Talk:Needle and syringe programmes/Archive 2

Third Opinion Needed
Stigmatella, I am concerned by the removal of the text on the 2010 Palmateer and 2006 US Institute of Medicine (IOM) reviews in the second paragraph of the article and its replacement with a description of the 2004 Wodak/Cooney review here, which has verifiable errors. The reason I believe the IOM review (later published as Tilson et al. in 2007) must appear is because it is the most rigorous study to date with 24 scientists, medical practitioners and reviewers involved in their review, and it is recognised by the two 2010 Palmateer-initiated and the 2008 NICE reviews of reviews to be the most rigorous - see p 126 here and see footnote p 32 here. The Palmateer reviews should appear because they are the most recent ‘reviews of reviews’.

You are concerned that Drug Free Australia distorts the science, and I assume you are asserting it distorts what the US IOM review has said. I believe this to be incorrect. I will venture that if the 4 questions below receive a Yes when full scrutiny of the IOM review p 145ff here is complete, then Drug Free Australia is fully justified in questioning the Palmateer review of reviews on its finding re HIV incidence p 115 here.


 * 1) Does the 2006 IOM review indeed find that the science on NEP effectiveness re lowering HIV incidence is ‘inconclusive’?p 149
 * 2) Does the IOM review, when considering multi-component prevention programs which include NEPs, find evidence of effectiveness?
 * 3) Given that question 2 is a different consideration to that of question 1, do the four ecological studies mentioned at Conclusion 3.4 in the IOM review p 149 here indeed fail to add any weight of causality for NEPs to question 1, but add weight to question 2?
 * 4) If the IOM in fact does find that the science on NEPs apart from a multi-component prevention setting is inconclusive, isn’t Palmateer wrong to upgrade the evidence to ‘tentative’ when considering NEP effectiveness apart from multi-component programs, given that she has questions about the positive conclusions of two of her four acceptable ‘core’ reviews (Gibson et al. and Wodak/Cooney) in the second EMCDDA review of reviews, and when her fourth Kall et al. ‘core’ review finds the science inconclusive?

My read of the evidence is that Drug Free Australia is correct in rendering the science on NEPs apart from multi-component prevention efforts inconclusive and is correct in questioning Palmateer’s upgrading of the evidence in the light of the issues surrounding her four core reviews. This is therefore, to my thinking, a correct reading of the science and not a distortion. I have previously given reasons as to why Drug Free Australia’s assertions must be given some weight in the article and why their notability as the most science-oriented analysts of drug policy information amongst the prevention organisations world-wide is important. I would then ask - if their observations about the science are correct, should Wikipedia readers be given a picture which is otherwise when we have already covered its success in the multi-component prevention setting in the page’s text? Minphie (talk) 01:44, 1 August 2013 (UTC)


 * You have listed a 3O request.
 * Please note on the 3O page where it states: "If more than two editors are involved, 3O is not appropriate."
 * In opposition to you, active members in this dispute include Gabbe, Steinberger, Doc James, Soulparadox, Ohiostandard as well as myself. All of us agree that Drug Free Australia (DFA) is non-MEDRS-compliant, and we agree that, with an occasional exception, the great bulk of material published in the Journal of Global Drug Policy and Practice (JGDPP) is non-MEDRS-compliant. We agree that DFA is an advocacy group and that JDGPP is the publication organ of an advocacy group. Stigmatella aurantiaca (talk) 05:18, 1 August 2013 (UTC)
 * I specifically object to your highlighting individual sentences from major reviews and meta-analyses which seem at odds with their overall conclusions and which, taken out of context, apparently support your position. This is represents "selective quote mining", and is also a technique that I have noted is used by various advocacy groups. An egregious example is this DFA pamphlet that you have cited on multiple occasions, and which has been removed on multiple occasions by myself and others. Stigmatella aurantiaca (talk) 12:25, 1 August 2013 (UTC)
 * Anyone wishing to assist with this disagreement can search this Talk page (CTRL-F) and enter the words 'distort' and 'misuse' to see that this is an argument developed by you alone. MEDRS is a RS/N issue, which is quite distinct from this conflict resolution issue. I have moved this text back into its original position so that it can be found by the Active Disagreements listing which pointed to my text here before it was moved elsewhere. Minphie (talk) 12:30, 1 August 2013 (UTC)
 * I have changed the wikilink on the 3O page to point to this section and removed your duplication of content. PLEASE try, whenever appropriate, to add new comments to the bottom. Scattering your comments up and down the page and duplicating sections makes the discussion hard to follow. Stigmatella aurantiaca (talk) 12:52, 1 August 2013 (UTC)

About your Third Opinion request: (To other 3O volunteers: I've not "taken" or "reserved" this case and, indeed, may not offer an opinion here even if the issues are clarified, so feel free to jump in.) I am a regular volunteer at the Third Opinion project. Though multiple editors have weighed in on this matter in the past, the current dispute on this talk page seems limited to just Minphie and Stigmatella aurantiaca. No other editor has edited this talk page since May 26, with the exception of a single, relatively minor edit by Soulparadox. In my opinion, a 3O could be available except for the fact it's not at all clear what the specific issue or issues are for which a 3O has been requested. Remember that 3O's work far better for simple, well-defined issues ("Is X a reliable source?") than for broad, diffused issues ("There's a huge NPOV problem with this page.") and that 3O's are nothing but that: utterly non-binding opinions which do not even "count" towards consensus. If that's what you think will help here, let me recommend that you restate the issues below this posting, trying to keep them no longer than this posting. That will increase the chance that a 3O volunteer will decide to give an opinion. Regards, TransporterMan  ( TALK ) 14:17, 1 August 2013 (UTC)
 * 1) Minphie, in his/her revision of 11:49, 28 July 2013, cited a web news item by the non-MEDRS-compliant advocacy group Drug Free Australia (DFA) to discredit comprehensive studies by the World Health Organization in 2004, the United States Institute of Medicine in 2006, and two major "reviews of reviews" in 2010 sponsored by the European Monitoring Centre for Drugs and Drug Addiction. The news item referred to a study by Käll et al. that appeared in the non-MEDRS-compliant Journal of Global Drug Policy and Practice, which is a publication arm of the advocacy group Drug Free America Foundation. I reverted Minphie's revision since DFA is a political lobbyist group rather than a scientific or medical organization.
 * 2) Minphie, in his/her revision of 01:56, 8 July 2013, selectively quoted, out of context, single words and sentence fragments from the 2006 United States Institute of Medicine study, stating that "the evidence for the effectiveness of NSPs in preventing HIV was 'inconclusive' and that 'multiple studies show that NSEs do not reduce transmission of HCV(Hepatitis C)." I reverted Minphie's revision, since by "inconclusive", the USIOM review meant that the available studies were inadequate for judging the effectiveness of NSPs in preventing HIV, and specifically did not mean that NSPs were ineffective. Stigmatella aurantiaca (talk) 04:19, 2 August 2013 (UTC)
 * Here is the nub of the problem between us, I think. If the IOM says that the science on NEP effectiveness is 'inconclusive' then they are saying they are neither proven to be effective nor ineffective. If you read the Drug Free Australia literature they are addressing studies which claim they are effective, and claim massive financial benefits to society as a result, when there is no proven science of their effectiveness or ineffectiveness. See if the DFA literature says anything otherwise. This may clarify things a little. Minphie (talk) 08:46, 2 August 2013 (UTC)
 * Worldwide efforts to combat the spread of HIV almost always involve some combination of opioid substitution therapy (OST), needle and syringe programs (NSPs), antiretroviral therapy (ART), psychosocial interventions for drug dependence, HIV testing and counseling, condom distribution, education programs, compulsory detention, and so forth. Such combination efforts appear to have varying degrees of effectiveness at combating the spread of HIV, but given the heterogeneity of the treatment environment and limitations of the scientific research, proof for the effectiveness of the individual components of these programs is lacking. (Compulsory detention appears to be definitely counterproductive.) True, the individual effectiveness of NSPs has not been proven, but neither has the individual effectiveness of OST or (depending on country, population group, socioeconomic factors etc.) ART! This is in agreement with mathematical modeling studies, which show that no individual approach has more than a limited degree of effectiveness in reducing the overall incidence of HIV infection. The definitive sorts of studies that would be capable of isolating and quantifying the contributions of each individual approach to combating the spread of HIV are practically, morally and ethically impossible. Your focus on needle exchange represents a political agenda, not a scientific one. Stigmatella aurantiaca (talk) 12:33, 2 August 2013 (UTC)
 * Focusing on overall HIV incidence alone, there are insufficient studies to establish the effect of HIV testing and counseling, individual/couple/group behavioral interventions, opioid antagonists, or cognitive behavioral therapies on the incidence rate. Condom provision is effective at lowering HIV incidence. The literature on NSPs and OST is difficult to evaluate, with multiple studies pointing towards a definite desirable effect, multiple studies showing little or no effect, and no studies showing an undesirable effect on overall HIV incidence. ART is effective in population groups capable of affording the expense. Compulsory detention of drug users is counterproductive. Stigmatella aurantiaca (talk) 11:50, 3 August 2013 (UTC)
 * Stigmatella, I am reticent to get into an extended discussion especially when seeking a Third opinion, but I cannot let the inaccuracy of your statement about NSPs and HIV incidence go unchallenged as it may unfairly bias opinions. Even the discredited 2004 World Health Organisation Wodak/Cooney review, for all its positive findings on studies that are actually inconclusive, found 3 of the 11 accepted studies on NEP and HIV incidence to be associated with increased HIV rather than decreased HIV in their NEP populations. I would like our discussion to be based on accurate information. Of course it is those studies deemed to be pointing to a desirable effect that is under discussion by the US IOM and Kall et al, who do not have such optimism when evaluating that science. Minphie (talk) 02:24, 4 August 2013 (UTC)
 * If you study the circumstances objectively, you will see that in those cases that you mention, increased incidence of HIV occurred DESPITE the existence of needle exchange programs, not because of them. The lesson long known since the famous Vancouver study, and one that I myself have repeatedly emphasized, is that "Needle Exchange is Not Enough." Stigmatella aurantiaca (talk) 03:30, 4 August 2013 (UTC)

