1. Poster produced by Faculty & Curriculum Support (FACS), Georgetown University Medical Center
The cost-effectiveness of syringe exchange programs
for HIV prevention in injection drug users
Meghaan P. Walsh1
; Mary Beth Levin, MPH1
; Chris Collins, MPP2
Abstract
1
Georgetown University School of Medicine, Washington, DC;
2
amfAR, The Foundation for AIDS Research, Washington, DC
Introduction
Methods
Discussion
Conclusions
References
Acknowledgments
Georgetown
University
1. Hall HI, Song R, Rhodes P, Prejean J, An Q, Lee LM, Karon J, Brookmeyer R, Kaplan EH, McKenna MT, Janssen RS. Estimation of
HIV Incidence in the United States. JAMA. 2008;300(5):520-529.
2. “Estimates of New HIV Infections in the United States, 2006-2009.” CDC Fact Sheet, August 2011.
3. “HIV-Associated Behaviors Among Injecting Drug Users—23 Cities, United States, May 2005-February 2006.” CDC MMWR April 10,
2009;58(13):329-332.
4. Des Jarlais DC. Preventing HIV infection among injecting drug users: Intutitive and counter-intuitive findings. Applied & Preventive
Psychology. 1999;8:63-70.
5. “HIV Infection Among Injection Drug Users—34 States, 2004-2007.” CDC MMWR November 25, 2009.
6. Santibanez SS, Garfein RS, Swartzendruber A, Purcell DW, Paxton LA, Greenberg AE. Update and Overview of Practical
Epiemiological Aspects of HIV/AIDS among Injection Drug Users in the United States. Journal of Urban Health: Bulletin of the New
York Academy of Medicine. 2006;83(1):86-100.
7. “Trends in HIV/AIDS Diagnoses—33 States, 2001-2004.” CDC MMWR November 18, 2005;54(45):1149-1153.
8. “Syringe Exchange Programs – United States, 2008.” CDC MMWR November 19, 2010;59(45):1488-1491.
9. “Syringe Exchange Programs.” CDC Fact Sheet, December 2005.
10.Chen RY, Accortt NA, Westfall AO, Mugavero MJ, Raper JL, Cloud GA, Stone BK, Carter J, Call S, Pisu M, Allison J, Saag MS.
Distribution of Health Care Expenditures for HIV-Infected Patients. Clin Infect Dis. 2006;42:1003-1010.
11.Schackman BR, Gebo KA, Walensky RP, Losina E, Muccio T, Sax PE, Weinstein MC, Seage GR, Moore RD, Freedberg KA. The
Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States. Med Care. 2006;44:990-997.
12.Wodak A, Cooney A. Do Needle Syringe Programs Reduce HIV Infection Among Injecting Drug Users: A Comprehensive Review of
the International Evidence. Substance Use & Misuse. 2006;41:777-813.
13.Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. The
Lancet. 1997;349:604-608.
14.Laufer, FN. Cost-Effectiveness of Syringe Exchange as an HIV Prevention Strategy. J Acquir Immune Defic Synd. 2001;28(3):273-278.
15.Lurie P, Gorsky R, Jones S, Shomphe L. An Economic Analysis of Needle Exchange and Pharmacy-Based Programs to Increase
Sterile Syringe Availability for Injection Drug Users. J Acquir Immune Defic Synd and Human Retrovirol. 1998;18(Suppl 1):S126-S132.
Results
In response to a Congressional bill passed in December 2011
reinstating the ban on federal funding for syringe exchange
programs, and in preparation for the National Day of Action for
Syringe Exchange in March 2012, amfAR tasked me with
reviewing the existing literature on syringe exchange programs
in the United States and the cost-effectiveness of syringe
exchange programs as a public health intervention for HIV
prevention. The findings of the literature review could then be
adapted for use in a policy brief for more effective advocacy by
amfAR and their partners for federal funding of syringe
exchange programs. More than 30 primary research and review
articles were selected as part of the literature review process.
Overall, review of the literature from the last two decades
suggests that syringe exchange programs are a cost-effective
intervention for HIV prevention in injection drug users.
