The only existing supervised injection site for hard drug users in North America is Vancouver's Insite, but panelists at a session of the International Drug Reform Conference in Denver last month said activists in a number of US cities are working to be next. (Plans are also afoot in a couple of Canadian cities.)

Supervised injection sites (SIS) are a proven public health and harm reduction intervention that can save lives by preventing overdoses, bring a measure of stability to the sometimes chaotic lives of addicts, reduce the spread of bloodborne infectious diseases such as HIV/AIDS and Hepatitis C, and reduce crime and disorder in the community.

SISs also exist in a number of European countries and Australia, but face both legal and political hurdles in the US. Still, advocates are ready to push the envelope here in a bid to bring the life-, health-, and money-saving innovation here.

Donald Macpherson, executive \director of the Canadian Drug Policy Coalition and former head of Vancouver's Four Pillars drug policy program explained the prehistory of Insite, offering hints of possible courses of action in the US.

"We had a public health disaster," he said, referring to the city's escalating heroin problem in the 1990s. "Drug users themselves opened an SIS in 1995, and the police watched it, but didn't shut it down. A second opened in 2002. A year later, another non-sanctioned injection site opened up. It was really messy and it took years."

But in the end, Vancouver ended up with Insite and has managed to keep it open despite the best efforts of the Conservative federal government in Ottawa.

"Insite survives because it has an exemption from Canadian drug laws," Macpherson explained. "We won in the British Columbia courts, we won in the Canadian Supreme Court, which instructed the health minister to issue a permit. But we still barely have Insite, and though other cities are working on it, there is a big chill in Canada right now and we're just trying to hang on to what we've got."

Plans for SISs in the US face similar obstacles, but that isn't stopping advocates in a number of cities -- notably Austin, New York City, San Francisco, and Seattle, as well as somewhere in New Mexico -- from pressing forward with plans to open them there.

"I don't know if we'll be first, but we'll be one of many," said Robert Cordero, president and chief program officer of Boom! Health in the Bronx.

Boom! Health, which resulted from the merger of Bronx AIDS Services and Citiwide Harm Reduction, is a multi-service organization with a three-story building that includes a pharmacy, pharmacists with a harm reduction orientation, and a seven-day-a-week drop in center.

"Safe injection would be embedded with all these other services," he said.

"I don't know if we want to be first, but we want to be one of many," said Olivia Sloan, outreach and education associate for the Drug Policy Alliance (DPA) in New Mexico, which has been working patiently to bring cutting edge programs like SISs to the state. "We passed harm reduction, including needle exchange, through the state legislature, but it's not working," Sloan said. "We have overdose deaths at four or five times the national average."

Advocates in New Mexico have been and continue to lay the groundwork for SISs, Sloan said.

"We took a political and academic approach, and our conversation about injection facilities started a few years ago," she explained. "We have mobile syringe exchanges. We drafted legislation last year and the Senate passed a memorial to require we study the feasibility of SISs in New Mexico. We have partnered with the University of New Mexico and are looking for a principal investigator."

In San Francisco, preliminary discussions with local officials about SISs have been going on for some time, but the San Francisco Drug Users Union may follow the path taken by organized Vancouver drug users, as well as many of the needle exchange pioneers in the US, and just do it.

"We have a committee very committed to an SIS that meets every Monday for two hours," said Holly Bradford, the union's coordinator. "We're really on the verge. We have a very active bathroom here; you just open the door," she smiled. We're bringing it to San Francisco," she said. "It might not be sanctioned or aboveground, but it's going to happen."

Whether underground or not, SISs face a hazard-strewn trek. State, local, or federal officials can throw up any number of obstacles, said Lindsay LaSalle, a Berkeley-based law fellow for DPA.

"Drug possession remains illegal and could impact any SIS user, although probably not the staff or operator because they're not handling the drugs," she explained.

"Then there are the crack house laws, which both the federal government and some states have. They make it illegal for anyone to maintain, own, lease, or rent a property where drugs are used, consumed, or manufactured. These laws could cover SISs, and this could impact both clients and staff and operators alike," she elaborated.

"Then there are civil forfeiture statutes. They've used them to go after medical marijuana dispensaries," she enumerated.

Winning local official support reduces some risks, but not all, LaSalle said.

"If SISs were sanctioned at the local level, many of the legal risks dissipate, but state actors could still choose to prosecute," she warned. "In most states, local officers are deputized to enforce state law, so they could still go after an SIS. If authorized at the state level, that would be an incredible victory, but we would still have to deal with the federal government."