Third opinion
I'm afraid here, a third opinion is not going to be much help. The two-editor involved suggestion isn't a strict limit, but I see this discussion involving too many editors for one additional voice to have much of an impact. Accordingly, I would suggest either informal or formal mediation if all parties agree, or a request for comment to get many previously uninvolved editors to take a look at the situation. Seraphimblade Talk to me 19:46, 4 August 2013 (UTC)

Cases where active NSP participation was initially associated with increased incidence of HIV
Minphie wrote, "I would like our discussion to be based on accurate information."

Here is an extended quotation from Tilson (2007). I have highlighted in bold two paragraphs:


 * Two prospective cohort studies from Montreal and Vancouver in the 1990s associated NSE participation with higher risk of HIV seroconversion (Strathdee et al., 1997; Bruneau et al., 1997). In Montreal, Bruneau et al. (1997) used three risk-assessment approaches to examine the association between NSE use and HIV infection. All three analytical approaches associated NSE attendance with a substantial and consistently higher risk of HIV infection. For example, in the cohort approach, in which there were 89 incident cases of HIV infection, the researchers found a 33 percent cumulative probability of HIV seroconversion for NSE users, compared with a 13 percent probability for non-users. In the nested case-control study, consistent NSE use was associated with HIV seroconversion during follow-up (OR=10.5; 95% CI: 2.7–41.0). The analyses employed methodologies to control for a range of confounders, including drug of choice and frequency of injecting drug use in the previous month. These findings persisted after controlling for confounders.


 * The authors and commentators on this research pointed out that the Montreal NSE appeared to have attracted high-risk cocaine injectors, who injected much more often than heroin users. Also, as shown by the seroprevalence data at baseline, Montreal NSE users had high baseline rates of HIV and hepatitis B infection (Bruneau et al., 1997). The NSE also originally strictly limited the number of needles and syringes users could receive during any one visit. The authors further noted that the ready availability of clean injecting equipment through pharmacies might have meant that the NSE attracted marginalized, high-risk individuals (Bruneau et al., 1997).


 * These early research results prompted the Montreal NSE to remove limits on the number of needles and syringes users could obtain, to provide access to other injection equipment, and to expand the number of distribution points to 25 (Personal communication, Carole Morissette and Pascale Leclerc, Health Protection Sector, Public Health Department, Agence de Santé et Des Services Sociaux de Montréal, June 6, 2006). In addition to syringes, NSEs began to provide alcohol swabs, individual disposal containers, sterile water vials, and “stericups” (kits containing a filter, cooker, and post-injection swab). Of 429 pharmacies in Montreal, injection equipment is available at roughly 40 percent, and some (n=70) sell kits containing four syringes, condoms, alcohol swabs, sterile water vials, stericups, and education material for $1.


 * Following these changes, HIV incidence among participants in the Montreal SurvUDI study dropped from 6.1 per 100 person-years in 1995 to 4.7 per 100 person-years in 2004. The SurvUDI study is a surveillance network that began in 1995 and targets hard-to-reach, mostly out-oftreatment IDUs in Eastern Central Canada (Hankins et al., 2002). HCV incidence—reported retrospectively among Montreal SurvUDI participants between 1997 and 2003—remains high, at about 26 per 100 person-years. (Personal communication, Carole Morissette and Pascale Leclerc, Health Protection Sector, Public Health Department, Agence de santé et des services sociaux de Montréal, June 6, 2006). The SurvUDI network also provides data on trends in syringe sharing in Montreal, including the proportion of participants injecting with a syringe used by someone else (at first study participation). That proportion fell from 45 percent in 1995 to 28 percent in 2004.


 * In Vancouver, Strathdee et al. (1997) also found that frequent NSE attendance was an independent predictor of HIV seroconversion. After adjusting for confounders, the authors found that the adjusted odds ratio for HIV infection status among NSE users compared with non-NSE users was 1.68. The authors noted that cocaine was the drug of choice among 72 percent of HIV-seropositive IDUs, and that cocaine puts IDUs at elevated risk because it is associated with more frequent injection (Anthony et al., 1991; Chaisson et al., 1989). A follow-up study by Schechter et al. (1999) in the same setting found no relationship between NSE use and HIV incidence, and a case-control study found borrowing of syringes to be the most significant behavior associated with seroconversion among IDUs (Patrick et al., 1997). After multivariate analysis controlling for confounders, the authors found no association between frequency of NSE use and seroconversion.


 * As in Montreal, the Vancouver NSE originally operated with strict limits on the number of needles and syringes that users could exchange at any one time, and the program operated in only one location. The Vancouver program also made dramatic changes in response to early results. Specifically, the NSE switched from a limited exchange approach to a need-based approach—allowing unlimited distribution of needles/syringes—and greatly increased the number of access points. The program also began offering a variety of distribution methods, including fixed, mobile, and home delivery. HIV incidence among IDUs has since fallen by 30 percent (Personal communication, Chris Buchner, Vancouver Coastal Health Authority, May 5, 2006).

Stigmatella aurantiaca (talk) 07:01, 5 August 2013 (UTC)
 * Stigmatella, I am very aware of the material you have cited from the US IOM review, but I note that they, on the basis of these considerations which they have included outside the available journal studies they reviewed, does not change their conclusion that the science on the effectiveness of NEPs is inconclusive. You can see in their text on the Montreal situation that with the provision of much more equipment than just clean needles there was a decrease measured in HIV but not in HCV, which alone confounds any finding that the NEPs were responsible - it is obvious that the rate of sharing needles and equipment has not decreased as per self-report or else there would be consequent decreases in HCV transmission. This is the point that Drug Free Australia makes about NEP failure to reduce HCV - that it opens the self-reported changes to risk behavior into question via objective data indicating no significant changes to that behavior, and that any decreased HIV transmissions are more likely to result from changes to sexual behavior, the alternate mode of transmission. Unfortunately the IOM review doesn't have stats on HCV in Vancouver to make the same sort of judgment. But again it is crucial to recognize that the IOM doesn't overrule their own 'inconclusive' finding on the basis of what you have cited above because there are too many other considerations involved to find that it was the NEPs responsible for those decreases in HIV.
 * Now I see no reason to be removing text on the conclusions of the IOM and their statement about the inconclusive science. It would be wrong to upgrade their own conclusion when they have not upgraded it themselves for good reason. The IOM conclusion about self-reported risk behaviors should also remain, despite the questions that can be raised about self-report validity in light of stubborn HCV rates. I believe the text I last contributed is accurate, and that the Palmateer reviews of reviews should remain as the most recent review of reviews along with the very valid questions on their finding as stated by Drug Free Australia. My understanding is that you want to keep text about the IOM, Palmateer and Drug Free Australia observations off the page and keep text on Wodak/Cooney in place. In light of this and the Third Opinion above I believe that we best seek the next step in conflict resolution, mediation - what do you think? Minphie (talk) 01:06, 6 August 2013 (UTC)


