needle and syringe programmes needle and syringe programmes a needle and syringe programme (nsp), also known as needle exchange program (nep), is a social service that allows injecting drug users (idus) to obtain clean and unused hypodermic needles and associated paraphernalia at little or no cost. it is based on the philosophy of harm reduction that attempts to reduce the risk factors for blood-borne diseases such as hiv/aids and hepatitis. needle and syringe programmescontents of a needle-exchange kitother namessyringe-exchange programme (sep), needle exchange program (nep) history "sharps" container (for safe disposal of hypodermic needles) needle-exchange programmes can be traced back to informal activities undertaken during the 1970s. the idea is likely to have been rediscovered in multiple locations. the first government-approved initiative (netherlands) was undertaken in the early to mid-1980s, followed closely by initiatives in the united kingdom and australia by 1986. while the initial programme was motivated by an outbreak of hepatitis b, the aids pandemic motivated the rapid adoption of these programmes around the world. operation needle and syringe programs operate differently in different parts of the world; the first nsps in europe and australia gave out sterile equipment to drug users, having begun in the context of the early aids epidemic. the united states took a far more reluctant approach, typically requiring idus to already have used needles to exchange for sterile ones - this "one-for-one" system is where the same number of syringes must be returned.: 192 according to santa cruz county, california, exchange staff interviewed by santa cruz local in 2019, it is a common practice for exchanges to not count, but approximate the returned sharps by "eyeballing" the volume. holyoke, massachusetts, also uses the volume system. united nations office on drugs and crime for south asia suggests visual estimation or asking the client how many they brought back. the volume-based method left potential for gaming the system and an exchange agency in vancouver devoted significant effort to game the system.: 140 some, such as the columbus public health in ohio weigh the returned sharps rather than counting. the practices and policies vary between needle and syringe program sites. in addition to exchange, there is a model called "needs-based" where the syringes are handed out without requiring any to be returned.: 15–16 according to a report published in 1994, montreal's cactus exchange which has a policy of one-for-one, plus one needle with a limit of 15 had a return rate of 75-80% between 1991 and 1993. an exchange in boulder, colorado, implemented a one-for-one with four starter needles and reported an exchange rate of 89.1% in 1992.: 391 in the united states, where the one-for-one system still dominates, some 25% of injecting drug users are living positive with hiv; in australia, which hands out equipment for free to anyone needing it (only charging a small fee for some more expensive equipment, like wheel filters and higher-quality tourniquets), only 1% of the idu population is hiv-positive as of 2015, compared to over 20% in the late 1980s when nsp programs began to spread nationally and became accessible to most of the population. international experience programs providing sterile needles and syringes currently operate in 87 countries around the world. ia comprehensive 2004 study by the world health organization (who) found a "compelling case that nsps substantially and cost effectively reduce the spread of hiv among idus and do so without evidence of exacerbating injecting drug use at either the individual or societal level." who's findings have also been supported by the american medical association (ama), which in 2000 adopted a position strongly supporting nsps when combined with addiction counseling. australia the melbourne, australia, inner-city suburbs of richmond, and abbotsford are locations in which the use and dealing of heroin has been concentrated. the burnet institute research organisation completed the 2013 'north richmond public injecting impact study' in collaboration with the yarra drug and health forum and north richmond community health centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. in the surrounding city of yarra, an average of 1,550 syringes per month was collected from public syringe disposal bins in 2012. paul dietze stated, "we have tried different measures and the problem persists, so it's time to change our approach". on 28 may 2013, the burnet institute stated that it recommended 24-hour access to sterile injecting equipment in the melbourne suburb of footscray after the area's drug culture continued to grow after more than ten years of intense law enforcement efforts. the institute's research concluded that public injecting behaviour is frequent in the area and injecting paraphernalia has been found in carparks, parks, footpaths, and drives. furthermore, people who inject drugs have broken into syringe disposal bins to reuse discarded equipment. a study commissioned by the australian government revealed that for every a$1 invested in nsps in australia, $4 was saved in direct healthcare costs, and if productivity and economic benefits are included, the programs returned a staggering $27 for every $1 invested. the study notes that over a longer time horizon than that considered (10 years) the cost-benefit ratio grows even further. in terms of infections averted and lives saved, the study finds that, between 2000 and 2009, 32,000 hiv infections and 96,667 hepatitis c infections were averted, and approximately 140,000 disability-adjusted life years were gained. united kingdom from the 1980s, maggie telfer from the bristol drugs project advocated for needle exchanges to be established in the united kingdom. the british public body, the national institute for health and care excellence (nice), introduced a recommendation in april 2014 due to an increase in the number of young people who inject steroids at uk needle exchanges. nice previously published needle exchange guidelines in 2009, in which needle and syringe services were not advised for people under 18, but the organisation's director professor mike kelly explained that a "completely different group" of people were presenting at programmes. in the updated guidance, nice recommended the provision of specialist services for "rapidly increasing numbers of steroid