critical that state dollars remain in place to continue the program. b.
Maintain and expand capacity to obtain any future federal funds released to support this evidence-based and proven HIV prevention program.
Again, although no federal dollars are available to date, it is important to maintain current funding and expand the capacity of the existing program to assure that Delaware can access federal dollars when and if they become available.
Annotated Bibilography (Attached )
10

References
1. Delaware Division of Public Health. 2008 Delaware HIV/AIDS Surveillance Report. 2008:1.
2. Delaware Department of Health and Social Services. Delaware Department of Health and Social
Services Legislative Proposal Form SFY 2011. 2010:2.
3. Delaware Division of Public Health. Needle Exchange and Community Outreach, Questions and answer about the need in Delaware. October 2009:1.
4. amfAR AIDS Research. Fact Sheet No. 1, Revised November 2007. The Effectiveness of Harm
Reduction in Preventing the Transmission of HIV/AIDS. Available at http://www.amfar.org/ uploadedFiles/In_the_Community/Publications/The%20effectiveness%20of%20 harm%20reduction. pdf.
5. Title 29 DE Code. Chapter 79.Department of Health and Social Services, Subchapter VIII Sterile
Needle and Syringe Exchange Pilot Program for Prevention of AIDS and Other Diseases [Subject to sunset according to the term of Subsection 7997 of this title . Subsection 7992 (a)(b).
6. Delaware Division of Public Health. 2009 End-of-Year Report-Delaware 5-Year Pilot Needle
Exchange Program. 2009:2-10.
7. Delaware HIV Consortium Planning Council and Delaware Division of Public Health. 2010-2014
Comprehensive HIV Prevention Plan and Statewide Coordinated Statement of Need. 2009:3-101.
8. National Alliance of State & Territorial AIDS Directors. Health Department Role in Expanding
Syringe Access:1.
9. New York State AIDS Advisory Council. Report on Needle Exchange Programs and Deregulation of
Needles and Syringes.1996. Available at: http://www.health.state.ny/us/ diseases/aids/workgroups/aac
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10. Wodak A, Cooney A. Effectiveness of Sterile Needle and Syringe Programs. Int J Drug Policy. 2005;
16s:S31-S44.
11. Strathdee SA, Patrick DM, Currie SL, et al. Needle Exchange is not Enough: Lessons from the
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Friedman SR. HIV Incidence among Injection Drug Users in New York City, 1990 to 2002. Use of
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95(8): 1439-44.
13. amfAR AIDS Research. FactSheet Public Safety, Law Enforcement, and Syringe Exchange, January
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2010.pdf.
14. Centers for Disease Control. Syringe Exchange Programs December 2005. Available at: http://cdc/gov/idu/facts/aed_idu_syr.pdf.
15. Bluthenthal, R, Clear A, Des Jarlais D, Friedman S, Grove D, Hagan H, Heimer R, Heller D, Kral, A,
Sherman S, Tolbert R. Results of A Consensus Meeting. Recommended Best Practices for Effective
Syringe Exchange Programs in the United States. 2010: 4, 17, 26.
16. Syringe Exchange Programs: Frequently Asked Questions. Updated June 2009. Available at: http://saveneedleexchange.org/syringe_exchange_faq/.
17. National Institutes of Health. Consensus Development Statement. Interventions to prevent HIV risk behaviors. February 11-13, 1997:7-8.
18. Shalala, DE. Needle Exchange Programs in America: Review of Published Studies and Ongoing
Research. Report to the Committee on Appropriations for the Departments of Labor, Health and Human
Services, Educations and Related Agencies. February 18, 1997.
19. U.S. Department of Health and Human Services (HHS). Evidence-Based Findings on the Efficacy of
Syringe Exchange Programs: An Analysis for the Assistant Secretary for Health and Surgeon General of the Scientific Research Completed since April 1988. Washington, D.C.: U.S. Department of Health and
Human Services; 2000.
20. Centers for Disease Control. 2007 review of 185 NEPs in the U.S. and Puerto Rico. Available at http:
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//www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a4.htm.
21. Des Jarlais, et al.. HIV incidence among injection drug users in New York City, 1990 to 2002.
AJPH.2005;95(8):1439-1444.
22. Kwon J; Iversen, J, Maher L, Law M. Wilson D. The Impact of Needle and Syringe Programs on
HIV and HCV Transmissions in Injecting Drug Users in Australia: A Model-Based Analysis. 2008.
23. Strathdee SA, Celentano DD Shah N, Lyles C, Stambolis VA, Macalino G, Nelson K and Vlahov D.
(1999). Needle-exchange attendance and health care utilization promote entry into detoxification.Journal of Health Issue: Volume 76, vol. 4, P:448-460, Springer Boston
24. Watters J, Estilo J, Clark G, Lorvick J. Syringe and Needle Exchange as HIV/AIDS Prevention for
Injection Drug Users. JAMA 1994:271(2):115-120.
25. Martinez JB. Narrative: Science-based literature on Syringe Exchange Programs (SEPS) 1996-2007.
October 9, 2007.
26. Marx MA, Crape B, Bookmeyer RS, Junge B, Latkin C, Vlahov D, Strathdee SA. Trends in Crime and the Introduction of a Needle Exchange Program. AM J Public Health. 2000; 90(12):1933-1936.
27. Center of Innovative Public Policies, Inc. April 2001. Needle Exchange Programs: Is Baltimore a
Bust?
28. Heimer R, Khoshnood K, Bigg D, Guydish J, Junge B. 1998. Syringe use and reuse: Effects of syringe exchange programs in four cities. Journal of Acquired Immune Deficiency Syndromes and
Human Retrovirology 18 (Supplement 1): S37-S44.
29. Hogan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. 2000.Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors.Journal of Substance Abuse Treatment 19(3):247-252.
30. Doherty MC, et al. Discarded Needles Do Not Increase Soon After the Opening of a Needle Exchange
Program. American Journal of Epidemiology 1997;145(8):730-737.
31. Kaplan EH, Heimer R.A Circulation Theory of Needle Exchange. AIDS. 1994;8(5):567-574.
32. Delaware Pilot Needle Exchange Program. Standard Operating Procedures.
33. Schackman, BR et al. (2006). The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States. Medical Care, 44,11:990-997. Results: From the time of entering HIV care, per person projected life expectancy is 24.2 years, discounted lifetime cost is $385,200,and undiscounted cost is
$618,900 for adults who initiate ART with CD4 cell count _350/_L. Seventy-three percent of the cost is antiretroviral medications, 13% inpatient care, 9% outpatient care, and 5% other HIV-related medications and laboratory costs. For patients who initiate ART with CD4 cell count _200/_L, projected life expectancy is 22.5 years, discounted lifetime cost is $354,100 and undiscounted cost is $567,000. Results are sensitive to drug manufacturers’ discounts, ART efficacy, and use of enfuvirtide for salvage. If costs are discounted to the time of infection, the discounted lifetime cost is $303,100.
34.Harm Reduction Coalition. Statistics available at http://www.harmreduction.org/article.php?list=type
&type=49.
35. Division of Public Health. Pilot Needle Exchange Program Implementation Plan.
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