 * What I desire is a cessation of attempts to mine quotations from IOM and Palmateer in such fashion to misrepresent the overall conclusions of these reports.
 * It is practically and ethically impossible to perform the sorts of controlled studies that would definitively establish the role of needle exchange in reducing HIV incidence. The authors of the IOM and Palmateer reports are very careful not to commit the logical fallacy of post hoc ergo propter hoc. The mere fact that high coverage NSP programs are in most cases associated with decreasing HIV incidence does not prove that NSPs are responsible for the decreased incidence. Tilson and Palmateer are exercising proper scientific caution in refusing to over-interpret the available evidence.
 * We know that HCV is not controlled by needle exchange because of its higher infectivity and different modes of transmission. Observed failure to control HCV does not invalidate the observed desirable effects of NSPs on HIV risk behaviors and, to a lesser degree of certainty, HIV incidence.
 * Peer-reviewed follow-ups to the Vancouver studies (Hyshka et al. 2012) and the Montreal study (Bruneau et al. 2011) are available which confirm the private communications cited in the IOM report. Therefore, if you continue in the future to count the Vancouver studies and the Montreal study as evidence that needle exchange programs can cause increases in HIV incidence, you will be disingenuous.
 * I do not believe that there, presently, are any conclusive scientific arguments against needle exchange, and I will continue to oppose any attempts to misuse the available scientific evidence. However, there are many moral, ethical, social, religious and legal arguments against needle exchange, as I demonstrated in Anti-Needle Exchange Arguments. I agree with Humphreys and Piot (2012) that "Scientific evidence alone is not sufficient basis for health policy." In addition, there are many gaps in our scientific knowledge. For example, NIMBY fears that NSPs could "bring down the neighborhood" and lower local real estate values could very well be real, even though I know of no scientific studies on this matter. Stigmatella aurantiaca (talk) 04:21, 6 August 2013 (UTC)
 * Stigmatella, perhaps you could nominate which sentences you feel are quote mining out of my last contribution, which we can then seek mediation on. Just on HCV - needles and associated paraphernalia are the only source of infection other than the fairly negligible mode of blood transfusion, which then makes it a pretty workable indicator of the truth or otherwise of self-report on risk behavior. Minphie (talk) 12:31, 7 August 2013 (UTC)


 * Quite frankly, Minphie, every time you have used the term "inconclusive" without explaining the scientific meaning of the term, you have been distorting the facts. To a scientist, a rigorously "conclusive" result requires a carefully controlled experiment in which the factors being studied can be isolated and independently varied, and which provides data which can be subject to statistical test, yielding p values of less than, say, 0.001. Anything else is "inconclusive". To a layman, the word "inconclusive" has entirely different connotations. A layman reads or hears the word "inconclusive" and thinks, "crap data", "failure", "doesn't work". In mining the quotations that you do out of context and with no other explanation, you deliberately seek to convey the layman connotations of the term.


 * Remember, the USIOM recommendation is that "Given consistent evidence that multi-component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risks, such programs should be implemented where feasible." Multiple mathematical models have been published which help elucidate the relationship between NSPs and HIV incidence, which has been difficult to establish through cohort studies. As I've indicated before, randomized controlled trials would provide superior statistics, but it is not likely that a randomized controlled trial will ever be performed.


 * In regards to HCV, your facts are wrong. Only about 30-40% of HCV infection is attributable to drug use (some sources quote as high as 60%, and the breakdown varies by country). Although most spread among drug users is through shared needle use, cocaine users may transmit the virus by sharing straws. Sexual activity with multiple partners is strongly associated with transmission, as is tattooing, ear-piercing, and acupuncture, and even day-to-day contact with another household member who has HCV. Contact with blood in health care settings is also responsible for many cases of HCV. In more than 10% of all cases, no risk factor can be identified, so there are clearly other, as yet unidentified modes of transmission. Most of the time, HCV infection results in minimal or no symptoms during the initial few decades of the infection, and in general, the infected individual does not seek treatment during this period.


 * HIV is a very fragile virus that does not survive long outside the body. Depending on conditions, however, HCV can be environmentally stable for days or weeks. The risk of infection by using a shared needle is much higher in the case of HCV versus HIV.


 * There are various reasons why HCV is more difficult to control than HIV. Starting with one simple example, given the known biological differences between HIV and HCV, simple mathematics shows that needle exchange programs will be much less effective at controlling HCV than HIV. Let us imagine a once-a-week heroin user. Assume a 0.5% chance of acquiring an HIV infection using a shared needle, versus 5% chance of acquiring an HCV infection when using a shared needle.
 * Over a two year period, using shared needles only, our hypothetical user will have a 40.6% chance of acquiring an HIV infection, and a 99.5% chance of acquiring an HCV infection through needle use.
 * Let us assume that the availability of clean needles allow our hypothetical user to use clean needles 80% of the time.
 * Over a two year period, using clean needles most of the time but still sharing 20% of the time, our hypothetical user will have a 9.9% chance of acquiring an HIV infection, and a 65.6% chance of acquiring an HCV infection.
 * In other words, our hypothetical user will have a 4.1-fold less chance of acquiring an HIV infection through shared needle use, but his/her odds of acquiring an HCV infection through shared needle use is only lowered 1.5-fold. When you take into account the other risk factors associated with HCV, it is quite understandable why NSPs do not show demonstrated effectiveness against this disease.
 * Detailed mathematical modelling studies of vastly more sophistication exist than my trivial, highly over-simplified illustration. These models provide valuable insight into why the spread of HCV is so difficult to control.
 * Stigmatella aurantiaca (talk) 11:04, 9 August 2013 (UTC)

Stigmatella, 1. No matter how you read the conclusion of the most authoritative review on NEPs to date, the US IOM review does not find any weight of evidence which demonstrates the effectiveness for NEPs on HIV incidence, as did the previous 2004/5 Wodak/Cooney WHO review. Nor does this give the connotation that NEPs are somehow now, as a result, to be construed as generally having negative outcomes (ie increasing HIV) - something I have not said anywhere or implied in my text. It simply says that the science is inconclusive, according to their review, and by inference the claims of demonstrated effectiveness cannot be made. 2. You have resorted to newer studies not yet reviewed for the robustness of their methodology (mathematical modelling, for instance, is full of questionable assumptions) but I am just citing the best review to date as it reads. 3. You are again arguing that the IOM, in finding a positive association between reduced HIV and 'multi-component programs which include NEPs' is now somehow reversing their 'inconclusive' finding on NEP effectiveness apart from the multi-component programming, which it does not. 4. Australia and UK have some of the best sustained coverage of free availability of clean needles worldwide yet Australia's figures for HCV transmission is 89% from intravenous drug use, 7% from migration and the remainder via other routes - see page 8 here. 5. Just a reminder that Drug Free Australia, which I cite, is only saying that the science has not yet demonstrated NEP effectiveness when claims of their effectiveness in reducing HIV incidence are indeed being made. A third opinion is needed here. Minphie (talk) 00:36, 13 August 2013 (UTC)


 * 1) No matter how much you deny it, by focusing on a selected few sentences from the US IOM review to the complete exclusion of everything else from the report, your aim is to completely misrepresent the report's recommendations and conclusions. The report finds sufficient evidence that NSPs reduce risk behaviors for HIV and HCV to recommend expansion of such programs, even though the available research studies are of insufficient statistical power to conclusively demonstrate their effectiveness in lowering incidence rates.
 * 2) In citing figures for HCV, I clearly stated that "the breakdown varies by country." Among other things, infection rates in medical settings are much lower in advanced countries than in second and third world countries.
 * 3) I am glad that you cited Vickerman et al.. It means that you have trust in what this article has to say concerning HCV. Here are selected quotes from their findings. I have bolded a few sections:


 * "For the UK, data supported the assumed baseline of 40% of injectors chronically infected with hepatitis C and half of all injectors engaged in either opiate substitute prescribing programmes or high-coverage needle and syringe provision. The simulation extrapolated back to a hypothetical zero access to substitute prescribing and adequate needle exchange, leading to an estimate that assumed current service coverage of 50% may have reduced what would have been a 65% infection rate among injectors to 40%."


 * "It was calculated that over the long term, recruiting just another 10% (up from 50% to 60%) of UK injectors to these programmes would result in modest further reductions in infection rate, but that substantial progress would require scaling up these interventions so that both reach not half the injectors, but at least 8 in 10. This level sustained for 10 years meant the infection rate would drop from 40% to 30%, and for 20 years, to about 20%. Achieving increased coverage means recruiting more injectors to these programmes and/or retaining those who do use them for longer. Without increased retention, the recruitment rate has to be much higher. For example, at eight months retention, to get 8 in 10 injectors in to these programmes requires over half those not yet attending to join each month. If retention doubles to 16 months, then just under 30% need to join each month – still over twice the assumed 12.5% baseline, but a more achievable figure."


