With needle exchange programs (NEPs) now well into their second decade in the US, the programs continue to expand across the country, but coverage remains spotty and significant obstacles remain.
According to a recently released survey of NEPs conducted jointly by the Beth Israel Medical Center in New York and the North American Syringe Exchange Network (http://www.nasen.org), the number of NEPs operating in the US had climbed to 127 by the time of the survey last fall, up from 96 in 1997 and 29 in 1992. In 1987, one NEP was operating in the US. NEPs now distribute sterile syringes to injection drug users in 36 states, the District of Columbia and Puerto Rico, the survey found.
"We're at 211 active programs now," said NASEN head Dave Purchase this week. "That's the good news. The number of programs continues to expand."
Not only are the programs expanding, the range of services they offer is increasing. More than 90% of surveyed NEPs offered HIV and hepatitis prevention information and information on safe injection techniques, and 87% offered vein and abscess care information. But when it came to onsite medical services, the numbers declined dramatically. While 88% offered HIV testing and counseling, fewer than half offered counseling for hepatitis, sexually transmitted diseases or other medical care. Similarly, fewer than half of the NEPs offered any onsite social services assistance.
Funding for NEPs remains a mix of public and private funds. Although the federal government still refuses to fund NEPs, state and local governments kicked in almost two-thirds of the more than $8 million spent operating NEPS last year.
"No federal funding, that's the bad news," Purchase told DRCNet. "There is not a dime of federal support for NEPS in the US. They are the most proven, documented and effective AIDS prevention method known, but the federal government is blind to the science," Purchase said. "Over the years, state and local authorities have been coming around, but we are at an impasse at the federal level."
The creation and development of new NEPS is an uneven and uncertain process, said Donald Grove of the New York-based Harm Reduction Coalition (http://www.harmreduction.org). "It really goes state by state, and sometimes city by city," Grove told DRCNet. "Here in the northeast, there are rays of hope. In both New York and Massachusetts, the state has created legal mechanisms for NEPs. Here in New York, the success of the law to allow syringe sales at pharmacies has helped convince the state health department that there is legislative support for HIV prevention programs," Grove explained. "That showed the health department more people were interested in NEPs than just angry, complaining merchants."
But it isn't looking so good across the Hudson River, Grove told DRCNet. "Things are still locked up in New Jersey," he said. "Governor McGreevey said he would support NEPs, but he has not expended any political capital to make it happen. And that's a shame, because New Jersey is the epicenter in terms of constantly increasing rates of infection."
Farther south along the Atlantic seaboard, NEPs face the additional challenge of operating underground -- without official sanction and sometimes at risk of arrest, Grove said. "In the South, everything is underground. And North Carolina, Jesse Helms' home state, has more underground NEPS than any state in the region. Throughout the South, these NEPs are illegal, but they're generally tolerated," he said.
But it's not only the South where NEPS have to skirt the law. Although city officials in San Diego authorized an NEP earlier this year, the Harm Reduction Center in suburban Encinitas still runs a large, technically illegal NEP in the city and surrounding areas of San Diego County, where officials refuse to take the steps necessary to authorize a legal NEP.
"There's no chance we're going away," said Brent Whitteker, the center's executive director. "We're exchanging 20,000 syringes a week, we're doing home deliveries -- which the city program cannot do -- we have lots of work everyday. We have about 1500 to 2000 participants annually, and through them we reach about 5-7,000 more," he told DRCNet. "But that's out of an estimated 23,000 injection drug users in the county."
Whitteker said the program would like to go legit, but would stay underground if it could not do the work it saw needed doing. "We would like a legal platform, but we cannot conform in San Diego unless they change their regulations," he said. "And there's so much more to it than just needles. The exchange only unlocks the door, it provides the opportunity to begin to show people how to protect themselves, how to get referrals and information about services, basically to assist them in using in a safe way so they can live a long, healthy life."
Community hostility and resistance to NEPs continue to flare up as well. Casa Segura was firebombed in Oakland last year, the Albuquerque city council moved against a local NEP earlier this year, and the "Peoria Needle Lady," nurse Beth Wehrman, has gotten a rather chilly reception in the heartland as well (http://www.drcnet.org/wol/236.html#peoria). It's not always so dramatic, but it is a recurring theme, said Purchase.
"Even the most well-established programs go through cycles with their communities," he said. "It's not about the science or the truth -- if it were, we wouldn't be having these fights -- but it's about politics, the war on drugs mythology and even some more malignant impulses. For some opponents, it's an educational process as well," said Purchase. "That's a slow process."
The movement is starved for resources, said Purchase, and it needs more political support, but he pronounced himself at least partially satisfied with the current state of affairs. "We're not stalled and we've learned a lot, over that period we've managed to back up what was common sense then with science, and now there are over 200 programs," he said. "We've grown more knowledgeable about tailoring programs for a more diverse population. We've made progress with state and local officials."
But Grove pointed to yet another concern. "The model for NEPs has been to start small, gain public acceptance and then grow, but the evidence from the Beth Israel surveys doesn't support that," he said. "If they start small, they tend to stay small. It's great that the movement is spreading, but in many places that means if a key person goes, the program is in real trouble."
And for Purchase the overriding issue remains the same as when he first began working on AIDS prevention in the 1980s. "The unpleasant feeling is no different than it was years ago. Here we are trying to stop the epidemic transmission of blood borne pathogens in a population of millions, and we lack the resources to do it. For me, anger control is always an issue."