Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

Our Government’s Failure to Adopt A Policy For Needle Exchange Programs Rooted in Social Theories For IDUs – Aude Wilhelm

History of the government vs. NEPs
In the late 1970’s and 80’s, local community members, injection drug users and health care workers began Needle Exchange Programs (NEPs) to meet the growing concern of injection drug users (IDUs) about the rising rates of HIV [1]. NEPs provided IDUs with sterile syringes in exchange for their used ones. Aside from reducing the chance of HIV transmission among IDUs, these programs also provided HIV education for a previously hard to reach population. Despite the growing support of public health authorities, federal opposition created a long uphill battle for NEPs across the country to acquire state and national funding. In the conservative politician’s eye, supporting NEPs was giving the nod to drug dealers/users to maintain their habits and could even increase the amount of drug use among IDUs due to the extra available needles. Moreover, NEPs clashed with both paraphernalia state laws (which make the manufacture, possession, or distribution of drug paraphernalia a misdemeanor or felony offense: observed in 46 states) and prescription laws (which require a physician's prescription in order to purchase a syringe: observed in 10 states and the District of Columbia) [2]. As a result, many NEP programs started out as illegal, underground programs, with only some receiving funding from local organizations, leaving many to struggle financially. For these reasons, NEPs had little initial political support and directly clashed with the federal government’s non-tolerance policy of all drug-related behaviors.

Over the next 20 years, the effectiveness of NEP programs at reducing HIV rates became undeniable and the rates of HIV among IDUs impossible to ignore. Of the three known methods of HIV transmission (sexual contact, blood contact, and mother-to-child-transmission), all three can stem from drug injection behavior. According to a CDC 1993 surveillance report, “by early 1993, 253,448 people in the US had been diagnosed with AIDS. Of these, 73,311 (29%) were IDUs, 8,481 (3%) were people with heterosexual contact with an IDU, and 2,420 (1%) were children born to IDUs and their sex partners” [3]. Due to these alarming numbers, the number of NEP programs nationwide shot up over the last two decades. As of November 2006, more than 190 NEPs were in operation across 36 states, the District of Columbia, Puerto Rico, and on American Indian lands, with over half operating on private funding [4].

A 2005 study (done by the Association for Public Policy and Management on Drug Use Forecasting data from 24 large US cities) looked at the effect of NEPs on adult male arrestees’ IDU behavior living in 9 of those cities. They reported that the presence of an NEP in a city is associated with a 13% decline in drug injection and 20% decline in needle sharing among drug injectors [5]. Moreover, a 1993 CDC report on the health impact of NEPS stated that these programs show no evidence of increased drug use by NEP clients or of having an effect on injection behaviors at the community level [6]. As it stands today, NEPs are now accepted as essential components of HIV and hepatitis C prevention in many parts of the world, the US being a major exception.

The proven efficacy of NEP programs is slowly changing the no-federal-funding-of-NEPs trend, but the change is slow. In December 2007, Congress finally lifted a 9-year federal-funding ban of all NEPs in the District of Columbia but conservative politicians are already looking for a way to repeal this motion. Also, 5 studies on NEPs are currently being federally funded to synthesize existing information on NEP effectiveness [6].

The issue: lack of incorporation of social theories
Despite the perceived legal and moral paradox of giving addicts syringes to use illicit drugs, the government’s policy of not providing federal funding to NEP programs is shortsighted and costing lives. NEPs are believed to be particularly effective at reducing HIV transmission rates because they not only provide sterile syringes but also employ social theory techniques such as self-efficacy, harm reduction and the use of social networks among IDUs to reach out to a larger population of IDUs and engages them to consider changing their behavior. Social theories in public health can clearly delineate that a non-tolerance, “prohibition” strategy will not prevent needle sharing among IDUs. Moreover, a prohibition strategy is a power/coercive behavioral change strategy, a type of strategy that often doesn’t work in public health [7]. In the end, the government’s ineffective non-tolerance policy fails to incorporate these powerful social theories and ultimately impedes the prevention efforts of NEPs.