 * "An important finding from the study is that the effectiveness of maintenance and needle exchange in preventing infection is a major influence on how many injectors become infected. Not just sustaining and extending but also optimising both services is important. As emphasised by Findings in a series of reviews on hepatitis C and needle exchange, this and other bodies of work stress that the best way to curb the spread of HIV and hepatitis C among injectors is high coverage supply of injecting equipment, enough and sufficiently easily available for a fresh set to be used each time, allied with high coverage substitute prescribing."


 * There is much more in the Vickerman article to ponder. Try actually reading it instead of just quote mining. Stigmatella aurantiaca (talk) 11:58, 14 August 2013 (UTC)

Third Opinion - Effectiveness of NEPs inconclusive or demonstrable?
We are needing a third opinion on the discussion immediately above between Minphie and Stigmatella aurantiaca. The issues are whether a. the science on Needle Exchange effectiveness in reducing HIV has now been demonstrated in some way according to the most authoritative review to date or whether the science remains inconclusive as far as it is concerned b. whether the review's support for NEPs as part of a 'multi-component' program changes the science on the effectiveness of NEPs apart from the multi-component program c. whether citing a conclusion by that review that the science on NEP effectiveness is inconclusive is in effect saying that they are neutrally neither demonstrated to be effective nor ineffective in reducing HIV or rather connoting that they are univocally demonstrably ineffective only. Minphie (talk) 00:36, 13 August 2013 (UTC)
 * 3O volunteer procedural opinion (Please note that this is not an opinion on the content of the matter, rather an opinion on the matter in and of itself) Having looked over this page, I would agree with the earlier comments by TransporterMan and Seraphimblade. Especially with the size and age of this debate, this could hardly be handled by 3O requests. I'd strongly recommend mediation of some kind, as the issues here are too complex for a simple 3O. The total size of this 3O request is almost 3000 words on-wiki, and a veritable FA-Load of stats and links to outside sources. It's more than I'd be comfortable handling on my own for a simple opinion, and, if I were to be mediating it, I'd almost certainly recruit help as well. To me, this has become an issue for either WP:DRN or WP:MEDCOM. Just my pair of Lincoln coins, however. Ham  tech  person  19:14, 13 August 2013 (UTC)

For the Record
Discussion has continued on Stigmatella's Talk page and I have copied the discussion here for the sake of keeping it on the most relevant Talk page to Needle Exchange Programs. Minphie (talk) 11:19, 17 August 2013 (UTC)

Third Opinion on Needle Exchange Science
Finally have had the time to list a 3O request. We may be able to find a way forward. Minphie (talk) 01:48, 1 August 2013 (UTC)


 * "If more than two editors are involved, 3O is not appropriate."
 * Please note on the 3O page where it states: "If more than two editors are involved, 3O is not appropriate."
 * In opposition to you, active members in this dispute include Gabbe, Steinberger, Doc James, Soulparadox, Ohiostandard as well as myself. All of us agree that Drug Free Australia (DFA) is non-MEDRS-compliant, and we agree that, with an occasional exception, the great bulk of material published in the Journal of Global Drug Policy and Practice (JGDPP) is non-MEDRS-compliant. We agree that DFA is an advocacy group and that JDGPP is the publication organ of an advocacy group. Stigmatella aurantiaca Stigmatella aurantiaca (talk) 05:12, 1 August 2013 (UTC)

Mediation - do we agree?
Stigmatella, I note that Third Opinion is of the view that our divergence of opinion on the US IOM and Palmateer studies is too complex for anything but mediation. Are you agreeable to pursuing this now? Minphie (talk) 23:56, 14 August 2013 (UTC)


 * The problem is, Minphie, that you have a history of not abiding by consensus. For example, Gabbe, Steinberger, Doc James, Soulparadox, Ohiostandard and I have all agreed that DFA is an advocacy group and is not MEDRS-compliant, yet you have persisted in your attempts to use DFA materials to discredit scientific publications with which you are in political/moral/ethical/religious disagreement. There is nothing wrong with being in political/moral/ethical/religious disagreement. I truly mean it when I say that I agree with Humphreys and Piot (2012) when they write "Scientific evidence alone is not sufficient basis for health policy."


 * What I have objected to is (1) your taking a conservative scientific refusal in the US IOM report to overinterpret the scientific evidence on the effectiveness of NSPs as being equivalent to a statement that NSPs are ineffective, and (2) focusing on those sentences in the US IOM report to the exclusion of everything else, and in so doing, completely misrepresenting the report's conclusions.


 * What is your reaction to the following excerpts from Australia's National Needle and Syringe Programs Strategic Framework 2010-2014?

2.3 NSPs - A Successful Public Health Response

The value of the Program as an evidence-based public health response to the risk of BBV transmission associated with injecting drug use is substantial. NSPs have been endorsed by the WHO, the UNAIDS, and the UNODC as an essential public health response to ensure “that drug users have their own injecting equipment and do not share it with others, that the circulation time of used needles and syringes is reduced, and that used equipment is disposed of safely” (WHO, 2004).

Australia’s first NSP was trialled in New South Wales in 1986 with the provision of NSP services becoming New South Wales Government policy in early 1987 and the remaining states and territories implementing NSPs soon after via primary, secondary and pharmacy outlets (Dolan et al., 2005). This occurred following the discovery of HIV and the potential threat that this virus posed to the Australian community. The establishment of NSPs throughout Australia would not have been possible without bipartisan political support which continues to be an important element in the continuing existence and operation of NSPs.

In Australia the Program is the single most important and cost-effective strategy in reducing drug-related harms among IDUs. Australian Governments invested $130 million in NSPs between 1991 and 2000 resulting in the prevention of an estimated 25,000 HIV infections and 21,000 HCV infections, with savings from avoided treatment costs of up to $7.8 billion (Health Outcomes International et al., 2002). In the decade 2000-2009, the gross funding for NSPs was $243 million. This investment yielded healthcare cost savings of $1.28 billion; a gain of approximately 140,000 Disability-Adjusted Life Years (DALYs); and a net cost saving of $1.03 billion. During this time, NSPs have averted 32,061 new HIV infections and 96,918 new HCV infections (NCHECR, 2009).

Historically some communities have been resistant to the establishment of NSPs, even though Dolan et al. (2005) note that based on international and national evidence the Program does not: Stigmatella aurantiaca (talk) 05:05, 16 August 2013 (UTC)
 * encourage more frequent injection of drugs;
 * increase recruitment of new IDUs;
 * increase crime or violence; or
 * increase the number of discarded needles and syringes in public places.


 * Stigmatella, I have stood against the consensus of Steinberger, Soul Paradox, Doc James etc because they have clearly demonstrated that they are united in obstructing valid Wikipedia content from getting onto pages such as the Needle Exchange Programme page, even if that content is totally valid, factual and reliably sourced. As can be clearly seen from their long campaign to keep Kall et al. off the Needle Exchange Programme page, saying that it could not be cited because it was from a non-MEDRS source (the Journal of Global Drug Policy and Practice [JGDPP]), they have some other motivation than allowing Wikipedia to neutrally present both sides, as common fairness demands, of what is a highly-conflicted issue politically. It is interesting that two major reviews of reviews, those by the UK NICE group referenced by the EMCDDA Monograph and then the EMCDDA Monograph itself both see Kall et al as one of only four reviews to make their final cull out of a good many more that were not rigorous enough. And if you have a look at the opposition of Steinberger, Doc James and co to Kall et al long after it had become plain that NICE and EMCDDA were not the least concerned whether it appeared in the JGDPP or elsewhere it becomes clear that the reason they wanted to keep it off the Wikipedia page had nothing to do with Wikipedia policy. That much is evidenced and clear.
 * You reference some material on NEP from the Australian Strategic Framework. But can you see how much error is in the Framework document you quote. Those tens of thousands of HCV deaths that NEPs are meant to have saved according to that Framework, when the science shows that NEPs have no demonstrated effectiveness in reducing HCV, and when Dr Wodak who wrote the 2004 WHO review admits, in an article that I have previously cited a number of times on the Talk page, that NEPs are not effective in controlling HCV and there is a need for some other strategy - do you not see that the Framework is dealing in illusion and not reality? And are Wikipedia readers to be given illusion? Why? And why should I let Steinberger, Doc James or Soul Paradox get away with it?
 * I believe it is time to go to mediation. What about you? Minphie (talk) 12:58, 16 August 2013 (UTC)


