In early 1995, the U.S. Centers for Disease Control and Prevention (CDC) reported injecting drug use as the second leading cause of new cases of Acquired Immune Deficiency Syndrome (AIDS) through the end of 1994. The CDC also reported that half of 1994's 40,388 new cases of Human Immunodeficiency Virus (HIV) were directly related to injecting drug use (Swan 1995). HIV is transmitted very efficiently through the sharing of needles and syringes and has moved rapidly through circles of injecting drug users, who go on to infect their sexual partners and their children. Injecting drug users and their contacts have replaced gay men as the majority of new cases of HIV. Despite the high numbers of injecting drug users among those infected with HIV and AIDS, public health measures to prevent the spread of disease in this population have been slow to emerge. Access to sterile injecting equipment has been a primary prevention strategy among this population in many developed countries, but has remained highly controversial in the United States. The cost of HIV/ AIDS among this population is significant. In addition to lost lives, 1994's 20,000 needle-borne infections are estimated to exceed $2 billion in health care costs, most financed by tax dollars via Medicaid (Drug Policy Foundation 1995).

In 1986, the U.S. Public Health Service (PHS) began to address the problem of HIV infection among injecting drug users. At that time, the National Academy of Sciences proposed the adoption of a public health policy that encouraged the use of sterile needles and syringes as a means of preventing AIDS. Sweden, the Netherlands, England, Scotland, France and Australia had all successfully incorporated needle exchange as part of public health efforts to reduce the rate of new HIV infections among injecting drug users. PHS officials were reluctant to endorse needle exchange as a federal strategy, fearing that this approach would appear to condone the use of illicit drugs. Consistent with the national war on drugs emphasis was placed on drug abuse prevention and treatment as a means of reducing the rate of HIV related to injecting drug use (Inciardi 1990; Anderson 1991).

The same year, AIDS activists in Boston and New Haven began operating informal needle exchange programs. Underground needle exchanges were also established in New York City and elsewhere by ACT-UP, the AIDS Brigade and other community-based coalitions (Des Jarlais & Stepherson 1991). As the AIDS epidemic progressed and evidence from abroad continued to document the success of needle exchange programs in decreasing the rate of HIV infection among injecting drug users, municipal public health officials began to take action. The first legal needle exchange in this country was established in Tacoma, Washington, in 1988. New Haven was the second city to sanction needle exchange. Seventy-five needle exchange programs operate in 55 American cities, using private and nonfederal financing (New York State Department of Health [NYSDOH] 1994; Leary 1995).

State and Federal Policy Toward Needle Exchange Programs

The Anti-Drug Abuse Act of 1988 (PL 100-690) prohibited states from using federal funds for needle exchange programs. In 1989, as evidence in the United States began to show the effectiveness of needle exchange programs in this country, the National Research Council recommended their use as a means of preventing the spread of HIV. This position was strongly condemned by the House Committee on Narcotics Abuse and Control and then-President George Bush (Anderson 1991). The 1992 ADAMHA Reorganization Act (PL 102-231) emphasized that none of the money provided under the Public Health Service Act was to be used to fund needle exchange programs. However, this act included the provision that if needle exchange programs could be proved effective in reducing the spread of HIV without encouraging illegal drug use, and the surgeon general recommended their use as a public health measure, then the funding ban could be lifted (Marwick 1995; Drug Policy Foundation 1995).

Policies at the state level also impact attempts at HIV prevention among injecting drug users, their partners and their children. Currently, 44 states have drug paraphernalia laws that penalize the possession and distribution of needles and syringes. Nine states also have laws that require prescriptions both to buy drug injection equipment and to possess it. The nine states with needle prescription laws include those with the largest numbers of injecting drug users and the highest incidence of drug-related AIDS cases. New York is one of the states with both drug paraphernalia and needle prescription laws. In New York State alone, it has been estimated that at least 550,000 people engage in injecting drug use. It has also been estimated that at least half of these are already infected with HIV (Benker 1995).

The authority to possess needles can be granted under needle prescription laws in several states by state health commissioners for the purpose of protecting the public health (Paone, Des Jarlais, Caloir, Clark & Jose 1995; Robens & Backstrom 1994). In 1992 the New York State Department of Health authorized the state health commissioner to approve needle exchange programs for the purpose of preventing the spread of HIV.

Population Affected

Injecting drug users who share needles and syringes with other users are at high risk of contracting HIV. People who inject drugs vary by ethnicity, socioeconomic status, gender, sexual orientation and age. They vary by drug of choice and frequency of injection as well (Stimson 1990; Koester 1994). Many members of this population are non-white and poor. They are unlikely to receive the preventative medical care which might help stem the spread of HIV. Injecting drug users are a highly marginalized population, often scapegoated for a variety of social problems and deemed unworthy of attention by service providers and government leaders.

