United States of Harm Reduction

In lieu of a “state of the union”, what follows is a review of the current states of harm reduction. The examples cited offer as many reasons for hope as causes for pessimism, but all reflect the resilience, creativity and growing sophistication of a robust and dedicated harm reduction community.

Needle exchange and community politics

Needle exchange programs grew rapidly across the country in the late ‘80s and early-to-mid ‘90s, but establishment of new programs has been relatively slow in recent years. Launching a new program legally requires a favorable political environment at the state level, and strong community support at the local level. Battles over needle exchange have been fought to a standstill at both state and local levels repeatedly, dampening momentum for needle exchange and stalling the creation of new programs.

Recent indications suggest that the tide is turning, as a number of new programs gained political support over the last year. In New York City, the AIDS Center of Queens County launched the Queens’ first needle exchange program last winter—the first new exchange program established in the city in nearly a decade. At least one other new program in Queens is expected to receive state approval this year, and a program in Brooklyn, After Hours, just obtained state authorization to conduct needle exchange.

Progress in New York City would not have been possible without the leadership of the city’s Mayor and Health Commissioner, the commitment by the state health department’s AIDS Institute in supporting and expediting new approvals, and the support of the local harm reduction community, which has organized and advocated for new programs and new funding. Harm reduction and needle exchange enjoy solid support from other parts of New York’s HIV/AIDS community, and the city is a center for much vital research into needle exchange, injection drug users, and HIV. The New York City experience indicates that gains and advances in needle exchange require strong collaborations between advocates, public health officials, researchers, and communities.

New Jersey also began taking steps to implement needle exchange, after former Governor James McGreevey signed an executive order last fall authorizing the state health department to establish programs in up to three cities. Only Atlantic City and Camden have applied to conduct needle exchange, having secured local political support to conduct needle exchange. Needle exchange remains controversial in New Jersey, and a group of state legislators have filed suit to strike down McGreevey’s executive order. At the same time, the current developments in needle exchange are long overdue; roughly half of New Jersey’s HIV/AIDS are linked to injection drug use, and New Jersey has the fifth highest adult HIV rate in the country.

The changes in New Jersey resulted largely from the community organizing and advocacy efforts of the Drug Policy Alliance (DPA), which established a coordinated grass-roots campaign around syringe access, needle exchange, and HIV prevention. Such campaigns are challenging and often too labor-intensive for most community-based organizations to take on alone in states and communities hostile to needle exchange and harm reduction. But the success of DPA’s efforts in New Jersey (and similar DPA projects in California and New Mexico) validate this strategy for change.

Similar political debates over starting needle exchange are being fought in the state legislatures of Texas and North Carolina and in the Massachusetts cities of Springfield and Westport. These battles can last for years, and final approval of needle exchange often comes with a range of burdensome requirements and constraints on hours and locations or on the number of needles that can be distributed to each exchange participant. As a result, many underground needle exchange programs operate without legal sanction—and typically with little or no funding—across the country.

Other states and municipalities restrict needle exchange operations to health departments, rather than community-based organizations. Health department-run programs tend to place more limitations on drug users—for instance, by enforcing a strict one-for-one exchange of new needles for used ones, and capping the number of needles that can be obtained at a visit. At the same time, these programs can potentially use other department resources to provide a range of health services and referrals to participants, though virtually all community-based programs offer similar services, depending on funding and capacity.

Funding

Beyond political opposition, the primary constraint on needle exchange programs has been funding. Federal funding—the major source of monies for HIV prevention—explicitly bans the use of federal dollars for needle exchange. As a result, programs have to cobble together resources from increasingly strapped city and state health budgets, foundations, and donations and other forms of fundraising. In many cases, larger programs have only been able to grow through securing HIV funds for related HIV services such as outreach and education, testing, and case management. But paradoxically, as such organizations grow by adding more programs, needle exchange becomes a smaller component of overall activities and resources.

With a few notable exceptions, private foundations have been reluctant to fund needle exchange programs, and available monies are inadequate to meet the shortfall in federal funding. One major funder has retreated from support for U.S. needle exchange programs in recent years, refocusing their grantmaking activities towards international programs and other domestic issues.

Until recently, corporate philanthropy has steered clear of needle exchange in favor of grants in less controversial or stigmatized areas. But last year, the Syringe Access Fund—a new partnership between the Levi Strauss Foundation, the Tides Foundation, and the National AIDS Fund—attempted to address this financial gap by awarding nearly $1 million to needle exchange and related advocacy in New York, New Jersey, Florida, Texas, California, and Washington, D.C. The current round of funding for 2005 is soliciting proposals from across the country with the support of additional partners, including the Elton John AIDS Foundation.

Meanwhile, activists are preparing for a long-term campaign to overturn the federal ban on needle exchange funding. Hopes for a quick victory were dashed when Senator John Kerry, who had pledged to end the ban, lost the 2004 presidential election. With a Republican administration and Congress firmly in place, nobody expects any immediate change, and many needle exchange advocates fear a potential backlash and would prioritize work on local issues.

However, a new wave of HIV organizing and community mobilization, crystallizing in the newly-formed Campaign to End AIDS (C2EA), has taken up federal funding for needle exchange as a key element in its platform. Ideally, a resurgence in activism would result in more needle exchange programs, as organizations become eligible for CDC funding. But most observers believe that meaningful progress on federal funding will take several years.