Many IDUs perceive themselves as unable to quit their habit. The ‘irrationality’ of their choice to continue engaging in this high-risk behavior is partly due to their physical addiction but also because they feel that they lack the willpower/are physically unable to change their behavior, despite any intention to do so. Critics of conventional rationality-based social theories have clearly shown that intention to change a behavior does not guarantee that the behavior will change. Just because an IDU wants to stop injecting drugs does not mean he will do so and one reason for this is self-efficacy. The theory of Self Efficacy states: “it is the perceived capabilities rather than the actual that often influence behavior” [8]. An IDU may not feel strong enough as an individual to quit the behavior, emphasizing the fact that changing a behavior is based on a complex combination of social, behavioral, and cultural factors [9].

This is as an important consideration in explaining why prohibiting access of clean needles to drug addicts won’t affect their drug-using behavior. Ultimately, most drug addicts are more interested in their continuing drug use than whether or not they are using clean or dirty needles. Incorporating some re-educative techniques (through treatment therapy, for example) to heighten one’s sense of self-efficacy is a better strategy than prohibition. Some NEPs do this by requiring IDUs to undergo some form of treatment to access clean needles, but many will focus on keeping IDU habits HIV-transmission-free. As a result, they are able to reach out to a large IDU population and create an effective prevention strategy. The government’s power/coercive approach doesn’t help drug users to believe that they can discontinue their drug use because there is no skill building or education involved. The failure to incorporate self-efficacy in their strategy is one of the reasons for their ineffectiveness at decreasing the number of IDUs in our nation and only impedes the HIV prevention efforts of NEPs.

Harm reduction
As previously mentioned and reiterated by Des Jarlais in his 1993 review of public health: “NEPs acknowledge that many IDUs, including some in drug treatment programs, continue to inject drugs and share injection equipment. They therefore seek to reduce the harm associated with these practices, a philosophy sometimes referred to as harm reduction or harm minimization” [10]. Harm reduction’s message is: we don’t judge your behavior but care about your health. This strategy involves IDUs by having them be the ones to decide whether to access the NEP programs for clean syringes and not judging them. This social approach has led to other successful public health interventions such as Florida’s truth campaign. Their amazing results at reducing smoking rates among teenagers statewide (resulting in a 7.4% decrease in middle school kids and 4.8% decrease in high school kids) were largely attributed to youth involvement. This was done by organizing focus groups to ask kids directly what factors get them to start smoking and using a non-judging tone when interacting with the kids. Since teenage kids do not want to be told what to do, the truth campaign released large-scale advertisements just giving the facts about long-term smoking and highlighted the manipulative strategies used by tobacco companies to conceal such facts. Based on this, the kids then were left to make their own decision, but were not judged for them [11]. NEPs do this by having IDUs come to them with their dirty needles and giving them the facts on dangers of injection drug use. They then let IDUs decide if want to change their behavior or not. The general public, leaders in public health, and even some conservative politicians now accept NEP’s use of harm reduction as a reasonable prevention strategy [1].

Based on the success of the truth campaign and the effectiveness of NEPs at reducing HIV rates among IDUs, it is clear that harm reduction is a much more effective strategy than a non-tolerance policy message. Moreover, the non-judgmental approach attracts greater numbers of IDUs, making NEPs extremely competitive in decreasing black market demand by providing clean needles free of charge. Our government fails to incorporate harm reduction into its strategy to eliminate drug injection behavior in our nation. Instead, they chose to decrease HIV transmission rates by being intolerant to IDUs and refusing to financially support NEPs. Having the government label NEP clients as “responsible” and “irresponsible” is at odds with the nonjudgmental harm reduction stance espoused by NEPs. NEPs already have difficulty establishing credibility among IDUs so punitive policies can only impede their reach efforts, reduce NEP attendance, and ultimately reduce HIV prevention [12]. In this case, the government is doing more harm than good.