It is not only persons who inject illicit drugs who are affected by needle-borne HIV and impacted by the limited availability of needle exchange programs. The majority of cases heterosexually acquired HIV appear to have arisen through contact with individuals infected through the sharing of injecting drug equipment (N. McKeganey & M. Barnard 1992). In 1994 needle-borne HIV was a factor in 71 percent of new HIV infections among women and 66 percent of those among newborns in the United States (Swan 1995).

Policy Dimensions of Needle Exchange

Needle exchange programs exist as part of a more comprehensive harm reduction approach. Harm reduction recognizes that drug use is a major factor in the continuing spread of HIV and acknowledges that despite efforts at prevention, substantial numbers of people will continue to inject drugs. Based on the high cost of AIDS to individuals, communities and society, the prevention of HIV and AIDS takes precedence over the prevention of drug use (NYSDOH 1994; Nadelmann et al. 1994).

The primary goal of needle exchange programs is to help injecting drug users reduce needle sharing behavior. This is done by providing sterile needles and syringes in tandem with education regarding HIV risk reduction. A secondary goal is to reduce the public's risk of exposure to contaminated needles by requiring the return of used needles for new ones. Ultimately needle exchange programs seek to decrease the rate of HIV transmission among injecting drug users, their direct contacts and the larger community (Paone et al. 1995; Vlahov & Brookmeyer 1994).

Needle exchange programs provide both goods and services. Participants are provided sterile needles and syringes, bleach decontamination kits and condoms. Services provided by public health workers and trained volunteers include HIV education and counseling as well as assessment and referral to health care, drug treatment, housing and social services. Needle exchange programs allow clients to decide which and how many services they need. A central tenet of the harm reduction approach is consumer sovereignty.

People who inject drugs are often perceived as sick, deviant and/or criminal. To reduce the impact of social stigma, needle exchange programs provide services in a manner that encourages the development of trust and rapport. Outreach efforts are employed to attract as many clients as possible. Needle exchange programs are cost effective. The average budget of existing programs in the United States is $169,000. Researchers have estimated the cost per HIV infection averted to be between $3,700 and $12,000, much lower than the recent estimate of $119,000 in lifetime costs of care for a person infected with HIV (Lurie et al. 1993; Vlahov & Brookmeyer 1994).

Entitlement rules for needle exchange programs are based on professional and administrative discretion. Intake workers assess eligibility of applicants based on guidelines established by state regulation and/or program administrators (Gostin 1994). The primary criterion is that the client is an active injecting drug user. Entitlement rules are potentially stigmatizing. Some users may not exchange needles for fear of being identified as illicit drug users. Needle exchange programs are inexpensive and utilize volunteers for staffing. The potential for raising overwhelming cost is not a concern.

There is substantial variation in the administrative structure of needle exchange programs. They may be administered by state government, by community-based organizations with or without government sponsorship or independently by AIDS activist organizations. Needle exchange programs use a variety of settings for the provision of service, including mobile vans, storefronts, walking teams and clinical settings (Lurie et al. 1993). The exchanges are designed to be easily accessible, operating in areas frequented by active drug users. Outreach activities rely upon indigenous workers who reflect the racial and ethnic diversity of the communities affected. Many needle exchange programs participate in reciprocal referral agreements with substance abuse treatment programs, community health centers, AIDS service providers and social service agencies. Many also include user advisory groups, which solicit client input (NYSDOH 1994; Paone et al. 1995). The continuity of needle exchange programs vary with that of the sponsoring organizations. In communities where needle exchanges have been approved, they have been well-integrated in the human service delivery system. Programs are accountable to local and state health authorities.

Funding for needle exchange programs has been unstable. Private donations are the primary source of funding, followed by foundation grants, city/county revenue, agency funds and money from state governments (Lurie et al. 1993). In New York State, the American Foundation for AIDS Research has allocated more than $ 1 million to seven approved needle exchange programs since 1992. Through the end of 1994, the New York State Department of Health had also allocated more than $1 million to fund needle exchange programs (NYSDOH 1995).

Harm reduction policy views the link between HIV and injecting drug use as a public health problem. This is in contrast to drug control policy, which considers the problem from a law enforcement perspective. The federal funding ban has arisen from the latter perspective, which interferes with the provision of HIV prevention services to the majority of those at risk through injecting drug use (Gostin 1994). Existing drug paraphernalia and needle prescription laws further render needle exchange programs unlikely to eliminate needle sharing entirely. Despite the legal protection bestowed upon participants in authorized programs, fear of arrest may deter potential clients from using services.

Policy Operation

Injecting drug users and their families are the primary beneficiaries of needle exchange programs. Providing services which reduce the rate of HIV infection among this group also serves to reduce HIV transmission throughout the broader community, both through sexual contact and through exposure to potentially infected needles discarded in public places. In addition, participation in needle exchange programs is often the first step toward treatment and recovery for injecting drug users, offering them the opportunity to become productive members of society. The small cost of funding needle exchange programs is far outweighed by the tremendous savings in AIDS-related health care costs offered by this strategy.

