A Publication from The Kaiser Forums; Sponsored by The Henry J. Kaiser Family Foundation
Edited by: Jeff Stryker, Center for AIDS Prevention Studies University of California-San Francisco; Mark Smith, M.D., M.B.A. -

A number of commonly available decontaminants have proved effective in killing HIV in vitro. Injection drug users are counseled to use household bleach to clean their works--to rinse the needle and syringe twice with full-strength bleach and twice with water to avoid injecting any traces of bleach. Outreach programs in many cities give drug users small, refillable vials of bleach and instructions on how to sterilize injection equipment, often supplemented by graphic illustrations or cartoons.18 Using bleach to disinfect injection equipment is a feature of many of the AIDS demonstration research projects sponsored by the National Institute on Drug Abuse.19 The degree to which bleach use under street conditions protects against infection is a matter of concern and study.20

Drawing the Battle Lines: The Claims for Needle Exchange

The primary controversy in the promotion of safer injection practices is this: Would promoting access to sterile needles and syringes interrupt the spread of AIDS, condone or encourage injection drug use, or perhaps do both? Should doctors and public health officials participate in--and should the government support--a program that appears to sanction injection drug use by promoting safer drug injection? Proponents of easier access believe that limitations on the distribution of sterile needles and syringes are cruelly misguided. They argue that several benefits are likely to result from easier access, namely:

* The use of sterile injection equipment would reduce the risk of the spread of HIV, hepatitis, and other diseases, even among users who fail to reduce the frequency of injection. * Needle and syringe exchange programs would be one way to bring injection drug users into drug treatment programs. * Needle exchange would be a bridge to general clinical care, including early intervention services for HIV infection. * Contact with a needle exchange program would be an opportunity to impart advice about adopting safer sexual practices.

Needle and syringe exchanges are not the only possible means of distribution. Pharmacies in some countries sell needles and syringes to drug users, in some cases giving a discount for equipment returned. They have the advantage of being open for long hours and, at least in urban areas, enjoy relative anonymity. A needle exchange program in Tacoma, Wash., operates out of a clinic pharmacy.

In at least thirty-eight states, over-the-counter sale of needles and syringes is permitted by law, but only a portion of pharmacists are willing to sell to customers who they believe are drug dependent. There aren't any guidelines or professional codes to inform pharmacists, whose discretion is highly variable.21

In St. Louis, Mo., which doesn't have a statute or ordinance prohibiting the sale of needles and syringes, two male graduate students--one black and one white--sought to purchase needles and syringes in local pharmacies. Fourteen of thirty-three drugstores refused to sell or they offered for sale a minimum number of needles and syringes so large as to be impractical. Stores refused to sell to the African American student more often than to the white student.22

Opponents of needle exchange, including some law enforcement, drug treatment, and church officials, have argued that easing access will undermine the "war on drugs," both symbolically and practically, by giving rise to new ranks of injection drug users.23 A program that is only partially effective in preventing the sharing of contaminated injection equipment could have the net effect of increasing AIDS deaths if it also boosts the number of injection drug users. Furthermore, opponents say, making sterile needles and syringes more readily available would not eliminate sharing. And they take issue with research findings that support needle exchange.24 They cite evidence that attributes needle sharing to a variety of cultural and psychological factors, in addition to convenience and economy.

Proponents of needle exchange also have encountered vigorous opposition from some black and Hispanic community and church leaders.25 In the wake of inner-city drug use follows crime and hopelessness for an entire generation. Despite widespread drug use among all sectors of society, drug use among the urban poor is more likely to be linked to violence. Drug dealing is more likely to occur in plain view, with the specter of involvement of the police and criminal justice system. Residents of neighborhoods blighted by drugs have expressed opposition to needle exchange programs because the programs appear to be at odds with the fight against drugs. The programs also have been viewed as a genocidal conspiracy. Harlon Dalton has eloquently voiced these concerns:

For us [African Americans], drug abuse is a curse far worse than you can imagine. Addicts prey on our neighborhoods, sell drugs to our children, steal our possessions, and rob us of hope. We despise them. We despise them because they hurt us and because they are us. They are a constant reminder of how close we all are to the edge. And "they" are "us" literally as well as figuratively; they are our sons and daughters, our sisters and brothers. Can we possibly cast out the demons without casting out ur own kin?26

Dalton explains the black community's skeptical view of proposals by the liberal public-health and HIV-prevention establishment to combat the spread of HIV through bleach and needle exchange programs. Addressing white America, he asks: Why can't we choose which of the many problems facing us to tackle first? Suppose we think that crack is more of a menace than AIDS. Are you willing to help us take on that one? Why do you want us to take all the risks? You say that making drug use safer (by giving away bleach or distributing clean needles) won't make it more attractive to our children or our neighbor's children? But what if you are wrong? What if as a result, we have even more addicts to contend with? Will you be around to help us then?26

These are some of the concerns on both sides of the issue. The debates have had an impact not only on whether needle exchanges get under way but also on how they operate. In some cases, needle exchanges have flourished, winning over community opposition. In other cases, attempts to fashion programs to overcome political opposition have yielded half-hearted and ineffectual efforts.

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