Social Networks
A third social theory consideration is based around the fact that IDUs tend to inject in known network groups and not with strangers. This concept is best explained by a public health theory known as Social networks theory. This theory states that a main behavior predictor is the social network that an individual belongs to since group factors affect behavior [13]. Indeed the social influence from these IDU social networks encourages needle sharing, resulting in higher HIV transmission rates within these individual IDU social networks [14]. As a result, NEPs serve as an ideal intervention since they use this network influence to reduce rather than encourage syringe sharing. Because of these networks, NEPs provide a unique opportunity to access these particularly high-risk, individual networks in the IDU community. Moreover, the fact that IDUs inject drugs as a group increases the chance that the one accessing the NEP (the provider) will promote safer injection drug use behavior to his/her social network [15]. The concept of safer injection drug practices among IDUs relying on their social network

An article in the journal of urban health reports that at the moment, “only 7% of IDUs have access to and use NEPs, leaving some IDUs to engage in secondary syringe exchange (SSE), where a ‘provider’ obtains syringes at an NEP to distribute to other IDUs (‘recipients’)”[15]. Since SSE is embedded in existing social networks, this provides natural opportunities for peer education on the dangers of injection drug use, which is something that may help change their behavior. This journal article on SSE also indicated that the primary motivation for providers to access NEPs was to help other IDUs, while recipients reported convenience as their primary reason for using SSE.

The government’s no-tolerance policy fails to account for the relationship between IDUs and Peer groups/social networks, which is another missed opportunity for them to employ an effective strategy at reducing HIV transmission. In the mean time, a no-tolerance approach and refusing NEP funding only harms HIV prevention efforts, once again highlighting the shortsightedness of this strategy.

“Substance use plays a major role in the transmission of HIV disease. Clearly, our nation's drug control policies must recognize this inextricable linkage between drugs and HIV disease and be designed to address the two aggressively and simultaneously” [16]. This is a crucial point that has not yet been understood by our government. In order to be truly effective at HIV prevention, the government must work with IDUs and employ these powerful social theories instead of blindly hoping that by prohibiting access to needles and refusing to cooperate with drug users, their behaviors will change. Increasing the sense of self-efficacy of IDUs, using harm reduction and paying attention to IDU social networks serves as a great starting point in creating a new national public health strategy to reduce HIV transmission through sharing of needles. NEPs understand the power of these theories when interacting with IDUs and should be used as a guiding arm by our government to start a new, powerful, re-educative public health initiative that will have a lasting impact on the health of our nation.

1. Henry J. Kaiser Family Foundation. Needle Exchange: a Brief History; San Francisco, CA: Needle Exchange Program Evaluation Project; 1993.
2. Gostin, L. The interconnected epidemics of drug dependency and AIDS. Harvard Civil Rights-Civil Liberties Law Review. 1991; 26:113-184.
3. Anon. Centers for Disease Control. HIV/AIDS surveillance report. January, 1993.
4. Tempalski, B et al. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. AJPH Volume 97(3), March
2007, pp 437-447.
5. DeSimone, J. Needle Exchange Programs and Drug Injection Behavior. Journal of Policy Analysis and Management; 24(3), January 2005, pp 559-577.
6. Centers for Disease Control and Prevention. The Public Health Impact of Needle Exchange Programs in the United States and Abroad Summary, Conclusions and Recommendations; Report by Institute for Health Policy Studies, University of California, San Francisco, CA; 1993.
7. Siegel, M. Education and persuasion versus coercion as public health approaches. The rest of the story: tobacco news analysis and commentary (blog). May 4, 2006. Available at
8. Bandura, A. (1977). Self efficacy: Toward a unifying theory of behavioral change. Psychological Review. 84, 191-215.
9. Becker, M.H. The Health Belief Model and Personal Health Behavior. Health Education Monographs. Vol. 2 No. 4.
10. Des Jarlais DC, Friedman SR, and Ward TP. Harm reduction: A public health response to the AIDS epidemic among injecting drug users. Annual Review of Public Health. 1993;14:413-450.
11. Hicks, J. The strategy behind Florida’s Truth Campaign. Tobacco Control 2001; 10:3-5.
12. Strike CJ, Myers T, and Millson M. Needle exchange: how the meanings ascribed to needles impact exchange practices and policies. AIDS Education and Prevention, 14(2), 126–137, 2002.
13. Turkat D. Social networks: Theory and practice. Journal of Community Psychology. 8(2), 99 – 109, 2006.
14. Neaigus A et al. Drug injectors' social networks can be risk factors for syringe sharing. Int Conf AIDS. 1996 Jul 7-12; 11: 41 (abstract no. Mo.C.462).
15. Snead, J et al. Secondary syringe exchange among injection drug users. J Urban Health. 2003 Jun;80(2):330-48.
16. National Commission on AIDS, The Twin Epidemics of Substance Use and HIV, 1991.


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