While acknowledging that lawyers can be "a buzzkill," LaSalle also hastened to add that things can change faster than we think.

"These legal barriers are not so different from the challenges we've faced with other drug policy issues, like syringe exchanges," she noted. "They were seen as completely radical, but now we have an almost universally accepted public health intervention with the exchanges."

Part of the process of initiating a supervised injection site is selling it to other stakeholders. Panelists had a number of ideas about messages that worked.

"For business people, you tell them this is how we clean up the neighborhood," said a Seattle activist.

"It is a very incremental change from syringe exchange to supervised injection sites," said LaSalle. "Position it as a very small change in an organization that provides all these other services to drug users."

"There's always 'what we're doing is not working,'" said Sloan.

"We're not going to arrest our way out of this problem," suggested Cordero. "But don't go straight to the SIS conversation. Let people see what we're doing, and then they say 'you're doing God's work' and second, 'Holy shit! Where would all those people be if you weren't open?'"

The obstacles to implementing supervised injection sites in the US are formidable, but the need to do so is urgent and increasingly understood, as are the benefits. With activists and advocates in a number of American locales pursuing SISs through a variety of means, the question is not whether it will happen here, but when and where.

Nevada's Republican governor, Brian Sandoval, Wednesday signed into law two drug reform measures, one allowing for medical marijuana dispensaries and one removing syringes from the state's drug paraphernalia law.

On the medical marijuana front, Sandoval signed into law Senate Bill 374, which will establish a state-regulated system of dispensaries. The law envisions up to 66 dispensaries across the state, with up to 40 in Las Vegas, 10 in Reno, and at least one in each county.

"We applaud Gov. Sandoval and the legislature for their leadership and commend those law enforcement organizations that expressed support for this much-needed legislation," said Karen O'Keefe, director of state policies for the Marijuana Policy Project, who testified in support of the bill. "It will make Nevada a safer and healthier place not only for medical marijuana patients, but for the entire community. This new law will provide patients with the safe and reliable access to medical marijuana that they deserve," O'Keefe said. "Regulating medical marijuana sales will also generate revenue and take a bite out of the state's underground marijuana market."

Introduced by Sens.Tick Segerblom (D-Las Vegas) and Mark Hutchison (R-Las Vegas), the bill creates rules and regulations not only for dispensaries, but also infused product manufacturers and cultivation and testing facilities. It also imposes 2% excise taxes on both wholesale and retail sales, with 75% of those revenues going to the education fund and 25% going to cover the cost of regulating the medical marijuana industry.

The state's voter-approved medical marijuana law, passed twice in 1998 and 2000, required the legislature to create a medical marijuana program that included appropriate methods of supplying medical marijuana to patients. Now, the legislature has finally done so. Nevada will now join Arizona, Colorado, Maine, New Jersey, New Mexico, and Rhode Island on the list of states that have state-regulated dispensaries. Two more jurisdictions, Washington, DC, and Vermont should come on board this summer, and the rule-making process for dispensaries is underway in Connecticut and Massachusetts.

On the harm reduction front, Sandoval signed into law Senate Bill 410, which decriminalizes the possession of syringes by removing them from the state's drug paraphernalia list. That opens the way for the over-the-counter sale of syringes and needle exchange programs.

"Back in 1996 when first elected, I was asked what bills I'd be pursuing for my first legislative session," said Sen. David Parks (D-Las Vegas).  "My response was employment non-discrimination, HIV/AIDS state funding and decriminalization of hypodermic devices. Little did I know it would be my 9th session before decriminalization of hypodermic devices would come to fruition."

Nevada becomes the 37th state to decriminalize syringe possession and allow for the over-the-counter sale of needles, as well as needle exchange programs, both proven means of reducing the transmission of HIV, viral hepatitis, and other blood-borne infections.

Nevada harm reduction workers said they were ready to get a needle exchange up and running as soon as the law takes effect.

"In addition to getting sterile syringe out to those who need them, our program will increase safe syringe disposal by individuals in the community," said Sharon Chamberlain, director of Northern Nevada HOPES in Reno. "We will educate these users about the new and needed community disposal options, and strongly encourage them to take advantage of this resource. Previously, no community initiatives provided safe disposal options. "

In a report released Tuesday, the New Jersey Department of Health and Senior Services has found that the state's needle exchange program has provided clean needles to nearly 10,000 drug users and gotten more than 2,000 of them into drug treatment. In the report, Health Commissioner Mary O'Dowd concluded that the program is a success and should be continued.

