Over a decade of syringe exchange: results from 1997 UK survey

© 2002 Society for the Study of Addiction to Alcohol and Other Drugs Addiction, 97, 845–850

INTRODUCTION

Syringe exchange represents the key investment inprimary prevention of HIV and other blood-borne infections targeted towards injecting drug users (IDU)(Norman, Vlahov & Moses 1995). Since its introductionin the United Kingdom in 1986, syringe exchange, alongwith other harm reduction activities, has been instru-mental in averting an HIV epidemic among injectingdrug users in Great Britain (Stimson 1995). HIV preva-lence among IDUs, at around 3% in London and 1%

elsewhere in the United Kingdom, is low and stable(Stimson et al. 1996; Unlinked Anonymous SurveysSteering Group 1998). Furthermore, in a recent surveyof IDU in England none of those injecting for 5 years orless were HIV positive ( Judd et al. 2000).

Increasing the number of syringes in circulation andencouraging their return means that each syringe is usedfewer times, reducing the chance of HIV transmission(Kaplan & Heimer 1994). International comparativestudies have suggested that cities with syringe exchangeshow a downwards trend in HIV prevalence among

Over a decade of syringe exchange:results from 1997 UK survey

James Parsons1, Matthew Hickman2, Paul J. Turnbull1, Tim McSweeney1, Gerry V. Stimson2,Ali Judd2 & Kay Roberts3

Criminal Policy Research Unit, South Bank University, London1,The Centre for Research on Drugs and Health Behaviour, Department of Social Science and Medicine, Imperial College, London2 and Area Pharmacy Specialist—Drug Misuse, Greater Glasgow Primary Care NHS Trust,Glasgow, UK3

ABSTRACT

Aims To describe syringe exchange provision in the United Kingdom .Design Two-phase cross-sectional survey: phase I, establishing a samplingframe of syringe exchange coordinators (n = 420); phase II, surveying thecoordinators seeking data on the number of syringe exchange outlets, visitsand syringes distributed during April 1997 (68% response rate).Setting United Kingdom.Findings In 1997, nearly all Health Authorities in the United Kingdom(96%) operated some form of syringe exchange service, except NorthernIreland. In April 1997, 1 707 000 syringes were reported as being distrib-uted. Assuming that non-responders coordinated the median number ofoutlets and distributed the median number of syringes as responders, weestimate that 27 million syringes were distributed annually from over 2000outlets in the United Kingdom. The number distributed in Scotland was 3–4times less than in England when measured as a number per adult (15–44),drug user in treatment, or estimated injecting drug user.Conclusions Overall, there has been a 6.5-fold increase in syringe distribu-tion in England since 1991. The number of syringes distributed in theUnited Kingdom may be higher than the United States. However, thereappears to be unequal distribution of syringes within the United Kingdom,which may be associated with higher levels of HCV among injectors inScotland compared to England.

KEYWORDS Harm reduction, injecting drug use, needle exchange, syringe exchange.

RESEARCH REPORT

Correspondence to:

Dr Matthew HickmanCentre for Research on Drugs and Health BehaviourDepartment of Social Science and MedicineImperial CollegeReynolds BuildingSt Dunstan’s RoadLondonUKE-mail: [email protected]

Submitted 18 June 2001;initial review completed 30 August 2001;final version accepted 20 December 2001

846 James Parsons et al.


injecting drug users compared to cities with no syringeexchange provision, which show an upward trend(Hurley, Jolley & Kaldor 1997; Des Jarlais et al. 1998).Some papers have suggested that syringe exchange itselfis not enough to prevent epidemics of HIV (Strathdee et al. 1997). However, it has been estimated that nearly10 000 HIV cases could have been prevented in theUnited States if wide-scale syringe exchange provisionhad been introduced earlier in the epidemic, and thebalance of evidence supports a protective effect (vanAmeijden et al. 1995; Lurie & Drucker 1997).

A previous survey of needle exchange in England in1989/90 estimated that there were about 120 outlets,distributing approximately 4 million syringes (Donoghoe,Stimson & Dolan 1992). This paper presents findingsfrom the first UK survey of syringe exchange services,and the second survey for England.

METHODS

Phase I of the survey constructed a sampling frame ofsyringe exchange coordinators responsible for the rangeof syringe exchange services in Health Authorities/Boards (HA/B) in the United Kingdom (as no complete listexisted). Pharmacy syringe exchange coordinators wereidentified by contacting pharmaceutical advisers in eachof the UK HA/Bs who typically coordinated pharmacysyringe exchange services, or were able to identify theindividual responsible. Coordinators were identified forall HA/Bs except one, were there was no pharmacyneedle exchange provision. Most non-pharmacy needleexchanges were coordinated by the service manager. Weupdated a list of non-pharmacy syringe exchange coordinators provided by the National AIDS Manual(NAM) (Browning & Cordani 1996) by contacting theidentified coordinators, providing them with a list ofknown local services and asking them to identify any missing from this list to identify new services andcoordinatators.