Needle exchange programs have been gathering support for nearly a decade. The World Health Organization and the National Academy of Sciences recommended the adoption of needle exchange programs as a component of HIV prevention as early as 1986. The National Research Council suggested their widespread implementation in 1988, a position supported by Surgeon General C. Everett Koop (Anderson 1991). As the AIDS epidemic has worsened, and attempts at prevention of injecting drug use as a means of preventing HIV have proved themselves ineffective, support for needle exchange has increased. In 1993 David Satcher, director of the CDC, recommended that the federal funding ban be lifted, after extensive research indicated that they were effective in reducing the rate of HIV transmission without increasing the rate of injecting drug use (Drug Policy Foundation 1995; Marwick 1995). Additional supporters include the American Foundation for AIDS Research, the National Commission on AIDS, the Black Leadership Commission on AIDS, the Latino Commission on AIDS, the American Public Health Association and the NYS Department of Health (NYSDOH 1994; Judson 1995).

Those opposed to needle exchange programs have included conservative politicians, prosecutors and law enforcement personnel who believe that needle exchange programs condone drug abuse. Drug treatment professionals have also opposed needle exchange, concerned that distributing needles would be a cheap substitute for treatment. Opposition has gradually declined as favorable reviews have accumulated and as public awareness of program benefits have increased. A 1994 public opinion poll conducted by Peter Hart and Associates found that 55 percent of 1,001 Americans surveyed were in favor of needle exchange programs (Paone et al. 1995; Marwick 1995). The Clinton administration has remained silent on the issue.

The evidence indicates that needle exchange programs have operated as predicted. These programs have resulted in decreased rates of new HIV infection without increased rates of drug use among program participants (Lurie et al. 1993; NYSDOH 1994). Extensive studies of needle exchange programs here and abroad consistently demonstrate that needle exchange programs help drug injectors significantly reduce needle sharing, which puts themselves or others at risk of HIV and reduce the risk of HIV exposure to the public by decreasing the number of potentially infected needles. The most comprehensive study of needle exchange programs done to date was conducted by researchers from the University of California. The researchers visited 23 sites and found that needle exchange programs offered a significant reduction in infection among injecting drug users, their sexual partners and their offspring, with mathematical models predicting a 17-70 percent decrease in HIV transmission within this population (Lurie et al. 1993; Marwick 1995).

Needle exchange programs have not been without operational problems. Street-based exchange programs and store-front models offer almost no privacy to people wishing to use them. Limited exchange hours and locations lead to difficulty in access for many potential clients (NYSDOH 1994).

Recent Developments

In 1993 and 1994, Maryland, Massachusetts and Rhode Island enacted laws authorizing pilot needle exchange programs, while Hawaii and Connecticut expanded existing legislation (Drug Policy Foundation 1995). In late 1994, the National Institute on Drug Abuse (NIDA) released the results of a three-year study that showed that the number of HIV-infected needles had dropped significantly and predicted that there would be a 33 percent decrease in new HIV infections among injecting drug users as a result of the New Haven needle exchange program (Vlahov & Brookmeyer 1994; Swan 1995).

In August 1995, the FY 1996 Appropriations Act for the Department of Health and Human Services was drafted. Section 505 of Title V again prohibited the use of federal funds for needle exchange programs. In September 1995, the National Academy of Sciences released the results of a study commissioned by Congress that offered further evidence that needle exchange programs were effective in reducing the rate of HIV infection among injecting drug users without encouraging increased drug use. The study recommended that the funding ban be lifted. Administration officials were quoted as saying that they would study the report and consult with the relevant congressional committees (Leary 1995). To date there is no record of any discussion and the federal funding ban remains in place.

Implications for Social Work

The HIV epidemic among injecting drug users, their partners and their children is too important a public health problem to ignore. Social workers must advocate for public health policy that can effectively address the dual epidemics of HIV and substance abuse. Needle exchange programs have repeatedly been proved to reduce needle sharing, decrease the incidence of HIV infection related to injecting drug use and draw injecting drug users into treatment. Needle exchange programs embody the notions of client empowerment and self-determination central to social work practice. Social workers can contribute by offering direct service to people at risk for HIV infection through injecting drug use and advocating for their needs.

Social workers can also contribute by developing and strengthening programs that focus on the multiple factors influencing injecting drug use. Poverty, discrimination and unemployment are all factors that promote and maintain drug use. It has been estimated that 90 percent of HIV in inner-city areas is related directly or indirectly to injecting drug use (Benker 1995; Koester 1994). We need to reaffirm our historical commitment to work among people who lack opportunity based on socioeconomic status, race, ethnicity, and other characteristics used to discriminate and oppress. Social workers need to advocate for change in economic policies, full employment and health care that meets the needs of all people. Only through addressing these underlying issues can we hope to be successful in any harm reduction strategy. •

Gretchen Schaefer is one of the second place winners in DPF's Student Paper Competition.
Ms. Schaefer is currently enrolled in the MSW program at the Syracuse University School of Social Work. She is a member of the local harm reduction initiative and has experience working in the fields of addiction and HIV prevention.

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