News feature Pins and needles 

Despite failed legislation, a grassroots needle exchange tentatively launches in San Antonio

Last month, Senate Bill 127, legislation that would have made it legal in Texas to exchange a dirty hypodermic needle for a clean one, died on the Senate floor. While legislators who supported the bill are heartened that for the first time in 12 years it made it out of committee, a small group of San Antonio citizens is taking action. Although needle exchange remains illegal, the Bexar Area Harm Reduction Coalition plans to found a needle exchange program in Bexar County.

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According to the Center for Health Care Services, an estimated 15,000 injection illegal-drug users live in Bexar County. Twenty-nine percent of those users are infected with HIV, and 90 percent are infected with Hepatitis C. Last year, Bexar County recorded 505 new cases of HIV/AIDS, 60 of which are known to have come from injection drug use.

Most needle exchange programs provide a clean needle for every dirty one exchanged, safely disposing of the used needles and often offering other free health services. The argument against needle programs is similar to the one against comprehensive sex education: By giving out clean needles we encourage drug use. Yet studies by the Centers for Disease Control, the American Medical Association, and the National Institutes of Health contradict that conclusion. Needle exchange programs not only reduce by 30 percent the incidence of blood-borne diseases such as HIV/AIDS and Hepatitis C, but they also increase access to treatment and rehabilitation for drug users. Conversely, they have not been shown to encourage new drug use or increase the drug use among those already using.

Legislation failed, says Senator John Lindsay (R-Houston), who authored SB 127, because "`Opponents to the bill` put their blinders on and don't pay attention to the facts. They think it's a litmus test of their conservatism. I'm as conservative as the next guy, but I'm a realist - this is good preventative medicine."

According to a CDC report, the lifetime cost of treating an adult infected with HIV is estimated to be $96,000. Drug therapies for the disease can total an additional $10,000 per patient per year. In contrast, the CDC estimates the cost of syringes and bleach kits per injection user per year to be $1,800. Because in many cases the health-care costs of HIV/AIDS are borne by Medicaid or similar tax-funded health-care programs, needle exchange has the potential to save taxpayers millions of dollars.

Yet, U.S. law prohibits federal funding of any program distributing sterile needles for injection drug use, and only Washington, Maryland, Connecticut, Hawaii, California, and New Mexico have legalized needle exchange programs.

For the last nine years, Curt Harrell, a retired blood-bank director, has worked as the co-chair of the HIV Prevention Community Planning Group for South Texas. A federally mandated national program, its local volunteers work with the Texas State Department of Health Services to determine the number of people infected with AIDS/HIV, conduct a needs-assessment survey, and recommend the appropriate interventions. The group publishes a report every six years.

In 1998 and 2003, "syringe exchange program" topped the list for nearly every at-risk group as the Planning Group's recommended intervention. Yet, the Department of Health, says Harrell, funded a different set of interventions that did not include syringe exchange.

"That was very frustrating," he says. "We lost the support of everyone in the Valley and had to recruit all new people; it's hard to recruit when the work is ignored."

In the midst of this debacle, Harrell met Bill Day, a semi-retired commercial real-estate broker, who, two years ago was planning to start a volunteer-based needle exchange. He wanted a letter of support from the Planning Group. Instead, Harrell joined the needle exchange.

Today Harrell and Day serve as president and vice president of the coalition's 12-member board, composed of health officials, professionals, and community volunteers that helped write its by-laws and is working on funding. The coalition is registered with the county and state, and is establishing tax-exempt status, the first step in securing private funding. Harrell believes the coalition can launch a needle exchange program in San Antonio for $80,000 a year. "At that rate, if we prevent only one injection drug user from becoming infected, we are ahead," says Harrell. The group's goals are strongly directed at the non-fiscal benefits, the protection of not only drug users, but a wider community base, including partners of drug users, women, and children.

By giving used syringes an exchange value, the program can reduce the number of dirty needles found in the parks, streets, and other public areas where they might endanger children, law enforcement officials, and others who are accidentally punctured by them.