In phase II of the survey, conducted in August 1997,syringe exchange coordinators were sent a questionnaireseeking information for 1 month (April 1997) on thenumber, type and location of outlets, the number ofsyringes distributed and the number of visits to services.Non-responders were contacted twice by telephone(October and November 1997).

Response rates

A total of 145 pharmacy syringe exchange and 275 non-pharmacy syringe exchange coordinators were identi-fied, with 78% (112) pharmacy coordinators and 63%(173) non-pharmacy coordinators returning question-

naires, giving an overall response rate of 68% (285/420).The frequency distribution of syringes distributed by ser-vices was highly positively skewed (with a small numberof outlets supplying a very large number of syringes).Therefore, median values for syringes distributed withineach RHA were used to impute the total number.

Annual figures were estimated by multiplying theApril data by 12. A series of rates also were estimatedusing the annual imputed number of syringes distributedas the numerator, and population estimates of adultsaged 15–44 years, reports from drug misuse databases ofopiate users in treatment, and estimates of the numberof injectors in the population as denominators (Frischeret al. 2001).

RESULTS

A total of 1733 syringe exchange outlets were reported,1326 (77%) operating from pharmacies and 407 (24%)from other outlets (Table 1). All regional health authori-ties (RHA) within England and nearly all of the 120health authorities in England and Wales and healthboards in Scotland (HA/B) provide pharmacy syringeexchange services and some form of non-pharmacysyringe exchange (99% and 90%, respectively). None of the HA/B in Northern Ireland reported any syringe exchange services. Non-pharmacy coordinatorsmanaged outlets provided through: specialist drugs ser-vices (219, 91% of coordinators and 54% of outlets);community outreach workers (95, 29% of coordinatorsand 23% of outlets); mobile services (24, 8% of coordi-nators and 6% of outlets); dedicated syringe exchangeservices (26, 9% of coordinators and 6% of outlets) andothers in accident and emergency (A&E), genito-urinarymedicine (GUM) or primary care (44, 18% of coordina-tors and 11% of outlets).

During April 1997 a total of 1 707 000 syringes werereported as being distributed over 75 400 client visits to syringe exchange services in the United Kingdom.Overall, pharmacy syringe exchanges distributedapproximately equal number of syringes as non-pharmacy syringe exchange outlets. However, on averagenon-pharmacy syringe services were visited more often(70 visits per outlet in April) than pharmacy syringeexchanges (35 visits per outlet) and non-pharmacy ser-vices distributed more syringes per visit (31 per visit)than pharmacy-based schemes (18 per visit). The averagenumber of syringes distributed by pharmacy and non-pharmacy exchanges varied, from eight to 12 per visit,respectively, in Scotland to 19 and 34 per visit, respec-tively, in England (Table 2).

Assuming that non-responding coordinators had themedian number of outlets as the survey respondents, it is

United Kingdom syringe exchange survey 847


likely that over 2000 outlets were offering syringeexchange in the United Kingdom in 1997. During April1997, we estimated that 2 293 000 syringes (afterimputing the total) were distributed which equates toabout 27 500 000 syringes distributed annually.

In England there was some regional variation in thenumber of syringes distributed, ranging from approxi-mately 109 000 in West Midlands to over 530 000 inNorth-west RHA (imputed totals allowing for non-response). Expressed as a number per adult populationaged 15–44 years or per drug user reported as being intreatment on the drug misuse database (DMD), these esti-mates correspond annually to: 250 syringes per 1000residents and 300 syringes per drug user in treatment inthe West Midlands; and 1000 syringes per 1000 resi-dents and 700 syringes per drug user in treatment inNorth-west RHA. Regional estimates of the number ofinjectors or problem drug users in the general populationare not currently available in any reliable form to take thecomparison any further.

However, a more significant variation in the numberof syringes distributed lies between Scotland England,and Wales (see Fig. 1 and Table 2). After allowing for non-response an imputed total of 81 000 syringes werereported as being distributed in Scotland in April 1997(970 000 annually), compared to 92 000 (1 100 000annually) in Wales and 2 120 000 (25 million annually)in England. It has been estimated that the number ofcurrent injectors in Great Britain ranges from 86 000 to171 000, with 72 000–144 000 in England, 11 000–21 000 in Scotland and 3000–6000 in Wales (Durante& Heponstall 1995; Frischer et al. 2001). In this scenariothe number of syringes available annually from syringeexchange services per injector would be 50–90 inScotland, 180–370 in Wales and 180–350 in England.Table 2 shows that the disparity between the countries inthe United Kingdom is also observed when comparinginformation on syringe distribution with the adult popu-lation aged between 15 and 44 years within eachcountry and per report of drug users presenting for treat-ment (DMD report). In Scotland the reported level ofdistribution is equal to 110 syringes per DMD reportmarkedly lower than Wales (480 per DMD report), andall RHAs in England (Fig. 1).