users", and that needles should be provided to people under the age of 18—a first for nice—following reports of 15-year-old steroid injectors seeking to develop their muscles. united states the centers for disease control and prevention and the national institutes of health confirm that needle exchange is an effective strategy for the prevention of hiv. the nih estimated in 2002 that in the united states, between 15 and 20% of injection drug users have hiv and at least 70% have hepatitis c. the centers for disease control (cdc) reports 1/5 of all new hiv infections and the vast majority of hepatitis c infections are the result of injection drug use. united states department of health and human services reports 7%, or 2,400 cases of hiv infections in 2018 were among drug users. portland, oregon, was the first city in nation to expend public funds on a nsp which opened in 1989. it is also one of the longest running programme in the country. despite the word "exchange" in the programme name, the portland needle exchange operated by multnomah county hands out syringes to addicts who do not present any to exchange. the exchange programme reports 70% of their users are transients who experience "homelessness or unstable housing" it was reported that during the fiscal year 2015–2016, the county dispensed 2,478,362 syringes and received 2,394,460, a shortage of 83,902 needles. in 2016, it was reported that cleveland needle exchange program sees "mostly white suburban kids ages 18 to 25". san francisco since the full sanction of syringe exchange programs (sep) by then-mayor frank jordan in 1993, the san francisco department of public health has been responsible for the management of syringe access and the proposed disposal of these devices in the city. this sanction, which was originally executed as a state of emergency to address the hiv epidemic, allowed seps to provide sterile syringes, take back used devices, and operate as a service for health education to support individuals struggling with substance use disorders. since then, it was approximated that from july 1, 2017, to december 31, 2017, only 1,672,000 out of the 3,030,000 distributed needles (60%) were returned to the designated sites. in april 2018, acting mayor mark farrell allocated $750,000 towards the removal of abandoned needles littering the streets of san francisco. general characteristics as of 2011, at least 221 programmes operated in the us. most (91%) were legally authorized to operate; 38.2% were managed by their local health authorities. the cdc reported in 1993 that the most significant expenses for the nsps is personnel cost, which reports it represents 66% of the budget. more than 36 million syringes were distributed annually, mostly through large urban programmes operating a stationary site. syringes are supplied nationwide by mail in the us by next distro. more generally, us neps distribute syringes through a variety of methods including mobile vans, delivery services and backpack/pedestrian routes that include secondary (peer-to-peer) exchange. funding in the united states, a ban on federal funding for needle exchange programs began in 1988, when republican north carolina senator jesse helms led congress to enact a prohibition on the use of federal funds to encourage drug abuse. the ban was briefly lifted in 2009, reinstated in 2010, and partially lifted again in 2015. currently, federal funds can still not be used for the purchase of needles and syringes or other injecting paraphernalia by needle exchange programs, though can be used for training and other program support in the case of a declared public health emergency. in the time between 2010 and 2011 when no ban was in place, at least three programmes were able to obtain federal funds and two thirds reported planning to pursue such funding. a 1997 study estimated that while the funding ban was in effect, it "may have led to hiv infection among thousands of idus, their sexual partners, and their children." us neps continue to be funded through a mixture of state and local government funds, supplemented by private donations. the funding ban was effectively lifted for every aspect of the exchanges except the needles themselves in the omnibus spending bill passed in december 2015 and signed by president obama. this change was first suggested by kentucky republicans hal rogers and mitch mcconnell, according to their spokespeople. legal aspects many states criminalized needle possession without a prescription, arresting people as they left underground needle exchange efforts. in some jurisdictions, such as new york, needle exchange activists challenged the laws in court, with judges ruling that their actions were justified by a "necessity defense" which permits breaking of a law to prevent an imminent harm. in other jurisdictions where syringe possession without a prescription remained illegal, physician-based prescription programmes have shown promise. epidemiological research demonstrating that syringe access programmes are both effective and cost-effective helped to change state and local nep-operation laws, as well as the status of syringe possession more broadly. for example, between 1989 and 1992, three exchanges in new york city tagged syringes to help demonstrate rates of return prior to the legalization of the approach. by 2012, legal syringe exchange programmes existed in at least 35 states. in some settings, syringe possession and purchase is decriminalized, while in others, authorized nep clients are exempt from certain drug paraphernalia laws. however, despite the legal changes, gaps between the formal law and environment mean that many programmes continue to face law enforcement interference and covert programmes continue to exist within the u.s. colorado allows covert syringe exchange programmes to operate. current colorado laws leave room for interpretation over the requirement of a prescription to purchase syringes. based on such laws, the majority of pharmacies do not sell syringes without a prescription and police arrest people who possess syringes without a prescription. boulder county health department reports between january 2012 and march 2012, the group received over 45,000 dirty needles and distributed around 45,200 sterile syringes. as of 2017, nsps are illegal in 15 states. nsps are prohibited by local regulations in cities in orange county, california, even though it is not disallowed by state law in california.