Syringes through pharmacies

Pharmacy sales of syringes have gained increasing prominence as an HIV prevention strategy in places with limited or no needle exchange. Even in areas with large, well-established needle exchange programs, pharmacy sale allows for much broader access to sterile syringes, particularly on evenings and weekends.

Despite the overall success of needle exchange in preventing HIV among injection drug users, advocates recognize that syringe access requires multiple strategies and a range of options—in Connecticut, needle sharing dropped by almost half since the state removed legal restrictions to pharmacy sales of syringes over a decade ago.

While pharmacy sale does not allow for the extent and quality of one-on-one education, counseling, and referrals provided through needle exchange, it substantially lowers barriers to access to clean needles. Ideally, clean needles would be available at low or no cost everywhere, all the time, for everyone.

Most states now allow for pharmacy sales of syringes, though availability and implementation vary. Syringe access through pharmacies has recently been implemented in New York, Illinois, and California.

In New York, researchers demonstrated a reduction in needle sharing since the implementation of the Expanded Syringe Access Demonstration Program (ESAP) in 2001 among drug users in Harlem and the Bronx, though needle sharing has not been eliminated.

The Chicago Sun-Times reported last fall on perceptions that few drug users are buying needles at pharmacies since a change in state law two years ago, likely due to lack of education about the availability of needles without prescription.

California—thanks again to efforts by the Drug Policy Alliance and allies in the HIV/AIDS community—passed a law enabling pharmacy sales of up to 10 needles without a prescription last fall, though Governor Schwarzenegger vetoed a companion bill to facilitate needle exchange in the state. Los Angeles, San Francisco, and Contra Costa County have already approved pharmacy sales, and other cities and counties are actively reviewing proposals.

Meanwhile, the Massachusetts state legislature is considering a bill to enable pharmacy sales of syringes, with broad support from public health and law enforcement, but faces opposition from Governor Mitt Romney.

Beyond HIV—other health needs

Needle exchange and harm reduction programs have begun to address a range of drug user health problems beyond HIV. Such programs have always tackled a range of health issues, especially treatment for drug addiction, and worked with hospitals, clinics, and medical schools to provide on-site, low-threshold medical services, including flu shots, tuberculosis screening, abscess and vein care, and hepatitis A and B vaccination.

But persistent barriers in access to medical care for drug users have led many programs to increase efforts to address persistent health needs among their participants.

Hepatitis C is primarily transmitted through blood—the majority of new cases occur among injection drug users. Hepatitis C is much easier to acquire through shared needles than HIV; as a result, the number of drug users infected with hepatitis C ranges from 50-90%. Relatively few drug users seek or receive medical care and treatment for hepatitis C, due in part to barriers to care and stigma, but also to a widespread perception that treatment is worse than the disease due to a range of physical and psychological side effects associated with interferon and ribavirin therapy.

Needle exchange programs and harm reduction advocates have responded to this epidemic by developing educational campaigns, promoting hepatitis A and B vaccination, and working with sympathetic doctors and liver specialists to help drug users living with hepatitis C to obtain medical care.

Harm reduction programs have turned to hepatitis C advocacy and policy in order to bring greater attention and resources to this problem. In many cases, harm reduction has become a central theme in hepatitis C planning and programs at state health departments; New Mexico has developed a viral hepatitis awareness campaign and includes goals for hepatitis C and needle exchange in its Statewide Comprehensive Health Plan.

New York City’s health department funds the Harm Reduction Coalition to provide technical assistance and support for needle exchange programs around implementing hepatitis C initiatives for drug users. Many HIV prevention programs have begun reassessing and retooling their efforts towards the prevention of hepatitis C, for which there is no vaccine.

Other new approaches to drug user health include campaigns and interventions to reduce overdose deaths. Naloxone (Narcan), a drug used by EMTs [emergency medical technicians] to revive people experiencing overdose from heroin or other opiates, is being prescribed and distributed to drug users in Chicago, New Mexico, San Francisco, and New York City as part of an education campaign targeting overdose that gives drug users the tools to revive each other.

The Chicago Recovery Alliance (CRA) has collected information from drug users educated and prescribed naloxone documenting hundreds of overdose reversals, paralleling a reduction in city statistics on overdose deaths since the start of CRA’s program. Similar results are reported in other cities where needle exchange programs institute overdose campaigns with naloxone.

Many programs are also educating drug users about buprenorphine (Suboxone), a maintenance therapy for opiate addiction. Buprenorphine can be prescribed on an out-patient basis by doctors, unlike methadone, which is tightly regulated and requires clinic visits. Buprenorphine has the potential to make maintenance therapy much more widely available and acceptable to heroin addicts, and has much less potential for abuse, when compared to methadone. But current federal law limits individual doctors and group medical practices—which potentially includes hospitals—to prescribing buprenorphine to only 30 patients, substantially undercutting the potential reach of this therapy. Many activists expect this limit on patients to be lifted this year, hopefully opening the door to broader adoption of this treatment option.

Altered states

The future of harm reduction in the United States will be shaped as much by the changing patterns of drug use—and the needs and voices of drug users themselves—as by the engagements and tensions between needle exchange and HIV advocates and conservative political forces. In many parts of the world, the U.S. is mistakenly perceived as a “backwater” of harm reduction, due to government policies and the war on drugs. But even under these conditions, needle exchange and harm reduction programs have managed to survive and flourish, and continue to develop innovative strategies to protect drug user health.

Daniel Raymond is Hepatitis C Policy Analyst for the Harm Reduction Coalition, in New York City.