 * Yet again, you confuse the lack of statistical power of most studies to quantitate the standalone effect of NSPs on HCV incidence levels, with proof that NSPs are ineffective and/or counterproductive. Most studies agree that as a standalone intervention, NSPs do not result in a large enough decrease in HCV incidence to show up above statistical noise levels. Opiate-Replacement Therapy (ORT) as a standalone intervention can result in modest decreases in HCV incidence. Combination approaches using multiple interventions work far better than single interventions alone. In a UK study, ORT was combined with enhanced HCV prevention counseling. In an Amsterdam study, ORT was combined with full NSP participation. Here is a quote from a recent review:
 * "In 2 studies, investigators examined the effect of participation in multicomponent interventions [Table 1f]. In the United Kingdom study, ORT combined with enhanced HCV prevention counseling was compared with ORT alone; HCV seroconversion was lower among those in the combined intervention group (9.1/100 PY vs 17.2/100 PY in the ORT alone group; P > .05) [52]. In the Amsterdam study, ‘‘full participation in harm reduction’’—defined as .60 mg methadone per day and always using SEP—was compared with ‘‘less than full harm reduction’’ or no harm reduction [12]. HCV incidence was 3.5/100 PY in the full–harm-reduction group compared with 23.9/100 PY in other study participants. As shown in Table 2f, the pooled RR was .25 (95% CI, .07–.83). Although the Q value was not significant, I2 was 55%." Hagan et al. 2011
 * Stigmatella aurantiaca (talk) 21:01, 16 August 2013 (UTC)
 * Stigmatella, a. my disputed text discusses the effectiveness of NEPs alone on HIV incidence as reviewed by the US IOM and the Palmateer-initiated studies b. I have indeed additionally covered NEPs in a multi-component setting in my text which you have deleted c. at no place have I ever said that inconclusive means that NEPs, on the weight of study evidence, increase HIV incidence, but rather that the science is that they neither increase nor reduce, on balance of all studies, HIV incidence d. The Wodak/Cooney study you have written into the first few paragraphs incorrectly finds a positive effect for NEPs when the science is inconclusive (and not negative as you keep on erroneously interpreting). Are you ready for this to go to mediation? Minphie (talk) 11:11, 17 August 2013 (UTC)


 * Please do your research. The material on Wodak/Cooney in the lede was originally added by Smgaller at 00:54, 7 January 2012, more than a year before my first contribution to this article. On that date, it read: "However, this meta-analysis was not consistent with the conclusions of a comprensive study by the World Health Organization (WHO) in 2004 stating that there is 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."[3]. The WHOs conclusion has also been supported by the American Medical Association (AMA), which strongly supports NSPs[4]."
 * I will respond to the rest of your comment later. Stigmatella aurantiaca (talk) 12:32, 17 August 2013 (UTC)

Response to Minphie's points (a), (b) and (c)
Minphie wrote: "Stigmatella, a. my disputed text discusses the effectiveness of NEPs alone on HIV incidence as reviewed by the US IOM and the Palmateer-initiated studies b. I have indeed additionally covered NEPs in a multi-component setting in my text which you have deleted c. at no place have I ever said that inconclusive means that NEPs, on the weight of study evidence, increase HIV incidence, but rather that the science is that they neither increase nor reduce, on balance of all studies, HIV incidence"

In regards to point (c), although you never attempted to imply that NSPs could increase HIV incidence in the Article itself, you clearly attempted to do so on this Talk page when you wrote, "Even the discredited 2004 World Health Organisation Wodak/Cooney review, for all its positive findings on studies that are actually inconclusive, found 3 of the 11 accepted studies on NEP and HIV incidence to be associated with increased HIV rather than decreased HIV in their NEP populations." You wrote these words despite admitting that you were "very aware of the material you have cited [ i.e. meaning the material that I had cited ] from the US IOM review" which discussed follow-ups to the Vancouver and Montreal studies.

In regards to points (a) and (b), a typical example of your quote-mining efforts was an addition that you made on 12:00, 21 May 2013, and which I removed on 20:48, 5 July 2013: "Contradicting the above study, the most extensive review to date of journal studies on the effectiveness of NSPs by the Institute of Medicine, comprising 24 scientists, medical practitioners and reviewers, found that the evidence for the effectiveness of NSPs in preventing HIV was 'inconclusive' and that 'multiple studies show that NSEs do not reduce transmission of HCV(Hepatitis C)." Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries 2006 p 149

In order to explain why this represents quote-mining, I have to go into a little background about study designs. Most of the studies examined in the US IOM report were cohort studies. In the wiki article, we read:
 * A cohort is a group of people who share a common characteristic or experience within a defined period (e.g., are born, are exposed to a drug or vaccine or pollutant, or undergo a certain medical procedure). Thus a group of people who were born on a day or in a particular period, say 1948, form a birth cohort. The comparison group may be the general population from which the cohort is drawn, or it may be another cohort of persons thought to have had little or no exposure to the substance under investigation, but otherwise similar. Alternatively, subgroups within the cohort may be compared with each other.


 * Randomized controlled trials are a superior methodology in the hierarchy of evidence in therapy, because they limit the potential for any biases by randomly assigning one patient pool to an intervention and another patient pool to non-intervention (or placebo). This minimizes the chance that the incidence of confounding (particularly unknown confounding) variables will differ between the two groups. However, it is important to note that RCTs may not be suitable in all cases and other methodologies could be much more suitable to investigate the study's objective.

Although RCTs offer superior statistics, serious ethical and practical issues would be attendant upon any attempt to perform such a controlled evaluation of the effectiveness of NSPs. Given that access to clean needles should enable IDUs to reduce their exposure to blood-borne viruses (BBV), how can you create a "control" group to whom you would deny clean needles even though they ask for them?

Cohort studies, on the other hand, face serious problems of interpretation, in that the results may be polluted by "confounding factors". IDUs who attend an NSP program are different than IDUs who do not. Positive effects of an NSP study may simply reflect the fact that people who attend an NSP may be more motivated to look after their health than people who don't. On the other hand, in a country with legalized access to needles, higher-income IDUs may prefer to buy their needles from a local pharmacy rather than go to a downtown needle distribution center where they would have to associate with disreputable types. In such a situation, NSP attendees would mostly represent a highly marginalized population, and in such a situation, an NSP study could show that people attending NSPs have higher rates of BBV infection than non-attendees.

The relatively poor statistical power of cohort studies means that even if there were, say, a 10% difference between NSP attendees and non-attendees in their rates of BBV infection, this difference could be lost in the statistical noise, or even if perceptible against the background noise, might have to be dismissed as a possible sampling artifact.

Another issue is that most NSPs offer other services than just needle and syringe exchange. They may combine needle and syringe exchange with outreach, health education in risk reduction, condom distribution, bleach distribution coupled with education on needle disinfection, referrals to substance abuse treatment and other health and social services, and so forth. In such a situation, it is difficult to disentangle the effects of needle and syringe exchange from the benefits of the other services offered.

The authors of the US IOM report were highly aware of these issues, and very cautious in their interpretation of study results. The various studies they had available to them included cohort, ecological, and cross-sectional studies. Three were case-control studies. Not a single one was a randomized controlled trial.

Let us examine a complete set of US IOM summary evaluations concerning the effectiveness of NSPs:


 * Conclusion 3-1: Nearly all programs included in our literature search combine needle and syringe exchange with other components such as outreach, risk reduction education, condom distribution, bleach distribution and education on needle disinfection, and referrals to substance abuse treatment and other health and social services.


 * Conclusion 3-2: Moderate evidence from a large number of studies and review papers—most from developed countries—shows that participation in multi-component HIV prevention programs that include needle and syringe exchange is associated with a reduction in drug-related HIV risk behavior. Such behavior includes self-reported sharing of needles and syringes, safer injecting and disposal practices, and frequency of injection.


 * Conclusion 3-3: Needle and syringe exchange is not primarily designed to address sex-related risk behavior. In two early prospective cohort studies, NSE participants reported decreases in sex-related risk behavior. However, this issue has not been well studied, and the existing modest evidence is insufficient to determine the effectiveness of needle and syringe exchange in reducing sex-related risk.


 * Conclusion 3-4: Four ecological studies have associated implementation or expansion of HIV prevention programs that include needle and syringe exchange with reduced prevalence of HIV in cities over time and after considering the local prevalence of HIV at the time of program implementation or expansion—although a causal link cannot be made based on these studies. The evidence of the effectiveness of NSE in reducing HIV prevalence is considered modest, based on the weakness of these study designs.


 * Conclusion 3-5: Moderate evidence indicates that multi-component HIV prevention programs that include needle and syringe exchange reduce intermediate HIV risk behavior. However, evidence regarding the effect of needle and syringe exchange on HIV incidence is limited and inconclusive.