DISCUSSION

Since 1986, there has been a rapid increase in thenumber and geographical spread of syringe exchangeservices in the United Kingdom. In 1989/90 a survey ofexchanges using lists kept by the Broadcasting SupportService and ongoing contacts with exchanges and coordinaters identified about 120 outlets in EnglandTa

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(Donoghoe et al. 1992); whereas this survey found atleast 1468 outlets provided by English HA/B, 125 outletsoperating in Scotland and 140 in Wales (with an imputedtotal of more than 2000 overall in the United Kingdom).In England, from the previous survey there has been asixfold increase in the number of syringes distributed bysyringe exchange services, from approximately 4 millionin 1989/90 to 25 million in 1997 (Donoghoe et al.1992).

The scale of syringe exchange provision in the UnitedKingdom is in stark contrast to the United States. Asurvey of 100 of the 113 syringe exchange programmesknown to be operating in the United States in 1997 estimated that around 17.5 million syringes wereexchanged, with the 10 largest volume of syringeexchange programmes exchanging three-fifths of thistotal (Update 1998). A follow-up survey in 1998 of110/131 (84%) NEX estimated that approximately 19million syringes were distributed, or 23 million in total ifnon-responders are assumed to be the same as respon-ders (Update 2001). Thus the United Kingdom, with apopulation of about 60 million, may be distributing moresyringes than the United States, which has a populationover four-and-a-half times as large. In the United States,around 35% of the 725 000 cases of AIDS reported wereassociated with injecting drug use, compared to 7% of 16 067 cases in the United Kingdom (HIV/AIDSSurveillance Report 1999; HIV/AIDS Surveillance inEurope 1999). The difference in syringe exchange provi-sion may be one of the reasons for the difference inburden of HIV among IDU populations in the UnitedKingdom and United States. Although most Europeancountries provide some form of syringe exchange thereare no data available that allow comparison of the scaleof provision between countries (EMCDDA 1999).

Community surveys of injectors suggest that IDUsinject a median of two times a day (Rhodes et al. 1993;Stimson et al. 1996). Clearly, our estimates of the size ofinjecting populations must be treated very cautiously.However, if there were 86 000–171 000 injectors inGreat Britain (which is a plausible range) then potentiallyfrom 160 to 320 syringes were available per injector in1997. This suggests that overall in Great Britain at 1997

levels, distribution may provide one syringe per day if thelower estimate is true or maybe one every 2 days if thehigher estimate is the true prevalence. The number ofsyringes and proportion of injectors in receipt of cleaninjecting equipment may be higher given additional salesfrom pharmacies of around 2.5 million syringes per year,of which a sizeable proportion will be used for illicit drug use (Sheridan et al. 1996). Outside the UnitedKingdom a starker contrast is offered by Montreal, whereit was estimated that less than 5% of the need for syringesis met by syringe exchange (Remis, Bruneau & Hankins1998).

However, this survey’s findings suggest that there are marked differences between countries in the UnitedKingdom. First, Northern Ireland seems to have nosyringe exchange provision. This was because at the timethere were perceived to be very low levels of injectingdrug use in the population. A more recent review hasconcluded that there is now a need in specific localities,with the result that a pharmacy-based needle and syringeexchange scheme will be introduced for the first time inthe Province (personal communication, Dr N. Morrow,Chief Pharmaceutical Officer, N. Ireland).

Secondly, Scotland was severely under-provided incomparison to England and Wales. In 1997, it appearsHA/B in England and Wales distributed three to four times the number of syringes than Scotland—whetherexpressed as a number per resident population, number ofdrug users in treatment or estimate of injecting drugusers. Also, the average number of syringes distributed toclients in Scotland was lower than in England and Wales.In part this may be due to the existence in Scotland of acommon-law crime of ‘reckless conduct’ that could beused against those supplying needles and syringes to beused for injecting controlled drugs (Roberts et al. 1998).This led to calls for guidance from the Lord Advocate, whogave the view that the crime of reckless conduct wouldonly arise very exceptionally with regard to the supply ofneedles and syringes by pharmacists although he wouldwish to retain the discretion to prosecute in exceptionalcircumstances. The Lord Advocate’s guidance initiallystated that ‘no more than 5 needle and syringes should besold to each drug misuser on each visit’, which the

Table 2 Syringes distributed by country, modality of provision and estimators of drug using populations, April 1997.

