in NSPs in Australia, $4 was saved in direct healthcare costs, and if productivity and economic benefits are included, the programs returned a staggering $27 for every $1 invested. The study notes that over a longer time horizon than that considered (10 years) the cost-benefit ratio grows even further. In terms of infections averted and lives saved, the study finds that, between 2000 and 2009, 32,000 HIV infections and 96,667 Hepatitis C infections were averted, and approximately 140,000 Disability-adjusted Life Years were gained. United Kingdom The British public body, the National Institute for Health and Care Excellence (NICE), introduced a recommendation in April 2014 due to an increase in the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services were not advised for people under 18, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programmes. In the updated guidance, NICE recommended the provision of specialist services for "rapidly increasing numbers of steroid users", and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles. United States The Centers for Disease Control and Prevention and the National Institutes of Health confirm that needle exchange is an effective strategy for the prevention of HIV. The NIH estimated in 2002 that in the United States, between 15 and 20% of injection drug users have HIV and at least 70% have hepatitis C. The Centers for Disease Control (CDC) reports 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use. United States Department of Health and Human Services reports 7%, or 2,400 cases of HIV infections in 2018 were among drug users. Portland, Oregon, was the first city in nation to expend public funds on a NSP which opened in 1989. It is also one of the longest running programme in the country. Despite the word "exchange" in the programme name, the Portland needle exchange operated by Multnomah County hands out syringes to addicts who do not present any to exchange. The exchange programme reports 70% of their users are transients who experience "homelessness or unstable housing" It was reported that during the fiscal year 2015–2016, the county dispensed 2,478,362 syringes and