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While many of you are commemorating those friends and loved ones who died of AIDS today, and discussing the latest efforts in the world-wide pandemic, let us not forget a battle right here at home that still needs to be won.

The United States still has a policy that bans the federal funding of Syringe Exchange Programs (SEPs, sometimes referred to as NEPs - Needle Exchange Programs).

The most recent issue of the Journal of the American Medical Association(JAMA) has a letter to the editor:
Syringe Access and HIV Incidence in the United States by Dr. Sharon Stancliff, from the Harm Reduction Coalition.

To the Editor: In their discussion of new estimates of incidence of human immunodeficiency virus (HIV) in the United States, Dr Hall and colleagues1 note that the rate of new HIV infections directly attributed to injection drug use has decreased by approximately 80% and continues to decline, citing the role of increased syringe access through needle exchange programs and pharmacies in reducing needle sharing among drug injectors. These revised HIV incidence figures provide further corroboration of the literature documenting that injection drug users successfully reduce needle sharing and related injection risk behaviors when provided access to appropriate education and safer injection tools, including syringe access.

The US Congress has maintained a prohibition on the use of federal money for providing syringes to injection drug users since 1988, leaving syringe exchanges to be supported by severely limited state, local, and private funds.

In a recent article, published in July:
Moving the Needle on Syringe Exchange by James Wortman he reviews the history and where we stand today:

The decision to lift the ban on federally funded syringe-exchange programs is gaining bipartisan momentum on Capitol Hill. This July, a new bill recommending lifting the ban is scheduled to hit Congress. Has the time finally arrived for evidence-based science to prevail over moral debates around the issue of providing clean syringes for safer injecting?
Since the days when Bill Clinton was president, overwhelming evidence indicates that providing injection-drug users with clean syringes has a significant impact on reducing the spread of life-threatening illnesses like AIDS and hepatitis C among intravenous-drug users and their sexual partners. Studies conducted in the United States have repeatedly shown that syringe-exchange programs are powerful tools in preventing the spread of these blood-borne illnesses. In addition, it has been well established that when people access syringe-exchange programs, they are often likely to simultaneously access critical health care, information and support. They are more likely to get into care and on treatment, and find the support they need to continue both. And yet, since even before the Clinton era, federal funding restrictions, first implemented in 1988, have prevented our government from supporting needle-exchange programs. As a result, local state officials and syringe-exchange and harm-reduction organizations must scramble for resources to implement the lifesaving programs.

Despite 20 years of debate and experience with syringe exchange in the United States through nearly 200 programs, the, well, needle, has barely moved on this issue. That is, until recently. On June 18, 2008, a letter signed by 55 members of Congress (including four Republicans) was sent to House of Representatives Speaker Nancy Pelosi and Minority Leader John Boehner urging that litigation be passed to remove the ban and allow for federally funded syringe-exchange programs.

"We believe it is now time to take a fresh look at the epidemic here at home, bolster efforts to reduce HIV infections and allow states to design programs with proven results," says the letter. "As supporters of effective and evidence-based HIV prevention, we are writing to urge you to remove the restrictions on use of federal funds for syringe-exchange programs (SEPs) in the Department of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act."

Barack Obama has stated that he supports lifting the ban.  Maia Szalavitz, in the Huffington Post has expressed concern about President Elect Obama's purported choice for a drug Czar and what his position is on this crucial issue>
Obama Drug Czar Pick: No Recovery from War on Drugs?

On paper, Jim Ramstad -- who is rumored to be Obama's choice for drug czar -- looks like the ideal man for the job . He's a recovering alcoholic himself and a Congressman who championed legislation recently passed to provide equal insurance coverage for addictions and other mental illnesses.

To top it off, he's a Republican, giving Obama what looks like a relatively harmless way to make his cabinet more bipartisan. Choosing Ramstad would appear to make a powerful statement about addiction as a medical, not a moral issue.

Unfortunately, Ramstad may be a drug warrior in recovering person's clothing. There is one issue that has consistently separated those who put science and saving lives in front of politics. That is needle exchange programs for addicts to prevent the spread of HIV and other blood borne illnesses.

I have no idea about whether of not this is the latest in a series of rumors, and as yet we have no idea whether or not there will be a "Drug Czar" at all.  I am concerned however that this crucial issue will fall through the cracks, at a time when the focus on the economy, the War, and other major crises will push AIDS onto the back burner, and at the bottom of the AIDS help list will be those drug injectors still sharing unsterile syringes.

Much of the discussion of AIDS globally has now shifted to heterosexual transmission, and the debate over PEPFAR and GWB's abstinence only provisions.

