In 1987, a needle exchange programme was started in Malmö. The background was that the first HIV-positive drug addict had been diagnosed a couple of years before, and a couple of more cases were reported in the following years.

The object of the needle exchange programme was to diminish the spread of primarily HIV and also Hepatit B. Part of the object was to motivate the addicts to treatment.

In 1992 the National Board of Health and Welfare decided to make an evaluation of the project - incidentally the first independent evaluation of this project.

The project has been critisized since the beginning, and, regardless of the results of the 1992 evalutation, has been allowed to continue. It still continues in 2000.
One critical point of view is that the needle exchange programme collides with two important Swedish laws regarding combating drugs.
First of the contradictions is paragraph 1, item 6 of the Narcotic Penal Code , which prohibits all use of drugs.
Those working with the needle exchange programme are fully aware of the fact that a patient who receives a syringe is going to violate the Narcotic Penal Code.

The other important cornerstone of the Swedish drug policy is the 'Care of Abusers (Special Provisions) Act', LVM.
This compulsory law aims at giving society the possibility to compulsory care of those who do not voluntarily seek treatment for abuse of alcohol, drugs or solvents; and who, through their abuse

1) Gravely risk their physical health
2) Run an obvious risk of destroying their lives
3) May gravely injure themselves or others

Paragraph 6 of the same Act states regarding the duty of a doctor to report
'A doctor must report a person he professionally encounters and who may be presumed to need treatment according to this Act…

As far as I know, no doctor responsible for the needle exchange programme in Malmö has ever since the start of the project reported anybody.

Thus, the needle exchange project goes deliberately against the official Swedish drug policy, which explicitly prohibits the use of illicit drugs.

To stop the spread of HIV. To stop the spread of other infectuous diseases through exchanging needles and motivating drug addicts to stop taking drugs.
There is, however, a number of important issues which the needle exchange project has difficulties to address.

• Several international studies show that intravenous addicts shared needles the first time they injected. Consequently, the needle exchange programme only reaches the already established intravenous addicts.
• There is a clear connection between needle exchange, unsafe sex, multiple sexual partners and bisexuality. When trust between people is at stake, safety often comes second hand.
  This also applies to the difficulty to persuade people to use condoms with casual sexual partners.
  A young boy or girl who on the first date picks up a condom from his or her pocket, gives a signal to the partner which is ambiguous and difficult to handle.

 
Two comments from an advocate to and a critic of needle exchange programmes

Even if a drug addict does not stop taking drugs when he or she would have done so -
had the needle exchange programme not existed - or even if the number of addicts has increased because of the programme, this must be outweighed by the dreadful HIV-epidemic.

Kerstin Tunving
Chief Medical Officer

What positive or negative effects do you think a needle exchange programme would have in Gothenburg?
No positive effects whatsoever. Needle exchange programmes are justified by being means of protection against infections. In Gothenburg the intravenous addicts are well informed about the risks of sharing needles and have as a rule their own syringes. They abuse amphetamine, which is a sexual stimulant. If we should distribute syringes, whe would facilitate their continued abuse and thus increase the spread of sexually transmitted infections. We know that they don't protect themselves against sexual transmission the way they do against intravenous transmission.

Birgitta Göransson
Coordinator of the
Outreach Treatment in
Gothenburg

What, then, are the results of the Malmö needle exchange programme, and how was it conducted?

A simple comparison between two other Swedish cities with no needle exchange programmes shows following (the tables refer to persons infected through intravenous injections):

	Inhabitans	hepatit B-86	hepatit B-91	Hepatit b-98	HIV-85	HIV-92	HIV-98
Stockholm	Ca 750 000	79	59	30	250	17	18
Göteborg	Ca 450 000	63	40	13	11	0	0
Malmö	Ca 250 000	32	21	7	1	4	3

 
ECAD:s comments

The study shows that the number of intravenous addicts infected by HIV or Hepatit B has decreased in all three cities. Consequently, no positive results in this regard can be attributed to the needle exchange programme.

Of the total of 982 participants in the Malmö programme, only 8 % were helped to contacts with drug treatment or self-help groups, a fact which in effect dismantles the last argument for the needle exchange programme.
This low figure cannot possibly satisfy anybody who works for decreasing drug abuse in the society.

Persons who visit the needle exchange clinic in Malmö seek help for other problems as well at the same time. It could be prescriptions of antibiotics, dressing wounds etc. Only 14 % come solely to exchange syringes.

So why any syringes at all? What we need instead is fresh ideas. It is surely not difficult (provided one wants) to meet drug addicts and persuade them to stop taking drugs without facilitating their continued abuse at the same time.

Tomas Hallberg
Director
ECAD