 * Conclusion 3-6: Five studies provide moderate evidence that HIV prevention programs that include needle and syringe exchange have significantly less impact on transmission and acquisition of hepatitis C virus than on HIV, although one case-control study shows a dramatic decrease in HCV and HBV acquisition.


 * Conclusion 3-7: Few studies have specifically evaluated whether HIV prevention programs that include needle and syringe exchange lead to unintended consequences, such as increases in new drug users, more frequent injection among established users, expanded networks of high-risk users, more discarded needles in the community, and changes in crime trends. Modest evidence shows that NSE does not increase the number of discarded needles in the community, and that injection frequency does not increase among NSE participants. Weak evidence and limited data suggest that programs that include NSEs do not lead to new users, expanded drug networks, or increases in crime.


 * Conclusion 3-8: Few empirical studies have evaluated whether HIV prevention programs that include needle and syringe exchange effectively link IDUs to ancillary health and social services. The few studies examining this issue show moderate uptake of these services among NSE attendees. However, none of the studies had comparison or control groups, so the overall use of such services among drug users who do not use NSE is unknown.


 * Summary Conclusion: Moderate evidence from developed countries points to a beneficial effect of multi-component HIV prevention programs that include needle and syringe exchange on injection-related HIV risk behavior, such as self-reported needle sharing and frequency of injection. Modest evidence also points to decreasing trends in HIV prevalence in selected cities studied over time. Although many of the studies have design limitations, the consistency of these results across a large number of studies supports these conclusions.

From a lengthy, complex discussion on the effectiveness of NSPs in preventing HIV, you extracted the single word "inconclusive" so as to mislead the reader into thinking that the US IOM opinion on NSPs was that they were of no benefit in the fight against HIV.

'''Likewise, your quote "multiple studies show that NSEs do not reduce transmission of HCV" was out of context. In context, the quote reads as follows:'''


 * Multiple studies show that NSEs do not reduce transmission of HCV, which has been attributed to the apparent failure of NSEs to provide enough ancillary injecting equipment such as sterile cotton, water, and alcohol wipes. While NSEs do reduce the frequency of reported needle and syringe sharing, they do not appear to reduce the sharing of other injecting equipment, such as cookers, cotton, rinse water, and drug solution (Hagan and Thiede, 2000; Sarkar et al., 2003; Taylor et al., 2000; Mansson et al., 2000). In contrast, a case-control study by Hagan et al. (1995) in Seattle found that NSE attendance was associated with a six-fold decrease in acquisition of hepatitis B virus (HBV), and a seven-fold decline in HCV acquisition. Given the high prevalence of HCV among IDUs, this represents an important area for future research.

My own rephrasing of the Summary Conclusion is the following: The available evidence points to multi-component HIV prevention programs that include needle and syringe exchange having clearly beneficial effects in reducing drug-related risk behaviors, although the statistical power of the available studies (mostly cohort studies) have thus far been inadequate to actually prove that NSPs reduce HIV incidence rates. Multiple ecological studies exist that show a positive correlation between implementation or expansion of NSP programs and a reduction in HIV prevalence, although it should be remembered that correlation does not prove a cause-effect relationship. The statistical power of cohort studies have been inadequate to prove that NSPs reduce rates of HCV transmission and acquisition, although a single case-control study reported a dramatic reduction. Not enough studies have been performed examining the possibility of NSPs having undesired unintended consequences; the few existing studies on this point do not point to NSPs having unintended negative consequences. Stigmatella aurantiaca (talk) 10:24, 18 August 2013 (UTC) Overall, although many of the studies have design limitations, the consistency of these results across a large number of studies supports the conclusion that NSPs have an important beneficial role in the fight against HIV and HCV. Stigmatella aurantiaca (talk) 15:31, 18 August 2013 (UTC)
 * Stigmatella, I can't agree with your interpretation of the US IOM review regarding either effectiveness of NEPs in regard to either HIV or HCV incidence. Now, do you agree to taking this to mediation? Minphie (talk) 03:55, 19 August 2013 (UTC)
 * Minphie, we agree that the major reviews and meta-analyses conclude that NSPs measurably reduce self-reported drug-related risk behaviors. We also agree that NSPs as an individual intervention do not have any proven effectiveness reducing HIV and HCV incidence. Likewise, OST as an individual intervention shows, at best, mediocre effectiveness. Educational outreach is cost-effective, but is a long ways from being the whole solution. ART is effective, but only cost-effective in certain limited circumstances (e.g. in the prevention of maternal-fetus transmission). Where we disagree is your refusal to acknowledge the important synergistic role that NSPs play when part of multi-component interventions against the spread of BBVs.
 * Consider this quote from a review by Hagan et al. 2011: "The meta-analysis found a substantial and statistically significant reduction in HCV incidence in PWID—of approximately 75%—when combination prevention strategies were applied. This finding is consistent with an understanding that an array of factors facilitate HCV transmission among PWID, including the large disease reservoir of HCV-infectious injectors, the efficiency with which HCV may be transmitted via a number of different drug injection–related practices, and the chaotic and rushed atmosphere of the injection setting [9, 10, 47, 50, 57]. Thus, multicomponent interventions that support a range of strategies (reduction or elimination of drug injection, adoption of safe injection practices through the provision of sterile syringes and drug-preparation equipment, or behavior-change counseling) would be expected to achieve greater success than those offering fewer options for lowering risk."
 * Here is a quote from a review by Degenhardt et al. 2010 "HIV can spread rapidly between people who inject drugs (through injections and sexual transmission), and potentially the virus can pass to the wider community (by sexual transmission). Here, we summarise evidence on the effectiveness of individual-level approaches to prevention of HIV infection; review global and regional coverage of opioid substitution treatment, needle and syringe programmes, and antiretroviral treatment; model the effect of increased coverage and a combination of these three approaches on HIV transmission and prevalence in injecting drug users; and discuss evidence for structural-level interventions. Each intervention alone will achieve modest reductions in HIV transmission, and prevention of HIV transmission necessitates high-coverage and combined approaches. Social and structural changes are potentially beneficial components in a combined-intervention strategy, especially when scale-up is difficult or reductions in HIV transmission and injection risk are difficult to achieve. Although further evidence is needed on how to optimise combinations of interventions in different settings and epidemics, we know enough now about which actions are effective: the challenge is to deliver these well and to scale."
 * The following quote from Kurth et al. 2011 supports a stance that I have consistently maintained throughout our debate: "No single HIV prevention strategy will be sufficient to control the HIV pandemic. However, a growing number of interventions have shown promise in partially protecting against HIV transmission and acquisition, including knowledge of HIV serostatus, behavioral risk reduction, condoms, male circumcision, needle exchange, treatment of curable sexually transmitted infections, and use of systemic and topical antiretroviral medications by both HIV-infected and uninfected persons. Designing the optimal package of interventions that matches the epidemiologic profile of a target population, delivering that package at the population level, and evaluating safety, acceptability, coverage, and effectiveness, all involve methodological challenges. Nonetheless, there is an unprecedented opportunity to develop “prevention packages” that combine various arrays of evidence-based strategies, tailored to the needs of diverse subgroups and targeted to achieve high coverage for a measurable reduction in population-level HIV transmission. HIV prevention strategies that combine partially effective interventions should be scaled up and evaluated." Stigmatella aurantiaca (talk) 23:48, 19 August 2013 (UTC)
 * Stigmatella, you have largely addressed issues here other than the central disagreement which is whether I have, in directly quoting the US IOM report's statement about research on NEP effectiveness being limited and inconclusive, somehow misrepresented their conclusion. I have stated clearly that I have not misrepresented their conclusion and you do not agree. You say that I have also misrepresented the science on NEP and HCV incidence. I say I have not. Your newer evidences may be of questionable quality, admit circularity etc when I have alternately cited the most authoritative review to date. Are we ready to got to mediation? Minphie (talk) 07:12, 21 August 2013 (UTC)
 * Remember, the Chapter 3 conclusion of the US IOM report reads as follows:


 * CONCLUSION


 * For injecting drug users who cannot gain access to treatment or are not ready to consider it, multi-component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risk behavior such as self-reported sharing of needles and syringes, unsafe injecting and disposal practices, and frequency of injection. Avenues of sterile needle and syringe access may include needle and syringe exchange; the legal sale of needles and syringes through pharmacies, voucher schemes, physician prescription programs, and vending machines; or supervised injecting facilities. Needle and syringe access is often part of a multi-component HIV prevention program. Other elements of multi-component programs may include outreach, education in risk reduction, HIV voluntary counseling and testing, condom distribution, bleach distribution and education on needle disinfection, and referrals to substance abuse treatment and other health and social services.