Additionally, syringe exchange programs have significantly
impacted the HIV epidemic among injection drug users, with an
approximate 80% decrease in HIV incidence in the transmission
category over the last 20 years.1
The HIV/AIDS epidemic has plagued the United States for over three
decades, and despite improved therapies available to those suffering
with the disease, it remains a significant public health issue both
nationally and internationally, with unchanging infection rates over the
past several years.2
The epidemic has disproportionately affected racial,
ethnic and sexual minorities, as well as injection drug users (IDUs).1
As
recently as 2007, using injection drugs was the third most frequently
reported risk for contracting HIV in the United States, and historically,
the transmission of HIV among the IDU population was rampant due to
efficient transmission through the sharing of drug injection equipment
and drug mixtures, as well as a lack of awareness of the threat of HIV
and restricted access to sterile injection equipment.3,4
The number of IDUs infected with HIV annually has dramatically
decreased over the course of the last two decades, in large part due to
reductions in syringe sharing between IDUs through increased
awareness of the epidemic and access to sterile syringes through
syringe exchange programs (SEPs) and pharmacies.1
The risk group is
one of the few that has experienced such improvements in HIV
incidence rates over the course of the US epidemic. However, despite
the apparent benefits of SEPs in reducing HIV infection among IDUs,
this method of harm reduction and HIV prevention continues to be
controversial in the United States. Several studies over the course of the
HIV epidemic have suggested that SEPs reduce the incidence of HIV
among IDUs and are a cost-effective public health intervention for the
prevention of HIV. For my Advocacy Elective, I performed a literature
review, which summarizes the present state of the HIV epidemic among
IDUs and syringe exchange programs in the United States, as well as
the cost of HIV therapy in the highly active anti-retroviral therapy, or
HAART, era. It also explores previously published studies evaluating the
cost-effectiveness of SEPs in the United States.
Using PubMed and OVID Medline, several primary articles and reviews were selected.
Specifically, those pertaining to the HIV epidemic among injection drug users (IDUs) in the
US, syringe exchange programs as a means of HIV prevention in IDUs in the US, the cost-
effectiveness of syringe exchange programs in preventing HIV in IDUs, and the current
cost of treating HIV and AIDS in the US were selected. More than 30 papers were read as
a part of the literature review. Additionally, the Centers for Disease Control and Prevention
(CDC) and other experts in the field, including Dr. Don Des Jarlais, were consulted in
order to clarify data presented in the literature.
Figure from CDC Fact Sheet “Estimates of New HIV Infections in the United States, 2006-2009,” August 20112
In general, the incidence of HIV among IDUs has decreased over the last several years. From 1994 to 2000,
IDUs accounted for one third of new HIV infections, with 23% of infections occurring among heterosexual IDUs,
5% in MSM/IDUs, and 4% in people infected through sexual intercourse with IDUs. However, during the same
time period, IDUs experienced a more drastic decrease in HIV infection rates compared to MSM, with rates
declining by 42% and 15% respectively.6
Between 2001 and 2004, a significant average annual decrease in HIV
incidence of 9.1% occurred among IDUs in 33 states, per CDC reports.7
Based on more recent estimates of HIV
rates in the United States, the HIV incidence among IDUs decreased by approximately 80% from 1988 to 2006; it
is the only adult transmission category to experience such a significant reduction.1
Current Lifetime Cost of HIV Treatment
Recent studies have estimated the annual and projected lifetime costs of HIV treatment
based on health care use of HIV patients. A group at the University of Alabama analyzed
the health care expenditures of HIV patients enrolled in the university’s HIV clinic from
March 2000 to March 2001, using the average wholesale price of medications and the
Medicare procedural technology and diagnostic related reimbursement rates for hospital
and clinic expenditures. The annual cost of HIV treatment per patient with a CD4 count
greater than or equal to 350/uL was found to be $13,885. For patients with CD4 counts
less than 50/uL, the annual cost of treatment was $36,532, about two and a half times
greater than the cost of treatment for the higher CD4 count group.10
In another recent study, Schackman et al. calculated the projected lifetime cost of HIV
treatment based on health care use documented through the HIV Research Network
(HIVRN), a consortium of high-volume HIV primary care sites throughout the United
States. The study calculated the discounted lifetime cost for HIV treatment with a CD4
count of <350/uL at the initiation of therapy to be $385,200 with a life expectancy of 24.2
years. Of total expenditures, 73% went to antiretroviral medications, 13% to inpatient care,
and 5% to other HIV-related medications and labs. For a person with a CD4 count
<200/uL at the initiation of therapy, discounted lifetime costs of HIV treatment were
calculated to be $354,100, with a life expectancy of 22.5 years from initiating therapy.11
Syringe exchange programs are a cost-effective
intervention for the prevention of HIV in
injection drug users.