The goal of needle exchange programs is to reduce harm to injection drug users and the community at large by reducing the spread of blood-borne diseases, such as HIV/AIDS and Hepatitis C. According to the report, injection drug users accounted for nearly 40% of new HIV/AIDS cases in the state through 2010.

"Sterile syringe access programs (SAPs) which include drug treatment and behavioral interventions are one model proven to significantly prevent/reduce the transmission of these diseases," the report noted. "These programs have also been shown to facilitate enrollment of IDUs into drug rehabilitation programs."

New Jersey passed a pilot needle exchange law in 2006, and Atlantic City became the first in the state to implement a needle exchange the following year. Camden, Newark, and Paterson came on board in 2008, and Jersey City in 2009.

Those programs saw 9,912 people enrolled between November 2007 and November 2011. Nearly 300,000 clean needles were distributed, with more than 160,000 dirty ones collected. In 2010, the state began providing each program with a nurse, and since then 59 pregnant injection drug users have received prenatal care and drug treatment.

"We are totally thrilled and certainly very grateful to the commissioner for her support," said Roseanne Scotti, head of the Drug Policy Alliance New Jersey office, who faced off against lawmakers, law enforcement, and social conservatives to help push the bill through. "This is a culmination of a 20-year battle, when Senator Wynona Lipman introduced the bill back in 1992."

The XIX International AIDS Conference took place in Washington, DC, last week, bringing more than 20,000 scientists, activists, government officials, and journalists to assess the science and determine best practices for reducing the spread of the HIV virus. The US was able to host the conference for the first time in 22 years after it finally repealed a law denying people with HIV admission to the country.

But other critical groups remained excluded -- drug users and sex workers. Although they make up a majority of people living with HIV in many countries, people who admit to ever using drugs or engaging in prostitution within the past 10 years are inadmissible under US immigration laws. The State Department could have issued a blanker waiver of inadmissibility for people attending the conference, but declined to do so.

Drug users and sex workers who wanted to attend the conference were thus faced with a dilemma: Tell the truth and be barred or lie on the visa application, which in itself is a violation of US immigration law. As a result, representatives of some of the groups most affected -- and most likely to be affected in the future -- were unable to attend.

"People do not want to run the risk of attending the conference in a country where they are told they are not wanted or desired," said Allan Clear, the executive director of the Harm Reduction Coalition. "It sends the message that people who have a history of drug use or sex work are not actually included in the dialog at all, and is a serious setback in the fight against AIDS. I don't think the US government has any particular interest in actually involving sex workers or drug users in policy or programming."

The exclusion of drug users and sex workers hasn't gone down well with activists. As far back as two years ago at the Vienna AIDS conference, Indian activist Meena Seshu called for a boycott of AIDS 2012, pointing out that it was unethical three decades into the AIDS epidemic to discuss AIDS policy without including those most affected. Some have boycotted the conference, opting instead to attend a Kiev conference that began July 9 for drug users and people living with HIV from Eastern Europe. Sex workers and their allies followed with a side meeting in Kolkata this week. While those two events are officially considered "hubs" of the International AIDS Conference, many attended them as a means of protesting the exclusion of drug users and sex workers in Washington.

Unhappiness broke into the open in Washington Monday when dozens of drug user and sex workers activists disrupted the conference's opening press event. They leapt from their seats unexpectedly and marched through the room, waving banners and shouting slogans such as "No drug users? No sex workers? No International AIDS conference!"

Discontent with AIDS policies that marginalize drug users and sex workers escaped from the conference rooms and onto the streets again on Tuesday, as hundreds marched to the White House chanting "No More Drug War" in a rally timed to coincide with the conference. The march broadened the scope of protest, linking the battle against AIDS with the war on drugs and corporate domination of US political life.

On the way to the White House, protestors stopped at UPS and Wells Fargo facilities to chide those corporations for unhelpful practices. UPS took heat for donating to politicians who voted to restore the federal ban on needle exchange funding, and Wells Fargo for investing in private prisons.

"Wells Fargo is literally invested in locking more people up," said Laura Thomas of Drug Policy Alliance (DPA).

Activism around drug users and AIDS also took place in the conference's Global Village, including the installation of a model of Vancouver's Insite supervised injection site and tours of a local needle exchange outreach van courtesy of DC's Family and Medical Counseling Services. The Harm Reduction and Global Drug Policy Zone in the village also featured special events and presentations put on by groups including the Harm Reduction Coalition, Harm Reduction International, the Hungarian Civil Liberties Union, the Eurasian Harm Reduction Network, and the International Network of People Who Use Drugs.

