CON: Needle Exchange Programs Should Not Be Instituted to Reduce Hepatitis C Virus Transmission.

Watch a video presentation of this article The opioid epidemic is more rampant now than ever before in the United States. Drug overdose deaths climbed 21% between 2015 and 2016. Of the 64,000 deaths in 2016, two-thirds were attributable to opioids.1 There has been a concomitant surge in intravenous (IV) opioid use, leading to an increase in acute HCV. NEPs have gained substantial support over the past two decades, with currently 228 programs in the United States. Backing of NEPs stems from earlier data evaluating prevention of transmission of human immunodeficiency virus (HIV) among persons who inject drugs (PWID).2 Without clear evidence of success, NEP implementation expanded in an attempt to curtail the spread of HCV. To date, there has been no direct evidence demonstrating that NEPs reduce HCV transmission in the United States.3 In fact, there are no randomized control trials directly evaluating the effectiveness of NEPs and HCV transmission. The North American Syringe Exchange Network (NASEN) conducts annual surveys of NEPs. These surveys over the past 20 years have shown both an increase in the number of NEPs and the number of cities with NEPs. In addition, there has been a concomitant marked increase in the number of syringes exchanged, with 45.9 million needles exchanged in the most recent survey data from 2013. Lastly, the total funding budget for NEPs has also steadily increased, with $21.9 million spent in 2013.4 Despite continued expansion, funding, awareness, and utilization of NEPs, the Centers for Disease Control and Prevention (CDC) illustrates the incidence of acute hepatitis C growing quickest among young adults ages 20-39; more than 70% of cases are attributable to IVDU. Furthermore, NEPs are not created equal; programs differ in regard to services provided, number of needles given, and geographic location. These variables further add to the ineffectiveness of NEPs in reducing the spread of HCV. Hagan et al.5 in a multisite study found that there were multiple risk factors besides sharing of needles that attribute to HCV seroconversion. Nearly 40% of HCV infections were attributable to shared use of equipment, including cookers, filtration cotton, and rinse water. NASEN surveys have shown that in addition to needles, more than 90% of NEPs provide cookers, cotton, and alcohol pads.4 Yet, despite providing these additional supplies, acute HCV among PWID is increasing. The National Institute for Health Research conducted extensive studies on the impact of NEP on HCV transmission in the United Kingdom.6 The study evaluated many variables, including high-coverage NEPs, and defined them as (1) obtaining 100% of needles from a safe source, (2) reporting 100% of injections covered by a clean needle or syringe, (3) regular attendance at least once a week at an NEP, and (4) obtaining most needles or syringes from an NEP in the past 6 months. As shown in Fig. 1, this systematic review with more than 3400 participants indicated no evidence of intervention effect of low NEP coverage on HCV infection. Furthermore, the same review revealed no evidence of intervention effect of high NEP coverage on HCV infection, as shown in Fig. 2. Des Jarlais et al.7 assessed trends in HIV, HCV, and HIV/HCV infection among PWID from 1990 to 2011 in New York City. During this time, there was a large expansion of syringe exchange in New York City, from 250,000 to 3,000,000. From 1990 to 2001, the HIV prevalence rate declined from 54% to 13%. The HCV prevalence rate declined from 80% to 59% among HIV-seronegative individuals and from 90% to 63% overall. However, there are two major limitations to this study. First, the patients enrolled in the study were from Beth Israel detoxification program, which is not a random or accurate representation of the average PWID in the United States. Second, people must be cautious in drawing inferences from temporal associations between NEPs and reduction in prevalence. Other HIV prevention services for IVDU, including community outreach programs, voluntary HIV counseling and testing, drug abuse treatment, and treatment for HIV infection, were also available during the study.7 Although this multifactorial approach seems to be effective, it is not readily available for the greater majority of PWID. Limited studies from Europe have shown that NEPs do work. A recent Cochrane systematic review evaluated the effect of high-coverage NEP, low-coverage NEP, and no-coverage NEP among HCV transmission. The data were derived from five studies with more than 3500 participants; these studies evaluated NEP and HCV transmission in North America and Europe. Results varied by geographical region, with an effect seen in Europe but none noted in North America.9 In addition, Turner et al.10 published a meta-analysis from six UK sites showing that OST and NEPs can reduce HCV transmission among PWID. However, it is important to note that OST is not currently being used in the United States; thus, we should not directly extrapolate the European data to the current situation in the United States. Over the past two decades, there has been an increase in both the number of NEPs and the number of cities with NEPs, along with increased funding and total number of syringes exchanged. Despite this, the incidence of acute hepatitis C is surging.11 A positive effect is apparent in Europe, but it is believed to be secondary to a multifactorial approach, that is, use of NEPs along with counseling and OST. This was not evident in North American studies, likely because most NEPs do not provide OST. Giving patients clean needles without providing other interventions is analogous to simply placing a bandage on a wound; it does not prevent the inciting or subsequent event of creating the wound, which is opioid addiction itself. Therefore, NEPs, in their current state, should not be implemented to reduce the risk for HCV transmission, because NEPs alone do not decrease this risk in North America. Nothing to report.