SAVING WOMEN'S LIVES -- The Dogwood Center, Princeton, NJ, USA

Every year about 80,000 young Americans use heroin for the first time; they are usually between ages 18 and 25.⁽¹⁾ Some become dependent and start injecting. Do we want any of these young people to get AIDS?

Each year about 6,000 women and 14,000 men in the United States become infected with HIV through injecting drug use.⁽²⁾ An effective way to prevent this HIV transmission is to make sterile needles available to persons who inject drugs through needle exchanges, programs where drug injectors can trade used needles for sterile ones.

Needle exchanges are harm reduction organizations. 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 to nonsmokers by requiring that smoking be done only in designated areas. We reduce the harm from excessive drinking at parties by encouraging the use of a designated driver who does not drink. The goal of needle exchange programs is to slow the spread of HIV and thus reduce the harm from injecting drug use.

Our top public health officials including Secretary of Health and Human Services Donna E. Shalala and U.S. Surgeon General David Satcher have called for needle exchange programs as part of our AIDS prevention efforts.⁽³⁾^{,
(4)} The American Medical Association, the American Public Health Association, and other medical associations also have called for government support of needle exchange programs.⁽⁵⁾

Six major, government-sponsored studies have concluded that needle exchange programs are effective AIDS prevention and do not increase drug use.⁽⁶⁾ Every year, more evidence of the effectiveness of needle exchange programs is published in medical journals.⁽⁷⁾

Unfortunately, in spite of substantial support in respected medical circles for AIDS prevention through improving access to sterile needles, legal access to sterile needles remains limited. State and local laws on needle prescription and drug paraphernalia are seriously hindering the development of needle exchange programs. Needle prescription laws require a prescription from a medical doctor before a pharmacy can sell clean needles.⁽⁸⁾ Drug paraphernalia laws make it illegal to possess sterile needles.

The policies limiting access to sterile needles were put in place before the AIDS epidemic was well understood. No study has ever shown that reducing access to sterile needles reduces drug use. Reducing access to sterile needles however does cause drug users to share contaminated equipment. So a failed policy for reducing drug use has become the major factor in the spread of HIV.

Laws restricting access to sterile needles can be changed by legislative action or judicial interpretation. In the courts, cases have been decided in different ways, depending on which sets of law the judge applies: those dealing with public health or those dealing with drug use.⁽⁹⁾ When the judge sees the situation as a health emergency in which public health authorities must act in order to stop an epidemic, the state laws giving broad authority to public health officials are applied. The distribution of sterile needles is seen not only as a legal but as a vital service to the community.⁽¹⁰⁾

When the situation is not defined as a health emergency, the state laws restricting access to sterile needles are applied, and persons distributing clean needles are subject to arrest and prosecution.⁽¹¹⁾

Some needle exchange programs are being established across the country every year, many more are needed. Of the ten states with the highest rates of injection-related AIDS, four (Delaware, New Jersey, Louisiana and Florida) have laws that prevent the establishment of needle exchange programs. ⁽¹²⁾, (13)

New York, Maryland, Connecticut, Pennsylvania, Rhode Island and Massachusetts permit injecting drug users access to sterile needles under some conditions, but even with these states, the situation is mixed. Maryland, for example, permits needle exchange only in Baltimore City. In Pennsylvania, needle exchanges exist only on the basis of local initiative. In Massachusetts, the Springfield metro area, which ranks 13th in the nation with regard to injection-related AIDS, has no needle exchange program.

States with the highest rates of injection-related AIDS, 1998
Rank in 1998	State		Rate per million
1		New York	314
2		Maryland	252
3		Delaware	227
4		Connecticut	205
5		New Jersey	198
6		Louisiana	106
7		Pennsylvania	102
8		Florida	100
*9		Massachusetts	98
*9		Rhode Island	98
*		Tie with another state

New York, which leads the nation in drug-related AIDS, has historically had a high concentration of heroin users. Needle exchange programs in New York City have resulted in a reduction of the per capita HIV rate.⁽¹⁴⁾ However the number of needle exchange programs are still inadequate to meet the need. And pharmacy sales of syringes are restricted throughout the state.

New Mexico, on the other hand, recently passed legislation making needle exchange legal, and the health department has established programs in areas of need.

Under California's new law, needle exchange is legal in counties where the boards of supervisors have declared a health emergency, so there are legal needle exchanges in Alameda, Contra Costa, Marin, Santa Cruz, San Mateo, and San Francisco counties. In Fresno, one of the California counties that has not declared a health emergency, needle exchange workers are being prosecuted as criminals.

