behaviors and enhance the impact of harm reduction services. Tilson (2007) concluded that only comprehensive packages of services in multi-component prevention programmes can be effective in reducing drug-related HIV risks. In such packages, it is unclear what the relative contribution of needle exchange may be to reductions in risk behavior and HIV incidence. Multiple examples can be cited showing the relative ineffectiveness of needle exchange programmes alone in stopping the spread of blood-borne disease. Many needle exchange programmes do not make any serious effort to treat drug addiction. For example, David Noffs of the Life Education Center wrote, "I have visited sites around Chicago where people who request info on quitting their habit are given a single sheet on how to go cold turkey -- hardly effective treatment or counseling." A 2013 systematic review found support for the use of NEPs to prevent and treat HIV and HCV infection. A 2014 systematic review and meta-analysis found evidence that NEPs were effective in reducing HIV transmission among injection drug users, but that other harm reduction programmes have probably also contributed to the decrease in HIV incidence. NEPs appear to be as effective in low- and middle-income countries as in high-income ones. Worker training Lemon and Shah presented a 2013 paper at the International Congress of Psychiatrists that highlighted lack of training for needle exchange workers and also showed the workers performing a range of tasks beyond contractual obligations, for which they had little support or training. It also showed how needle exchange workers were a common first contact for distressed drug users. Perhaps the most concerning finding was that workers were not legally allowed to provide Naloxone should it be needed. Drug use According to a 2022 study by Vanderbilt University economist Analisa Packham, syringe exchange program reduce HIV rates by 18.2 percent but lead to greater drug use. Syringe exchange programmes increased drug-related mortality rates by 11.7 percent and opioid-related mortality rates by 21.6 percent. Arguments for and against Needle disposal NSPs Do Not Increase Litter: Broad Arguments Activist groups claim there is no way to ensure SEP users will be properly disposed of. Peer reviewed studies suggest that there are less improperly disposed of syringes in cities with needle exchange programs than in cities without. Other studies of similar design find that syringe exchange program drop boxes were associated with an overall decrease of improper syringe disposal (over 98%