Wortman stated (my bold):

The ban on syringe-exchange programs has contributed to the continued rise in the number of people infected with HIV through the sharing of needles. In 2005, the Centers for Disease Control and Prevention (CDC) reported that 14,760 people with a risk factor related to IV-drug use received a diagnosis of AIDS or reported an HIV infection. The latest CDC figure for that group amounts to 383,000 people.

A bill to remove the ban will be introduced in the House in July by Democratic Representative Jose Serrano of New York, who in June 2007 succeeded in lifting the ban on city-funded syringe-exchange programs in Washington, DC, where the rate of HIV infections is twice the national average. Injection-drug use is the second-most-common mode of HIV transmission among men in the District of Columbia, and it is the No. 1 mode of HIV transmission among women.

Critics of federally funded syringe-exchange programs find them morally troubling, as they believe that offering free, clean syringes to injection-drug users indirectly promotes the use of illegal drugs such as heroin. They favor, instead, substitution therapy, which is aimed to get IV-drug users to stop injecting illegal drugs. Allan Clear, executive director of the Harm Reduction Coalition—a New York-based group leading the charge for the removal of the federal ban—finds criticism of these vital programs a barrier to successfully fighting the spread of HIV and other diseases that can be transmitted by sharing syringes. "Syringe exchange is the most effective HIV prevention we have for drug injectors," Clear told POZ. "The arguments never actually stand up, whatever they are. Sending a bad message to children is one of the favorites. I’m not sure what kind of message you’re sending to a child if you’re willing to let their parents get infected with HIV or hepatitis C. That’s not a good message either."

With Democrats gaining a Congressional majority, however, more and more federal leaders are beginning to see the lifesaving value of such programs. In New York City, for example, the number of new AIDS diagnoses among injection-drug users has dropped 90 percent since 1993 largely thanks to state- and city-funded interventions that provide syringe exchange.

I have worked with NEPS since they were illegal "guerrilla exchange programs" on the Lower East Side of Manhattan. As an AIDS researcher, I have observed drug injecting and syringe sharing in "shooting galleries" here in the United States and in Puerto Rico.  I have authored and co-authored numerous articles on AIDS risk behavior, and syringe access. Among them are:
Syringe Acquisition and Use of Syringe Exchange Programs by Puerto Rican Drug Injectors in New York and Puerto Rico: Comparisons Based on Quantitative and Qualitative Methods

Mapping the Air-Bridge Locations: The Application of Ethnographic Mapping Techniques to a Study of HIV Risk Behavior Determinant in East Harlem, New York, and Bayamón, Puerto Rico

I have also written about the related sexual risk behaviors of intravenous drug users:
Sexual Risk behaviours of Puerto Rican Drugs Users in East Harlem New York and Bayamon, Puerto Rico

But I don't want to address this issue as an academic.  I am worried that there are still many of us, even in the liberal community, who are willing to decriminalize marijuana, or push for legalization, but who still have moral judgments about "hard drugs" and "junkies".  I've read comments here, and on other Democratic blogs (I'm not even talking about the right wing) where there is still a "blame the victim" tone about addiction, and an unwillingness to discuss drug injectors.

There is also not enough discussion of Harm Reduction and why it works. The North American Syringe Exchange Network(NASEN) and the Harm Reduction Coalition are two good places to start.

The Kaiser Family Foundation maintains a list of States that have  Sterile Syringe Exchange Programs

For those of you not familiar with syringe exchange here is a brief description:

A hypodermic needle-exchange program is a sometimes controversial social policy, based on the philosophy of harm reduction where injection drug users can obtain hypodermic needles and associated injection equipment at little or no cost. These programs are called "exchanges" because many require exchanging used needles for an equal number of new needles. In practice, some programs vary in their stringency; in the Canadian capital Ottawa, for example, participating clinics do not demand used needles before giving out new ones.[1]

In addition to sterile needles, syringe exchange programs (SEPs) typically offer other services such as: HIV and Hepatitis C testing; alcohol swabs; bleach and sterile water; aluminum "cookers"; containers for needles and many other items.[2] There was a survey conducted by Beth Israel Medical Center in New York city and the North American Syringe Exchange Network, which showed among the 126 SEPs surveyed, 77% provided to material abuse therapy, 72% provided voluntary counseling and HIV testing, and more than two-thirds provided supplies such as bleach, alcohol pads, and male and female condoms.

In the United States around 1/5 of all new HIV infections and the vast majority of Hepatitis C infections are the result of injection drug use.[3] Supporters of SEPs estimated that with the aid of SEPs, the number of HIV infections could be prevented from 4000-10000 between 1987-2000. According to the analysis of New York State-approved SEPs, during one year period, SEPs contribute directly that 87 HIV infectons can be averted. Dozens of studies have shown needle exchanges to be effective at preventing the spread of HIV and Hepatitis C. Needle exchange programs are supported by the Center for Disease Control and the National Institute of Health. The National Institute of Health estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C. The presence of needle exchange programs has been attributed to a reduction of high-risk injection behavior by up to 74%.