Syringes Syringes Number perper visit per visit Number per 1000 drug user reported Number per (pharmacy) (non-pharmacy) of population (pop) in treatment (n) estimated injector (n)

Scotland 8 12 190 (5 100 000) 110 (9000) 90 50 (11 000–21 000)Wales 15 29 390 (2 800 000) 480 (2000) 400 200 (3000–6000)England 19 34 540 (47 100 000) 540 (52 000) 350 180 (72 000–144 000)Total UK 18 31 500 (55 000 000) 440 (63 000) 320 160 (86 000–171 000)

United Kingdom syringe exchange survey 849


Scottish office increased for subsequent visits to 15 inguidance in 1994. Before 1998, however, approval foreach new or continuing needle exchange scheme had tobe sought from the Scottish Office, who may equally beresponsible for the lower number of schemes operating in1997 compared to England and Wales.

In the United Kingdom, although HIV infection hasbeen low among injecting drug users in the 1990s(Unlinked Anonymous Surveys Steering Group 1998;Judd et al. 2000), hepatitis C infection (HCV), as in mostcountries, was thought to be high. New evidence for 1998suggests that among injectors in England HCV prevalenceoverall was about 40% and among injectors of less than3 years it was estimated to be less than 10% (Hope et al.2001). In contrast, recent surveys of injectors in Scotlandsuggest that HCV prevalence has fallen only modestlysince 1990 and was still 60% overall and over 30% inthose injecting for less than 3 years (Taylor et al. 2000).One explanation for the difference in HCV prevalenceamong injectors between Scotland and England could bedue to the difference in levels of syringe exchange activity,and certainly merits further investigation.

Interpretation of the estimates reported in this paperneed to take account of several potential biases. First,service activity was recorded for 1 month only (April) andthen multiplied up to estimate annual provision. As April

is at the beginning of the financial year the annual totalmay overestimate the true total if budgets became constrained during the year. Secondly, non-respondingsyringe exchange coordinators were all successfully con-tacted by phone implying that there were outlets to coordi-nate, although they did not return the questionnaire.However, imputing the total by taking the median fromresponders within the same area and RHA (althoughdeliberately more conservative than the mean) may stilloverestimate the total number of syringes distributed if allnon-responding outlets were small, or underestimate thetotal if a large outlet was missed. It is unlikely that ifpresent these biases would alter dramatically the order ofmagnitude of the estimates, or explain entirely the differ-ences between Scotland, and England and Wales. Further,local data from Glasgow can corroborate the compara-tively low numbers of syringes distributed in Scotland in1997 (Kay Roberts, personal communication).

There is a paucity of information on syringe exchangein the United Kingdom, except for a few notable excep-tions. It is vital that a routine monitoring system of allsyringe exchange services is established to collate andreport at least the number of syringes distributed,exchanged and client contacts. First, without such datathe unequal distribution of services will not be recog-nized nor can services be effectively planned. Secondly,these data are required to raise the profile and publichealth importance of syringe exchange as a key inter-vention against HIV and HCV and in order to support andjustify the continued provision and expansion of services.

CONCLUSIONS

The scale of the public health response to prevent HIVamong injecting drug users by providing supplies ofclean injecting equipment is to be applauded within theUnited Kingdom. However, although it is likely that the United Kingdom distributes more syringes than theUnited States there is inequity between the countrieswithin the United Kingdom and perhaps also regionallyin England. In 1997 Northern Ireland seems to have nosyringe exchange services. Scotland also appears to havea far more restrictive and smaller service compared toEngland and Wales. These anomalies need to be redressedin order to maintain the low transmission of HIV and tohave a chance of reducing HCV transmission.

ACKNOWLEDGEMENTS

The Centre for Research on Drugs and Health Behaviouracknowledges the financial support of the LondonRegion Office of the NHS Executive. The authors are

Syringes per report to RDMD

110300–449450–599600–714

Figure 1 Number of syringes distributed per report to DMD,April1997



grateful to Chris Cairns at the Pharmacy AcademicPractice Unit, St George’s Hospital, for help in identifyingpharmacy syringe exchange coordinators, and theNational AIDS Manual, for providing information on non-pharmacy syringe exchange services. We wouldespecially like to thank all the coordinators of syringeexchange services across the United Kingdom who filledin and returned questionnaires. Matthew Hickman issupported by a National Career Scientist Award from theDepartment of Health.

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Over a decade of syringe exchange: results from 1997 UK survey

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