One-for-One Needle Exchange: Evidence and Best Practices

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Background

A key goal of Needle Syringe Programs (NSP) is to reduce the transmission of HIV, Hepatitis C, and other blood-borne infectious diseases by providing new sterile needles to people who inject substances. One delivery model involves a one-for-one needle exchange rule. This only allows a person to receive a new sterile needle for every one they return to the NSP.

Bottom Line

In Canada, one-for-one needle exchange is not recommended.

Rationale

The one-for-one rule is considered outdated and not recommended in Canada because it is not responsive to the realities of substance use, program access, or sterile needle distribution networks.

NSPs aim for 100% coverage of injection drug use, which means that they aim to ensure that every injection occurs with a new sterile needle. One-for-one needle exchange is a barrier to achieving 100% coverage because:

Not all people who inject substances with new sterile needles access them directly from Needle Syringe Programs. Geographic barriers, limited NSP hours of operation, and stigma are some barriers to access. People who inject substances may get new sterile needles through peer distribution. Some NSP clients need to pick up more than one needle at a time so that they can distribute them among their network.
An individual cannot always store needles safely until they can be returned to the NSP
An individual may need to collect more than one needle in order to have one for an injection due to police confiscation, losing needles, giving them away, or needing more than one syringe to successfully inject (for long-term injectors)

Sources

There is wide consensus on this topic in Canada. Established and evidence-based best practice recommendations are against one-for-one needle exchange, and case studies affirm that it is outdated, as outlined in the documents provided below.

Foundational Documents

One-for-one needle exchange models have been examined and addressed in the foundational documents that guide harm reduction program delivery in Canada and Ontario. They are:

Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms – Part One | Pages: 8, 9, 15-18,
Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms – Part Two | Pages: 13, 16, 24, 25, 36
Ontario Needle Exchange Programs: Best Practice Recommendations | Pages: 36-7, 85, 147

Canadian Case Studies

Vancouver

Between 2000 and 2002, the health authority in Vancouver changed its syringe exchange policies to try to make it easier for people who inject drugs to get new sterile syringes. Program changes included getting rid of the one-for-one exchange rule. The program changes were linked to positive outcomes, including lower rates of HIV infection.

Read more about the Vancouver experience:

Research Summary: Improving Vancouver’s Needle Exchange Services to Reduce the Risk Of HIV
Research Article: Syringe sharing and HIV incidence among injection drug users and increased access to sterile syringes

Ottawa

In 2008, the City of Ottawa considered changing to a one-for-one needle exchange model, due to concerns about discarded needles in the community. After a report from the Chief Medical Officer of Health, they decided not to. Instead, the City of Ottawa “successfully implemented a comprehensive and integrated response to discarded needles” that did not include one-for-one needle exchange (quote from Integrated Response to Discarded Needles Report).