Daniel Raymond and Allan Clear of the Harm Reduction Coalition write about the history and where we are today in
United States and the Politics of Syringe Exchange

The history is important.  Many public health activists and addicts worked together to operate "illegal" exchanges prior to the legal test experiments.

U.S. Syringe-Exchange Programs Operate Underground
Syringe-exchange programs first emerged in the United States in the mid-to-late 1980s, as underground, activist-initiated efforts to adapt models first developed in Europe. These programs faced immediate opposition in the midst of the government’s intensified "war on drugs," which introduced the rhetoric of zero tolerance and "just say no" into American culture, alongside a concurrent moral panic surrounding crack cocaine use. These new HIV-prevention initiatives represented both an urgent, pragmatic response to astonishing rates of infection among people who inject drugs – by the late 1980s, researchers calculate that more than half of New York City’s estimated 200,000 injectors were already HIV-positive – as well as a form of civil disobedience, protesting the state laws and policies regulating the possession and distribution of syringes.

The patchwork of legal restrictions on syringe access, coupled with intensive law enforcement efforts targeting drug markets, had produced a severe and artificial scarcity of syringes that resulted in widespread needle-sharing and HIV transmission among drug injectors.

These struggles played out in various cities and states across the country, in several cases resulting in the arrest of syringe exchange pioneers. A planned arrest in New York City led to a trial resulting in the acquittal of the activists, who successfully mounted a "necessity defense," claiming that the public health imperative to prevent infection by averting a greater harm superseded the rationale for enforcing the penal code.

They also discuss where we have made progress:

A New Climate Emerges?
Several recent signs of progress in various states suggest that a political climate more favorable to syringe exchange may be emerging:

New Jersey, after years of debate and inaction, passed legislation authorizing pilot syringe-exchange programs in up to six cities, with the first four programs slated to launch in 2007. New Jersey had been one of the few remaining states with no legal form of syringe access for drug injectors (allowing neither exchange programs nor pharmacy sale without prescription), despite having the fifth highest HIV rate among adults in the nation, with roughly half of the state’s HIV/AIDS cases linked to injection drug use.

Texas passed legislation authorizing its first legal syringe exchange in Bexar County, which includes the city of San Antonio. The passage of this legislation marks a compromise, as the original proposal would have allowed for syringe exchange statewide. The program is expected to begin in 2008, with start-up funding from the city government.

Washington, D.C. has the highest rate of HIV in the nation, with a substantial number of cases attributable to injection drug use. The Senate and House of Representatives of the U.S. Congress each passed versions of bills that would strike a long-standing provision barring Washington, D.C., from using its own city funds to finance syringe exchange. The nonprofit organization, PreventionWorks, which operates the city’s only syringe exchange program, has long been a target of opponents in Congress. The city health department plans to spend $1 million on syringe-exchange programs, with a quarter allocated to PreventionWorks. Further action awaits the signing of these bills by President Bush, who has threatened a veto.

California, Delaware, Massachusetts, New York and other states have made significant progress in recent years through increasing syringe access by legal changes, establishment of new programs, and increased city and state funding. Advocates continue organizing efforts in several other states.

Here's a recent you tube on DC's program:


Reggie Jackson: Exchanging for Change

Reggie Jackson is the team leader for a mobile Syringe Exchange Program that operates out of an RV in Washington, DC. The program provides clean needles to drug users in order to prevent the spread of AIDS/HIV and other blood borne diseases. This is especially significant given the high rate of AIDS/HIV in the District. Reggie is a former drug addict and has been living with AIDS/HIV and hepatitis C for 22 years. He uses his experiences to counsel the addicts that come to the RV to exchange their used needles for clean ones.

Another on the Humboldt Park Needle Exchange in Chicago

And an overview of Harm Reduction:
Harm Reduction & the Drug War

There are also problems with limitations on existing programs.  In Puerto Rico moral limitations were placed on the number of syringes that could be exchanged.  In the beginning of the test program, though injectors brought in used syringes by the box-load, they only got 1-3 clean ones in return. They also were limited in the number of condoms they could get.  One program I observed, active sex-workers got one condom.

Local police Departments can cause failures.  If people are afraid to go to an NEP, knowing they may get busted after leaving, they won't work.

Issues of access, availability, confidentiality are important, as are the ancillary services provided by NEPs.

Find out where your congressional representative stands on sterile syringe exchange. Do you know?

Does your city or region have legal syringe exchange?

Silence=Death.  So does lack of access to sterile syringes.

 

Originally posted to Denise Oliver Velez on Mon Dec 01, 2008 at 04:15 AM PST.

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