As the Centers for Disease Control and Prevention has concluded, "For injection drug users who cannot or will not stop injecting drugs, using sterile needles and syringes only once remains the safest, most effective approach for limiting HIV transmission."⁽¹⁾

The numerous state and local laws and regulations that limit access to sterile needles were put in place just as the not-yet-understood HIV/AIDS epidemic was beginning to spread across the United States.  With no scientific studies to support their thinking, lawmakers merely assumed that if access to syringes were limited, injecting drug use would be reduced.⁽²⁾

This assumption proved tragically wrong.  Limiting access to sterile needles did reduce the supply of sterile needles, but it did not reduce injecting drug use.  Injecting drug use continued apace as users shared needles and, consequently, their HIV and other blood-borne infections as well.

The all-too-slow process of reform

Elimination of the barriers to accessing sterile needles is coming all too slowly.  The first wave of reform in any city or state often occurs as a few activists, concerned with saving lives right now, set up a needle exchange, giving out sterile needles and collecting used ones.⁽³⁾  This direct action cuts through restrictive laws and regulations.  But it is risky and requires courage.  The activists see themselves as public health workers; some police, prosecutors, elected officials, and community members see them as criminals. 

In the second wave of reform, activists in a particular city gain local support, and the local legal situation is reconfigured to give the needle exchange staff and participants protection from arrest for needle possession.  In the most successful instances of reform, such as in the states of Connecticut, Hawaii, and New Mexico, the state government, through its health department, begins running needle exchanges and expands service to other areas of the state where it is needed.

The third wave of reform involves changing laws and regulations so that pharmacists can sell syringes without a prescription.  To be effective, the pharmacy effort has to include educational programs to inform pharmacists of the public health importance of over-the-counter sales of syringes.  Care also must be taken that syringes are sold without regard to race or ethnicity.  A St. Louis study, for example, found that several pharmacies were willing to sell syringes to whites but not to African Americans.⁽⁴⁾

In the year 2000, New Hampshire, New York and Rhode Island reformed their laws, making it possible for pharmacies to sell without a prescription.  California, Delaware, Illinois, Massachusetts, Nevada, New Jersey, and Pennsylvania are the only remaining states with severely restrictive syringe prescription laws or regulations. 

A promising fourth wave of reform, just beginning, is physician prescription of syringes.  Prescribing syringes to prevent the spread of HIV is a legitimate medical purpose.  The relevant governing bodies in Rhode Island have recognized this to be the case, and some injecting drug users in that state are now able to get syringes by prescription from their doctor.

A final wave of reform involves changing the laws governing drug paraphernalia.  This reform is completed in only nine states (Alaska, Connecticut, Georgia, Maine, Minnesota, New Hampshire, New York, Oregon, and Wisconsin).  Laws prohibiting possession of sterile needles and other related safe injection equipment (such as cookers and cotton) need to be removed from all the state and local drug paraphernalia laws.  Anything less will continue the spread of HIV and other blood-borne diseases.  

Needle exchange programs today

In 1998, there were 131 needle exchange programs in the United States, up from 113 the previous year.⁽⁵⁾  Many major cities - including Chicago, Detroit, Honolulu, New York City, Philadelphia, and San Francisco - had needle exchange programs.  

Progress in making needle exchange programs legal has been much too slow.  Of the 110 exchanges responding to the 1998 survey, 59 were legal; 24 were illegal-tolerated by local officials, and 27 were illegal-underground.^{(6), (7)}

Once legal, programs have achieved considerable success in getting public funds.  In 1998, 51 programs reported receiving state or local government funds.

The illegal-tolerated exchanges are often able to exist in a relatively public fashion because, while officials have not yet reformed the needle access laws and regulations, they nonetheless understand that it makes no sense to arrest people working to stem an epidemic.