SEPs additionally serve to provide injection drug
users with important preventive health care services.
Further advocacy for this harm reduction intervention
is necessary in order to reestablish federal funding
for SEPs and expand current programs.
Overall, the literature suggests that syringe exchange programs are not
only cost-effective, but that they have also contributed to a significant
decrease in the HIV incidence among IDUs over the last two decades. In
fact, it is one of the subpopulations that have seen the most improvement in
HIV incidence and prevalence rates, especially in cities such as New York
City, where syringe exchange programs are robust and have been since
their expansion in the city in the early 1990s. Syringe exchange programs
have also been shown to provide other health care services to IDUs that
they would otherwise not access, such as vaccinations and HIV and STD
screening. They also help connect the subpopulation with drug
rehabilitation programs.
Through my Advocacy Elective, I gained valuable insight into the workings
of a large national HIV/AIDS advocacy organization and the value of sound
literature reviews and policy briefs as an approach to advocacy efforts. I
was periodically frustrated by scarcity of the literature for certain questions I
was exploring, and I also had difficulty comparing various studies with
different models and rectifying disparate results between seemingly similar
studies. In general, however, it was a very informative experience. I have
gained a better understanding of the challenge of effective advocacy,
specifically when it is for an issue, a population or an intervention that has
historically been controversial. It is fascinating that, despite numerous
studies demonstrating that syringe exchange programs are cost-effective
and a valuable intervention from an HIV prevention stand-point, the social
stigma and legal issues that surround injection drug use continue to make
support for a national syringe exchange policy a challenge.
Georgetown
University
Figure 2. Estimated New HIV Infections by Transmission
Category in the US and Washington, DC, 1977-2006
Syringe Exchange Programs in the United States
The first organized SEPs in the United States opened in the late 1980s in Tacoma, WA, Portland, OR, and New
York City, NY. They have since been established in numerous cities and states throughout the country, and they
operate in a variety of settings, including health clinics, storefronts, vans, and sidewalk tables. As of March 2009,
a total of 184 SEPs were operating in 36 states, Washington, DC and Puerto Rico. Based on a 2008 survey,
budgets for surveyed SEPs totaled $21.3 million, and individual program budgets ranged from $300 to $2.3
million, with a median annual budget of $63,258. Most SEPs report providing health care services beyond syringe
exchange, and they are thought to have a public health impact on the IDU population through referrals to
substance abuse treatment facilities and providing access to important vaccinations and health screening.8,9
Results
HIV Incidence in IDUs in the United States
In 2009, an estimated 4,500 new HIV infections occurred among IDUs, with black men and women IDUs
accounting for the greatest number of those newly infected (1,200 and 940, respectively).2
Between 2004 and
2007, a total of 19,687 IDUs were diagnosed with HIV, and the average annual rate of infection during that time
between different racial and ethnic groups within the IDU population varied dramatically. Black IDUs were
infected at a rate of 11 per 100,000 of the general population, approximately ten times that of white IDUs,
whose infection rate was 0.9 per 100,000 in the same time period. Hispanic/Latino IDUs were infected at an
annual rate of 4.9 per 100,000. 5
Figure from H. Irene Hall et al., “Estimation of HIV Incidence in the United States,” JAMA 20081
Data in figure from “Syringe Exchange Programs – United States, 2008.” CDC MMWR November 19, 20108
Figure 3. Percent of SEPs Offering Preventive Health
Services, 2008
Special thanks to Mary Beth Levin, Chris Collins, and the entire staff at amfAR for their support
and guidance in this project. Thank you to Dr. Don Des Jarlais and Vivian Guardino at Beth
Israel Medical Center for their assistance and suggestions, as well as the Centers for Disease
Control and Prevention for clarification of data.