 * Participation in multi-component HIV prevention programs that include needle and syringe exchange is associated with a reduction in self-reported drug-related HIV risk behavior among IDUs. Such behavior includes self-reported sharing of needles and syringes, safer injecting and disposal practices, and frequency of injection. Sterile needle and syringe access is not primarily designed to address sex-related risk behavior, and this issue has not been well studied. The existing evidence is insufficient to determine the effectiveness of programs that include needle and syringe access in reducing sex-related risk. The Committee calls for more research to determine the impact of such programs on sex-related risk, and on integrating effective strategies for reducing sexual risk behavior and sexual transmission of HIV into multi-component programs that include sterile needle and syringe access.


 * The evaluation of strategies to eliminate criminal penalties for possessing needles and syringes—and enhance legal access via pharmacy sales, voucher schemes, and physician prescription programs—have focused on assessing the acceptability of such programs by drug users, pharmacists, and physicians. A few studies have examined the impact on drug-related HIV risk, and found suggestive evidence of a reduction. The evidence regarding supervised injecting facilities and vending machines—while encouraging—is insufficient for drawing conclusions on the effectiveness of these interventions in reducing drug-related HIV risks among IDUs.


 * '''As with drug treatment, a common concern is that sterile needle and syringe access may produce unintended results, including more new drug users, expanded networks of high-risk users, more frequent injection, and more discarded needles in the community. While few studies have specifically examined such outcomes, studies to date have not found evidence of negative effects. More research is needed on potential unintended consequences of HIV prevention programs that include needle and syringe access, and strategies to address such problems if they are found.


 * Undiluted bleach can inactivate HIV on injecting equipment in the laboratory, and in the field if used according to guidelines. However, in practice, injecting drug users do not use bleach correctly, so programs that distribute bleach should also educate drug users on proper techniques. In some countries, bleach is not available or acceptable, and it may be necessary to use other disinfectants. Drug users should rely on such methods only when they cannot stop injecting, or do not have access to new equipment. More research is needed to identify the simplest and most acceptable effective disinfection techniques using bleach and the best methods for educating IDUs on these techniques as well as the effectiveness of alternative disinfectants in field settings, particularly in countries where bleach is not available or acceptable.


 * Outreach-based efforts to prevent HIV transmission—which may direct drug users to needle and syringe exchange, for example—are associated with reductions in drug-related risk behavior, including injection frequency and sharing of injection equipment. Outreach is effective in linking hard-to-reach IDUs with drug treatment and other health and social services. The impact of outreach on sex-related HIV risk behavior is less clear and more research is needed to study this impact. More research is also needed to determine the best way to integrate effective strategies for reducing sexual risk behavior and sexual transmission of HIV among IDU into outreach and education programs.


 * Although questions remain about the contribution of individual elements of multi-component programs that include sterile needle and syringe access and outreach and education on risk behavior and actual HIV incidence, the report recommends that high-risk countries act now to implement such programs. These programs should include multiple access points and methods of delivery, focus on reducing sexual risks, actively refer drug users to other services, focus additional efforts on preventing hepatitis C, and incorporate strong program and component evaluations.


 * Are you quite sure that third party mediators will agree that your extremely limited, single-word and sentence-fragment quotes fairly presented the conclusions of Chapter 3 of the US IOM report? Stigmatella aurantiaca (talk) 10:58, 21 August 2013 (UTC)
 * I am absolutely sure that the article needs a brief introductory statement on NEP efficacy. As such I believe the wording you deleted is adequate. More can be developed in the research section. Are you ready to take this to mediation? Minphie (talk) 10:41, 23 August 2013 (UTC)
 * You are being evasive. I asked if you believed that your extremely limited, single-word and sentence-fragment quotes from Chapter 3 of the US IOM report accurately summarize the authors' conclusions and recommendations concerning the role of NSPs in the overall fight against BBVs. Yes or no? Stigmatella aurantiaca (talk) 12:22, 23 August 2013 (UTC)
 * I don't believe there is any evasion here at all. I do believe the text that you deleted very adequately but succinctly describes the science on risk behaviour, multi-component programs which include NEP on HIV, NEP on HIV incidence, and NEP on HCV incidence. Recommendations you listed above are not the science, but rather their recommendations arising from their findings. I am becoming concerned that your wish not to go to mediation about this may in turn be an evasion. Are you ready to go to mediation? Minphie (talk) 05:00, 24 August 2013 (UTC)
 * Stigmatella, in light of two Third Opinions both urging mediation over this issue, I emphasise my wish to follow through on that advice. I am genuinely aggrieved by your allegations of quote-mining, misrepresentation etc which makes this most definitely an issue where conflict resolution beyond 3O is necessary. If you do not wish to go to mediation then I will take what I believe is only a fair and reasonable inference - that this as an indication that you no longer want to take action on my text, at which time I will reinstate the text you have removed. Minphie (talk) 02:02, 26 August 2013 (UTC)
 * Minphie, I don't believe that mediation will do any good BECAUSE YOU REFUSE TO LISTEN TO CONSENSUS. In your last restoration of text, you again used DFA as a reference despite consensus that DFA is a non-MEDRS source. Do I or do I not quote you correctly when you wrote, "I have stood against the consensus of Steinberger, Soul Paradox, Doc James etc because they have clearly demonstrated that they are united in obstructing valid Wikipedia content from getting onto pages such as the Needle Exchange Programme page, even if that content is totally valid, factual and reliably sourced." In other words, you feel that you are perfectly free to ignore consensus, because your opinion is better than everybody else's. Obviously, we do not believe your content to be "totally valid, factual and reliably sourced." Now, my wife is ill, and I can't immediately jump on your every post. But I cannot let you continue your attempts to pass off lack of direct evidence due to unavoidable defects in study design, as evidence of lack of effectiveness. Stigmatella aurantiaca (talk) 13:24, 1 September 2013 (UTC)

This issue has nothing whatsoever with any other contributor. None of them have said that I have misrepresented the US IOM review. You have. I am aggrieved by your baseless allegation and I am seeking resolution of the issue. You can drop the allegation or you can seek mediation. Sorry that your wife is sick, but that does not remove your responsibility on this issue and I would like an answer from you, rather than continued evasions as to whether you are ready for mediation. Minphie (talk) 04:08, 5 September 2013 (UTC)
 * Mediation is a means of generating consensus. Your attitude towards consensus is clearly expressed in your statement that I quoted above, and is manifest in your repeated posts of material that Steinberger, Soul Paradox, Doc James, Gabbe, Ohiostandard and I have opposed in various ways and degrees. Stigmatella aurantiaca (talk) 06:55, 5 September 2013 (UTC)


 * Incidentally, I have been very puzzled by your behavior, since there is absolutely nothing in Mediation that says that mediation requires the consent of both parties to initiate. There is absolutely nothing that I can do to block your filing of a formal mediation request. "In the case of advanced content disputes which regular talk-page discussion has been consistently unable to resolve, the formal mediation process may have to be used. Editors can request formal mediation by filing a request with the Mediation Committee at Requests for mediation." This is clearly an advanced content dispute, and you don't need me to agree. I have merely stated my belief that mediation won't do any good, because of your past behavior that demonstrates consistent opposition to the consensus-building process. Stigmatella aurantiaca (talk) 13:20, 5 September 2013 (UTC)
 * To the contrary, the Mediation policy clearly says:
 * Mediation in any form will have the following features:
 * Editors enter into mediation voluntarily and may withdraw from mediation at any time
 * Mediation is by definition neither coerced nor will it ever work with one party involved and not the other. Two parties must necessarily be involved. Yet I see no willingness on your part to follow though on what Third Party advice has been. My feeling is that if you are not willing to enter mediation on your baseless opposition to the US IOM content I have contributed, you should formally withdraw such opposition to it. Do you, or do you not, wish to proceed to mediation? Minphie (talk) 10:03, 7 September 2013 (UTC)
 * If you want to go ahead with mediation, go ahead. I do not withdraw my opposition. Stigmatella aurantiaca (talk) 14:02, 7 September 2013 (UTC)


 * I'm not that familiar with this topic, however after reading through this quite hostile talk page, perhaps not opposing mediation and actually supporting it may be worthwhile Stigmatella for everyone involved? Opposing it does not make sense. It looks like Minphie has got it right suggesting mediation, it seems like there has been no real movement for a long time? Just a lot of agro. Will keep an eye on things anyway. Hope you all get a good result for Wikipedia, that's the main thing.Mrm7171 (talk) 06:15, 9 October 2013 (UTC)
 * I meant that I do not withdraw my opposition to Minphie's EDITS. I have agreed to mediation. We are waiting for a response from the mediation committee. They are quite backlogged. Stigmatella aurantiaca (talk) 06:33, 9 October 2013 (UTC)


 * sorry stigmatella reading more about this heated debate, I must 'side' with Minphie on this one. I have noticed that Minphie rarely attacks or even comments on others behavior, whereas you seem to focus heavily on behavior rather than content. My reading of this page still indicates that you have opposed any arbitration, through refusal to participate, yet do not want to progress the article and move forward with content issues that have been raised by Minphie and others. Just an observation. I also will watch this issue further now and help out if I can to move the article forward, for the benefit of readers and the benefit of the encyclopedia. Thank you. Mrm7171 (talk) 08:29, 9 October 2013 (UTC)

U.S. bias
I have started a "U.K. programs" section to start the process of balancing this article, which is currently American-centric.--Soulparadox (talk) 03:36, 9 April 2014 (UTC)

Semi-protected edit request on 24 May 2015
The 3rd Sub-Topic, labeled "HIV Costs," following the intro paragraph, has a few minor errors in the last sentence.