But arrests do occur.  In 1998, there were 10 arrests of needle exchange staff or volunteers in five different states.  In the worst case, arrest and successful prosecution can shut down a needle exchange entirely.⁽⁸⁾  Arrest or the threat of arrest can reduce the effectiveness of a needle exchange by discouraging donations, by deterring volunteers from working at the exchange (effectively reducing the number of hours the exchange is open), and by frightening away prospective clients.  The threat of arrest can also force a program to move to a less accessible location, making it difficult for those who need the exchange's services to find it.⁽⁹⁾  As pointed out in Section 4, arrest or the threat of arrest also reduces the effectiveness of needle exchange programs in getting interested drug users into drug treatment.

Needle exchanges as harm reduction organizations

Needle exchange programs see themselves as part of a larger harm reduction movement. By slowing the spread of HIV, they are reducing the harm from injecting drug use.  Without calling it that, we, as a society, practice harm reduction all the time.  We reduce the harm of riding a motorcycle by requiring riders to wear helmets. We reduce the harm from car accidents by requiring people to wear seat belts.  We reduce the harm to nonsmokers by requiring that smoking be done only in designated areas.  We reduce the harm from excessive drinking at parties and bars by encouraging the use of a designated driver who does not drink.  By preventing the spread of HIV and other blood-borne diseases, needle exchange programs reduce the harm that comes from injecting drug use.

Making police into partners

Police education is a key component in the development of a successful needle exchange program.  In 1998, some 45 programs reported police harassment of people coming to use the exchange.  The most common form of harassment occurred when officers confiscated syringes or forced exchange participants to break the points off their syringes. 

Participant harassment occurred at legal as well as underground programs.  In 1998, participants in 17 legal needle exchange programs, 15 illegal-tolerated programs and 13 illegal-underground programs experienced police harassment.

Although individual police officers can remain confused about the role of needle exchange programs in disease prevention, when it is explained to them, many officers see both their own personal advantage and the public health benefits of needle exchange programs.   

An officer patting down a suspect is much less likely to get a dangerous needle stick when the suspect is carrying a new syringe with its protective cap (which is legal and the suspect feels free to mention) than when a suspect is hiding a used and (perhaps infected), illegal needle whose protective cap has long since been lost.

The continuing epidemic

For those concerned about the spread of HIV/AIDS among injecting drug users, their non-drug-using sexual partners, and newborn children, the pace of needle access reform has been far too slow.  Of the ten states with the highest rates of injection-related AIDS in 1998, substantial progress in reform has been made in three (Connecticut, New York, and Rhode Island).  Some progress had been made in another three (Maryland, Massachusetts, and Pennsylvania), but virtually no progress had been made in four (Delaware, Louisiana, New Jersey, and Florida).⁽¹⁰⁾

With 50 people in the United States being infected every day with HIV as a result of intravenous drug use, it is clear we must do more.⁽¹¹⁾  We need to continue to educate people to the harms of drug use, particularly injection drug use.  And we must listen to the expertise and wisdom of our public health officials and make sterile needles legally available to people who inject drugs.  We must:

• Eliminate the drug paraphernalia and drug prescription laws and regulations so that there will be no ambiguity about the legality of needle exchange programs and so that drug users can purchase and carry their own clean, safe needles without fear of arrest.

• Recognize that HIV prevention is a legitimate medical purpose, and encourage physicians to write syringe prescriptions for people who inject drugs.

As a humane society, we must reach the point where injecting drug users in every state can legally protect themselves from HIV and other blood-borne diseases and where needle exchange workers in every state are treated not as criminals but as the public health workers they are.   

Footnotes

(1) Centers for Disease Control and Prevention (CDC). "Drug-Associated HIV Transmission Continues in the United States,"  August 1999.

(2) Lawrence O. Gostin, Zita Lazzarine, T. Stephen Jones, and Kathleen Flaherty, "Prevention of HIV/AIDS and Other Blood-Borne Diseases Among Injection Drug Users: A National Survey on the Regulation of Syringes and Needles," Journal of the American Medical Association, January 1, 1997, vol. 277, pages 53-62.