The first needle-exchange program was started in Tacoma, Washington, in 1988. Since then, courageous volunteers, risking arrest in order to save lives, have started more programs. By 1997, there were 113 needle exchange programs operating in 80 cities in 30 states.⁽¹⁵⁾

In 1997, most needle exchange programs, despite limited resources, provided other public health and social services. Virtually all provided instruction in the use of condoms and dental dams to prevent sexual transmission of HIV and other sexually transmitted diseases. Over 90 percent of these programs referred clients to drug treatment programs. Health care services on site at needle exchange programs included HIV counseling and testing (64 percent); tuberculosis skin testing (20 percent); sexually transmitted disease screening (20 percent); and primary health care (19 percent). More exchanges would have provided these services if they had had the resources to do so.

Needle exchange programs not only prevent the spread of HIV among persons who inject drugs. They also help reduce AIDS spread through heterosexual sex. This is because large numbers of persons infected through heterosexual sex are infected through heterosexual sex with a person who at one time injected drugs.

With 20,000 people infected with HIV every year as a result of intravenous drug use and additional thousands infected because of heterosexual sex with current or former injecting drug users, it is clear substantially more HIV prevention efforts among drug users are needed. We need to expand drug treatment opportunities. 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 medical scientists and support needle exchange programs.

We must persuade the federal government as well as state and local governments to:

As a humane society, we must reach the point where injecting drug users in every state have an opportunity to protect themselves from HIV and other bloodborne diseases and where needle exchange workers in every state are treated not as criminals but as the public health workers they are.

(2) The Centers for Disease Control and Prevention estimate of 40,000 new cases a year for all exposure groups is taken from Morbidity and Mortality Weekly Report. 1999. “Guidelines for National Human Immunodeficiency Virus Case Surveillance, Including Monitoring for Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome,” vol. 48, no. RR-13. 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. The breakdown of the 20,000 new infections by sex is based on the distribution of people now living with AIDS who were infected through injecting drug use. See Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. Cases reported through Jun 1999. Midyear edition. Vol. 11, No. 1. Table 25.

(4) Surgeon General David Satcher, "You do not deserve a death sentence because you are addicted." Lou Kilzer, "Satcher supports needle exchange," Denver Rocky Mountain News, November 6, 1999.

(6) The federal government has funded a number of reports on clean-needle programs for persons who inject drugs. The reports have been unanimous in their conclusions that clean needle programs reduce HIV transmission and DO NOT increase drug use.

(7) HIV Prevention for Injection Drug Users. Special issue of the Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. Vol. 18, Supplement 1. 1998. 148 pages. Susan F. Hurley, Damien J. Jolley and John M. Kaldor, "Effectiveness of needle-exchange programmes for prevention of HIV infection," The Lancet, Vol. 349. June 21, 1997, pages 1797-1800. Don C. Des Jarlais, Teresa Perlis, Samuel R. Friedman and others, "Declining Seroprevalence in a Very Large HIV Epidemic: Injecting Drug Users in New York City, 1991 to 1996," American Journal of Public Health, Vol. 88. pages 1801-1806. Robert S. Broadhead, Yael Van Hulst and Doulas D. Heckathorn, "Termination of an Established Needle-Exchange: A Study of Claims and Their Impact," Social Problems, Vol. 49, no. 1, pages 48-66.

(8) The phrase "needle prescription laws" in the text refers to both laws passed by state legislatures and pharmacy regulations. Pharmacy regulations are enforced by state pharmacy boards. A pharmacy selling needles in violation of state pharmacy board regulations risks losing its license to operate. The role of pharmacy regulation in restricting access to clean needles is detailed in Lawrence O. Gostin, Zita Lazzarini, T. Stephen Jones, and Kathleen Flagherty. 1997. "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, vol. 277, no. 1, January 1, pp. 53-62.

(9) 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, pp. 1161-66.

(10) The courts traditionally have viewed the exercise of public health powers with considerable deference, and health measures aimed at controlling communicable disease have rarely been overturned.

(11) As of 1996, forty-six states and the District of Columbia had laws restricting the possession or delivery of drug paraphernalia. Only four states--Alaska, Iowa, North Dakota, and South Carolina--were without a form of the drug paraphernalia law. 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, pp. 1161-66.

(13) Since needle exchange programs reach out to drug users, helping them to get into both drug treatment and HIV treatment, if needed, areas with needle exchanges have a more accurate count of the number of persons infected than do areas where there is no needle exchange program.

(14) Don C. Des Jarlais, Theresa Perils, Samuel R. Friedman, et al, "Declining Seroprevalence in a Very Large HIV Epidemic: Injecting Drug Users in New York City, 1991 to 1996," American Journal of Public Health, 1998. vol. 88. p.1801-06.