The current sentence reads:

In the U.S., the cost per needle at a NEP is approximately US$0.97, whereas the estimated cost the daily does of HIV medication Truvada is US$36.[18]

But if should be changed to:

In the U.S., the cost per needle at an NEP is approximately US$0.97, whereas the estimated cost of the daily dose of HIV medication, Truvada, is US$36.[18]

The changes made were as follows:

''1. Changed "a" to "an" before "NEP," due to the vowel sound that the acronym makes when pronounced.

2. Added the word "of" before "the daily," for proper grammatical structure.

3. Corrected the spelling of the word "dose" which was originally spelt as "does."

4. Added a comma before and after "Truvada" due to it being an appositive, or non-essential information, used to identify the specific medication.''

RoronoaZoro73 (talk) 15:09, 24 May 2015 (UTC)


 * Thanks for your edit suggestions! I have implemented them as you requested. Stigmatella aurantiaca (talk) 12:26, 25 May 2015 (UTC)

Post-2011 Systematic Reviews on Disease Transmission
Hello,

I am by no means an expert on this topic but in doing some of my own research noticed that there are at least five systematic reviews/meta-analyses on disease transmission published since 2011 that are not included in this article. Including them might change the overall conclusions of the Research:disease transmission section but even if not they should be included as the research in this article is now quite out of date.

Here are the five studies that I found (note that two of them include other interventions as well and so might be less useful):

1: Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, Palmateer N, Doyle JS, Hellard ME, Hutchinson SJ. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014 Feb;43(1):235-48. doi: 10.1093/ije/dyt243. Epub 2013 Dec 27. Review. PubMed PMID: 24374889.

2: MacArthur GJ, van Velzen E, Palmateer N, Kimber J, Pharris A, Hope V, Taylor A, Roy K, Aspinall E, Goldberg D, Rhodes T, Hedrich D, Salminen M, Hickman M, Hutchinson SJ. Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. Int J Drug Policy. 2014 Jan;25(1):34-52. doi: 10.1016/j.drugpo.2013.07.001. Epub 2013 Aug 21. Review. PubMed PMID: 23973009.

3: Abdul-Quader AS, Feelemyer J, Modi S, Stein ES, Briceno A, Semaan S, Horvath T, Kennedy GE, Des Jarlais DC. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review. AIDS Behav. 2013 Nov;17(9):2878-92. doi: 10.1007/s10461-013-0593-y. Review. PubMed PMID: 23975473.

4: Turner KM, Hutchinson S, Vickerman P, Hope V, Craine N, Palmateer N, May M, Taylor A, De Angelis D, Cameron S, Parry J, Lyons M, Goldberg D, Allen E, Hickman M. The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence. Addiction. 2011 Nov;106(11):1978-88. doi: 10.1111/j.1360-0443.2011.03515.x. Epub 2011 Aug 24. PubMed PMID: 21615585.

5: Des Jarlais DC, Feelemyer JP, Modi SN, Abdul-Quader A, Hagan H. High coverage needle/syringe programs for people who inject drugs in low and middle income countries: a systematic review. BMC Public Health. 2013 Jan 19;13:53. doi: 10.1186/1471-2458-13-53. Review. PubMed PMID: 23332005;.

I don't feel like I'm qualified to analyze these studies for the article, but it seems to me that readers should at least know that current research exists.

Apologies if this is formatted badly, I made this account specifically to raise this issue. Mellowyellow250 (talk) 23:56, 4 August 2015 (UTC)

External links modified
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"Further reading" section
I removed a House of Representatives transcript from the "Further reading" section, as it didn't seem to do much more than report partisan views that should really be reported in the article. On review, I can't see any reason for this section to exist at all. If ideas or facts referenced in it are worthy of inclusion in the article, they should be included, and the document cited as a source. Otherwise, this is just a place for accumulating an arbitrary reading list of material for both pro- and con positions. I'm going to be bold and remove the whole section. -- The Anome (talk) 15:21, 1 November 2015 (UTC)

inaccuracy?
Australia had needle exchange programs as early as 1986. See eg 'The first Australian Needle and Syringe Program began in Sydney in 1986 as a trial project. The testing of syringes returned to this Darlinghurst Program detected an increase in HIV prevalence, suggesting that HIV was spreading among clients. In the following year [1987] Needle and Syringe Programs became NSW Government policy. Other States and Territories followed soon after':  The Sisters of Mercy were involved and by some criticised for that involvement by some conservatives but teh then government was grateful for their participationEleni aus (talk) 19:27, 2 December 2015 (UTC):

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In the "Harm Reduction" section, the line "Treating drug dependency as an illness absolves drug users of responsibility for their condition.[9]"
This strikes me as an opinion being stated as fact, and while the Heritage Foundation citation is a dead link, the Heritage Foundation is a conservative policy think-tank. It seems to me that the article would be improved by either removing this line or clarifying that this is an opinion of one organization. I can't edit the article, though. --Floatargen (talk) 06:10, 5 May 2018 (UTC)

Semi-protected edit request on 12 August 2018
"Treating drug dependency as an illness absolves drug users of responsibility for their condition.[9]"

I suggest either a. removing this line entirely, because the cited source no longer exists or b., changing the sentence to "Some people believe that treating drug dependency..." Golfingfondue (talk) 23:19, 12 August 2018 (UTC)
 * Yes check.svg Done Replaced the ref with a new one that contains the same publication Waddie96 (talk) 08:45, 13 August 2018 (UTC)

Semi-protected edit request on 29 July 2019
140.142.217.13 (talk) 21:01, 29 July 2019 (UTC)

Remove this citation. It is from an unpublished working paper that has not been peer-reviewed and is deeply flawed.
 * Red question icon with gradient background.svg Not done: it's not clear what changes you want to be made. Please mention the specific changes in a "change X to Y" format and provide a reliable source if appropriate. Melmann 17:39, 31 July 2019 (UTC)

Semi-protected edit request on 5 December 2019
== United Kingdom ==

Due to an increase in the amount of injectable drug users, , a British public body of the , introduced a set of guidelines in March 2014. It aimed to reduce the transmission of blood-borne infections caused by sharing of needles by i.v. drug users as well as people who inject steroids for body building.
 * 1) REDIRECT NICE (National Institute for Health and Care Excellence)
 * 1) REDIRECT Department of Health in UK

==== Updates in Nice Guidelines (2009) ====

1.	Inclusion of young people under 16 years of age 2.	Inclusion of performance- and image- enhancing drug users

==== Availability ====

UK distribute more than 200 syringes per person who injects drugs per year as per the WHO recommendation. Syringes are available without prescription, and can be obtained from fixed sites, syringe vending machines, mobile and outreach services.

==== Barriers to NEPs in UK ====

a.	Geographical distance: Most syringe users live in rural communities, and thus have to struggle to get access to NSPs, which are mostly located in cities. b.	Age: Teenagers and users below 16 years of age are denied services. c.	Women are usually fearful of accessing NSPs due to the associated stigma. d.	Specific needs of certain groups are not being met. For example, 8% of iv drug users are gay, and usually inject methamphetamines instead of opioids. There are no special services for such groups. Ambika Narain (talk) 17:33, 5 December 2019 (UTC)


 * ❌. It's not clear what changes you're requesting. Please be precise about what you want to do. –Deacon Vorbis (carbon &bull; videos) 23:12, 5 December 2019 (UTC)

Relying too heavily on NCBI.NLM.NIH.GOV sources
While those sources are proper for some parts, they're not authoritative to speak on issues on social impact, such as crime, adverse impact on property values and issues that are generally not in the alley of health researchers. Graywalls (talk) 05:47, 24 May 2020 (UTC)