(3) The overview of the process of needle access reform is based on Dr. Dawn Day's numerous conversations with leaders in the needle exchange movement.  The information on the legal situation in particular states with regard to prescription laws or paraphernalia laws is taken from Scott Burris, Peter Lurie, Daniel Abrahamson, and Josiah D. Rich, "Physician Prescribing of Sterile Injection Equipment to Prevent HIV Infection: Time for Action," Annals of Internal Medicine, August 2000, vol. 133, pages 218-226.  The information on the physician prescription experience in Rhode Island is taken from Josiah D. Rich, "Physician Syringe Prescription to Prevent HIV in Rhode Island," presentation at the North American Syringe Exchange Convention, Portland, Oregon, April 2000.  Follow this link for more information on physician prescription of syringes.

(4) W. M. Compton, L. B. Cottler, S. H. Decker, and others, "Legal Needle Buying in St. Louis," American Journal of Public Health, 1992, vol. 82, no. 4, pages 595-596. Another study found that when the state closed the local needle exchange, the pharmacists in the area who previously had been selling needles over the counter began refusing to sell syringes without a prescription. Robert S. Broadhead, Yael van Hulst, and Douglas D. Heckathorn, "The Impact of a Needle Exchange's Closure," Public Health Reports, September/October 1999, vol. 114, pages 439-447.

(5) The information on needle exchange programs in 1998 is taken from Denise Panoe, Don C. Des Jarlais, Mytri Ptritam Singh, Courtney McKnight, and Stephen Titus, "National Syringe Exchange Survey 1998," presentation at the North American Syringe Exchange Convention, Portland, Oregon, April 2000. The 1997 information is from "Update: Syringe Exchange Programs - United States, 1997," Morbidity and Mortality Weekly Report," August 14, 1998, vol. 47, no. 31,  pages 652-655. Abstract.

(6) Paone and her colleagues define legal needle exchange programs as those operating in states that had no law requiring a prescription to purchase a hypodermic syringe or that had an exemption to the law allowing the program to operate. Illegal-tolerated programs operated in states with a prescription law and received a formal vote of support or approval of a local elected body such as a city council. Illegal-underground exchanged operated in states with a prescription law and did not have formal support of local elected officials.

(7) Scott Burris, Davis Finucane, Heather Gallagher, and Joseph Grace, "The Legal Strategies Used in Operating Syringe Exchange Programs in the United States," American Journal of Public Health,  August 1996, vol. 86,  pages 1161-1166.

(8) This is what happened in New Jersey.  See Dawn Day, "Sad Termination of a Life-Saving Project," Trenton Times, December 25, 1998, page A13. 

(9) Ricky N. Bluthenthal, Alex H. Kral, Jennifer Lorvick, and John K. Watters, 1997, "Impact of Law Enforcement on Syringe Exchange Programs: A Look at Oakland and San Francisco," Medical Anthropology, vol. 18, pages 61-83.

(10) Dawn Day, States and Metro Areas Hardest Hit by the HIV/AIDS Epidemic, Princeton, N.J.: Dogwood Center, November 1999.

(11) The figure of 50 new HIV infections each day from using HIV-infected needles comes from dividing 20,000 by 365. The CDC estimates there are 40,000 new HIV infections every year. CDC, "Guidelines for National Human Immunodeficiency Virus Case Surveillance, Including Monitoring for Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome," Morbidity and Mortality Weekly Report, 1999, vol. 48, no. RR-13, page 19. Our best estimate is that half of all new HIV infections are occurring among injecting drug users. See Scott D. Holmberg, "The Estimated Prevalence and Incidence of HIV in 96 Large U.S. Metropolitan Areas, American Journal of Public Health, May 1996, vol. 86, no. 5, pages 642-654.

For a list of other materials used on this website, see References.