Figure 1. Estimated New HIV Infections for the Most-
Affected Subpopulations in the United States, 2009
Cost-effectiveness of SEPs in HIV Prevention (cont.)
 In a 1997 study estimating the number of HIV infections that could have been
prevented if a national syringe exchange program had been adopted early on in the
HIV/AIDS epidemic, they calculated that with a low estimate of SEP effectiveness (15%
reduction in incidence with program implementation), 4394 HIV infections could have
been prevented between 1987 and 1995 with a national SEP program. A total of 9666
infections could have been avoided in the same time, if using a high estimate of
effectiveness, or 33% incidence reduction. They further calculated that such an
intervention would save between $244 million and $538 million in health care costs.13
 A cost-effectiveness ratio of $20,947 per HIV infection averted was calculated for NY
state approved SEPs (total of 7 programs included in study), based on an estimated 87
infections averted across the 7 programs and total program costs of $1.82 million.14
 Another group estimated the cost of providing sterile syringes through five syringe
distribution strategies (SEPs, pharmacy-based SEPs, free pharmacy distribution of
injection kits, sales of kits to IDUs, sale of syringes in pharmacies) in three representative
cities (New York, NY; San Francisco, CA; Dayton, OH). Based on their estimations, the
cost per syringe distributed for each strategy was: $0.97 per syringe for SEP; $0.37 per
syringe for pharmacy-based SEP; $0.64 per syringe for pharmacy injection kit
distribution; $0.43 per syringe for pharmacy injection kit sale; and $0.15 per syringe for
pharmacy syringe sale. They also calculated the annual HIV seroincidence at which each
of the distribution strategies would be cost-neutral compared to HIV treatment, which
were 2.1% for SEP, 0.8% for pharmacy-based SEP, 1.4% for pharmacy injection kit
distribution, 0.9% for pharmacy injection kit sale, and 0.3% for pharmacy syringe sale.15
 Based on a MEDLINE search of published articles from Jan 1981 to Oct 2005 of
practical epidemiologic aspects of HIV/AIDS among IDUs in the US, studies have shown
that “SEPs were found to not lead to an increase in drug injection or recruitment of first-
time injectors, to be cost-effective, to not lead to more discarded syringes, to provide
ways to access drug users for referrals to medical and social services, to be effective at
reducing syringe sharing, to be associated with less HIV infection and to correlate with
decreased HIV incidence.”6
Cost-effectiveness of SEPs in HIV Prevention
 One study in 1992 estimated the cost per HIV infection prevented by syringe
exchange and HIV counseling and education to be approximately $4,000.12
 A 1997 study estimated the cost per HIV infection prevented at a specific SEP in New
York City to be $2,667, with $53,000 to $77,000 total medical expenditures averted
through syringe exchange based on HIV treatment costs at the time of the study.12
 In a 1998 study, a mathematical model was used to estimate cost of providing 100%
sterile syringes to US IDUs and the potential cost per HIV infection averted through such
an intervention. They estimated a cost of $423 million for approximately 950 million
syringes, or 100% coverage of sterile syringes. Despite this seemingly astronomical cost,
they further calculated that complete provision of sterile syringes would result in 12,350
HIV infections prevented and a subsequent $34,278 cost saving per HIV infection
averted, which was also significantly less than the average lifetime medical cost of HIV
treatment at the time of their study (approximately $108,500).12
 Kahn et al. found the cost per HIV infection averted to range from $12,000 to $99,000
in an analysis of four hypothetical SEPs with various HIV prevalence and incidence
rates, using a simplified Yale Needle Circulation Model to estimate cost-effectiveness.12