The coalition models itself after the 220 illegal and legal programs that already exist in the U.S. The Seattle & King County Public Health Department started its needle exchange, one of the first in the country, in 1989. A state, city, and county-funded program, it distributes 2.2 million needles annually - one clean for one dirty - from vans that cover seven sites around the city. The program includes a downtown clinic where injection drug users receive screening for HIV/AIDS, hepatitis, and tuberculosis, as well as overdose response and prevention, tips on avoiding abscesses, and drug-treatment counseling.

Michael Hanrahan, director of HIV/AIDS Program Administration with the King County Health Department, says the program has stabilized the rate of HIV infections in this population to 2 percent for the last 15 years; states that don't have needle exchange show rates 5 to 20 times higher. This year, the budget for the program is set at $900,000. "If we prevent only five infections we will have offset the cost of medical care," Hanrahan says. Last year, Seattle reported only one case of mother-to-fetus HIV transmission.

A Washington State Department of Health suggests that 72 percent of those surveyed in King County support needle exchange. "The rub is in the neighborhoods where the program is located," says, Hanrahan. "Most people understand the goals of the program, but there is a NIMBY-ism issue. The challenge is to structure the program so that it can be a good community neighbor and partner."

But, Hanrahan adds, "community buy-in is great, but you can do it without it. Public health issues aren't solved in a vacuum: The public will bear the cost of indigent medical care one way or the other, either directly through medical care or indirectly through higher health-care rates."

In San Antonio, community support for a needle exchange is mixed. Although unavailable for comment, Bexar County Sheriff Ralph Lopez faxed a non-committal but supportive statement, saying, "Law enforcement must acknowledge that an effective needle exchange program is the most viable way to prevent disease ... persons suffering from a disease or addiction should be provided medical and psychological counseling instead of automatic incarceration."

Roy Reyes, supervisor of the HIV/AIDS intervention program at Metro Health Department, says he believes the rise in incidence of HIV/AIDS and Hepatitis C underscores "a public-health need for needle exchange programs that overrides the illegality."

Yet, he emphasized that he spoke for himself, not the organization.

George Perez, co-chair of the HIV Prevention Community Planning Group in Bexar County and a health department employee, says policy makers refuse to publicly endorse needle exchange programs because they are too removed from the affected population. "If it were their family it would be a different story," he says, but there are also issues of responsibility. "If we support needle exchange, then we have to build a net to catch the people we discover are infected," Perez says. "In the political waters we tread, no one is going to say they support needle exchange, it's a moral issue."

Harrell is cagey about when the Bexar Area Harm Prevention Coalition will launch its needle exchange program because of the legal risk.

Day says the population the coalition will serve is not the homeless, but the working poor and, to a lesser extent, the middle class. In all cases, it will take the program time to establish credibility. "These folks are very skeptical of everyone - everything they do is illegal," he explains. "They have to be able to trust that there won't be challenges to their lifestyle or risk of getting busted when they come to exchange their dirty needles."

That will not be their only challenge. Six years ago, a grassroots needle exchange program called Street Works Connection launched in San Antonio. Like the coalition, it had non-profit status and a board of directors, and the support of local progressive policy makers, including San Antonio State Senator Letitia Van de Putte, a former pharmacist, who this year co-authored SB 127. Street Works had also partnered with a local pharmacist that agreed to accept vouchers for clean needles.

After two years, the program was ready to grow, but ran into issues: The local pharmacy couldn't handle the volume, and no national pharmacy would join the program, and, again because of the legal risk, it was hard to find volunteers willing to distribute the needles. When its most active volunteer bowed out, the program folded.

The coalition has trained two community health-care workers to distribute needles, and has a small stockpile of syringes and condoms for them to hand out. They will also provide information about social services.

Although Harrell doesn't believe finding volunteers will be difficult, he admits that "most of the board members are skittish about volunteering, and rightfully so. Some of them are attorneys and nurses who would lose their operating license if they were arrested. But Bill and I are not under any restrictions."

By Susan Pagani


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