Advocates also took advantage of the AIDS conference to unleash a campaign on the theme of "You Can't End AIDS Unless You End the Drug War." Articles to that effect appeared on Alternet and the Huffington Post (and were picked up elsewhere), while Global Commission on Drug Policy member Richard Branson penned a USA Today op-ed piece on how drug prohibition contributes to the spread of HIV. As part of the same campaign, Politico ran a full-page ad signed by Global Commission members and other notables, repeating the message and directly challenging both President Obama and Gov. Romney to "do the right thing." Giants in AIDS advocacy like Michael Kazatchkine and Stephen Lewis joined the calls in speeches given during the conference.

In an unexpected cap to things, former President Bill Clinton called for drug use to be treated as a public health issue, not a criminal justice one, in remarks at the closing plenary. Clinton cited The Huffington Post and Alternet op-eds, coauthored by the Drug Policy Alliance's Ethan Nadelmann and American Foundation for AIDS Research founder Matthilde Krim.

Activists demanding a larger role for drug users and sex workers in setting the policies that are supposed to help them fight AIDS came armed with powerful ammunition. Two recent reports clearly lay out how criminalizing drug use helps spread the disease and how many countries are failing to adequately deal with the spread of HIV among injection drug users.

The first report, from the Global Commission on Drug Policy, makes its findings clear in its title: "The War on Drugs and HIV/AIDS: How Criminalization of Drug Use Fuels the Global Pandemic." In the report, the commission noted that injection drug use now accounts for one-third of new HIV infections outside of sub-Saharan Africa, including some 354,000 people in the US.

"Throughout the world, research has consistently shown that repressive drug law enforcement practices force drug users away from public health services and into hidden environments where HIV risk becomes markedly elevated," the commission said. "Mass incarceration of nonviolent drug offenders also plays a major role in spreading the pandemic."

The commission also remarked on "the remarkable failure" of drug prohibition in reducing the global drug supply. The worldwide supply of illicit opiates, such as heroin, has increased almost four-fold in recent decades, the commissioners noted. They also noted the drug war's contribution to the growth of organized crime and violence.

The commission identified proven addiction treatment and evidence-based public health measures that countries should put in place to reduce the spread of HIV and protect community health and safety. They include needle exchange programs, safer injecting facilities, and prescription heroin programs.

"Failure to take these steps is criminal," the commission said.

In the second report, "The Global State of Harm Reduction 2012: Towards an Integrated Response," from the London-based Harm Reduction International (formerly the International Harm Reduction Association), researchers found that while injection drug use has been identified in 158 countries, only half of them have any programs aimed at preventing the spread of HIV among injectors, and the situation internationally is not improving. Even in countries that are addressing the problem, programs suffer from lack of funding and donor support is decreasing. That is undermining the global response to AIDS, the report concluded.

"In the last two years, we have seen a significant scale-down of services in countries with some of the highest HIV burdens among people who inject drugs," said Rick Lines, the group's executive director. "As tens of thousands gather in Washington this week to call for an end to AIDS, it is becoming increasingly clear that governments have neither the will nor the intention of ending the spread of HIV among people who use drugs."

"We have seen the number of needle exchange programs in Russia drop for 70 in 2010 to only six in 2012. This is made worse by a retreat of many bilateral and multilateral donors to funding effective harm reduction interventions in many countries," said Claudia Stoicescu, public health analyst at Harm Reduction International and author of the report. "Such developments significantly limit progress toward global commitments to halve HIV transmission related to unsafe injecting by 2015, let alone any hope of achieving universal access to HIV prevention, treatment, care and support for people who inject drugs."

"The reluctance of governments to fund an adequate response to HIV and injecting drug use stands in stark contrast to the seemingly limitless budgets for ineffective and punitive law enforcement responses," said Lines. "Governments care more about fighting a losing war on drugs than they do about winning the fight against HIV."

As the world enters its fourth decade of living -- and dying -- with HIV/AIDS, this week's conference and its barriers to participation by and concern for some of those most directly affected by the crisis -- drug users and sex workers -- demonstrate how far we still have to go. They also make achingly clear the destructive role that drug prohibition and the criminalization of marginalized populations play in perpetuating the epidemic.

Maybe next time the International AIDS Society will hold its conference someplace where drug users and other marginalized groups can attend and be heard. Or maybe the United States will alter its harsh visa requirements aimed at drug users and sex workers. Either one would be good. Ending drug prohibition, the stigma it generates, and the obstacles to fighting disease it engenders would be better.