The 1988 San Francisco’s Needle Exchange Program
The 1988 San Francisco’s Needle Exchange Program
The United States has struggled to combat the drug abuse epidemic for a long time through a combination of policy deterrents and over addict-focused approaches. Criminalization of illicit drug use, along with drug abuse paraphernalia, has not yielded the desired results as the opioid crisis persists to date. Moreover, although methadone therapy has been effective in treating drug dependence, it does not address diseases such as hepatitis C and HIV/AIDS, which are transmitted by sharing of contaminated needles during intravenous drug use. However, needle exchange programs or syringe exchange programs have emerged to address these challenges and combat the spread of drug-related viral infections. If a needle exchange program such as the one in San Francisco is implemented universally in the United States, it can stop the spread of HIV/AIDS among people who inject drugs. The effectiveness of needle exchange programs and their unintended consequences are discussed while referring to the 1988 San Francisco’s Needle Exchange Program.
The Needle Exchange Program was mooted in San Francisco in 1988 following the spread of HIV/AIDS among intravenous drug users in the 1980s. Moreover, methadone as an addiction medication approach did not contain the HIV/AIDS epidemic that was spreading rapidly in San Francisco at the time. Besides, the possession of needles without a prescription remained illegal across all government levels under the Controlled Substances Act of 1970 (San Francisco AIDS Foundation, 2020). This forced many injectable drug users to access and share needles in hiding, exacerbating their health wellbeing. The situation was worsened by the large number of Vietnam veterans who had returned with a drug habit. In 1988, volunteers in San Francisco established Prevention Point, which introduced needle exchange as a practical countermeasure to the criminalization of drug use and paraphernalia (San Francisco AIDS Foundation, 2020). Despite having operated underground for four years, the needle exchange program gained acceptance after it evidenced the link between HIV/AIDS and access to syringes. It was integrated into San Francisco AIDS Foundation in the 90s and is administered on a need-based needle access modality (San Francisco AIDS Foundation, 2020). Therefore, the persistence of Prevention Point in circumstances that judged its activities as illegal paid off when demonstrable benefits emerged from their data. Today, the needle exchange program is categorized as a harm reduction initiative, which is a public health philosophy, commonly used to the harmful effects of substance abuse rather than eliminating addictive behavior. The program recognizes that abstinence is not feasible for drug addicts and therefore accepts a continued level of drug use while focusing on reducing morbidity and mortality instead (Leslie, 2008). In this regard, the needle exchange program recognizes the deadly link between the injection of drugs such as heroin, opioids and crystal meth and the spread of viral infections such as HIV, Hepatitis B and Hepatitis C (Leslie, 2008).
Initially, Prevention Point provided injectable drug users with 10 new syringes and replaced every syringe returned. By early 1990, accessibility was increased to 20 syringes, and by August of that year, the syringe limit was lifted and users could access any number of syringes based on their needs (San Francisco AIDS Foundation, 2020). The Needle Exchange Program gained political recognition in 1993 when Frank Jordan, San Francisco’s mayor at the time, pledged $138,000. In 2005, California enacted a policy change that allowed the purchase of syringes without a prescription under the Disease Prevention Demonstration Project in the legislation SB1159 (Riley, 2010). However, the legislation required that pharmacies register to sell syringes over the counter. Glide Memorial Church, which is an advocate of the civil rights movement, enlisted is support by supplying needles to the Tenderloin neighborhood that was leading in injectable drug use and homelessness in downtown San Francisco (Riley, 2010). This roped in non-profit organizations to help fund the program because public funds were not forthcoming, particularly for the purchase of syringes for drug addicts. Therefore, Prevention Point initiated a social movement that morphed into a cross-cultural phenomenon, which has been replicated in other drug-ridden cities in the United States. As of 2018, San Francisco had 13 sites for accessing and disposing of needles and syringes available to drug users and was distributing about 400,000 syringes monthly (Associated Press, 2018). With the city was receiving over 9,000 requests for new syringes and needles per year, it was evident that the needles exchange program had been embraced by the intravenous drug users in the city (Associated Press, 2018). Increasing evidence about their efficacy has caused the needle exchange programs to spread across the country, although resistance against public funding and decriminalization of injectable drug use prevails. By 2015, there were close to 200 needle exchange programs across 33 states in the United States. In addition, policymakers and politicians were increasingly supporting this approach, as demonstrated by their endorsement by the Emergency Plan for AIDS Relief Blue Print by the President in 2012 and the National HIV/AIDS strategy in 2015 (Frakt, 2016).
Needle exchange programs deliver numerous benefits, including the lowering of the number of contaminated needles in the community. Intravenous drug users have access to sufficient needles while returning the used ones to the program administrators for safe disposal, which mops up used syringes in the community. The removal of contaminated syringes from public circulation reduced the spread of infections such as Hepatitis B (HBV), Hepatitis C (HCV) and human immunodeficiency virus (HIV) (Frakt, 2016). Similarly, Martinez, Lorvick and Kral (2014) revealed that syringe exchange program sites in San Francisco provided safe disposal of used syringes and were used by injecting drug users more than pharmacies. However, pharmacies complemented needle exchange programs by providing additional sites for needle access and disposal.
The drug users are referred to drug treatment services from where they can be tested and diagnosed for hepatitis B and C and HIV/AIDS, enabling early and timely disease management. In this regard, the needle exchange programs served as entry points into drug-related medical and social services that would rehabilitate them from their addictive habits (Elkins, 2017). Takácsa and Demetrovics (2009) demonstrated the efficacy of needle exchange programs in reducing the spread of HIV/AIDS among intravenous drug users in a study that reviewed existing literature. They viewed these programs as vital prevention and harm reduction interventions that could address the HIV scourge when directed by the needs and sociocultural circumstances of the targeted populations. This not only reduces the prevalence of new infections but also raises awareness about the dangers of drug behavior. Moreover, the needle exchange programs have redefined the relationship between city administrators and drug users, making it possible to enlist and interact with the hard-to-reach drug-ravaged populations (Elkins, 2017). In this regard, needle exchange programs provided a channel for reaching communities that were afflicted by drugs and HIV/AIDS that would have been otherwise difficult to reach (Frakt, 2016). As such, these programs helped address the bigger public health concerns that were afflicting entire communities rather than individuals only.
Consequently, increased communication with the targeted people has increased access to education, which has reduced drug-related and sexual-risk behaviors among drug users. For instance, between 1987 and 1992, needle sharing in San Francisco fell from 66% to 36% due to participation in Prevention Point (San Francisco AIDS Foundation, 2020). Moreover, new HIV infections halved from a peak of 212 incidences in 1992 to roughly 100 in 1998 (San Francisco AIDS Foundation, 2020). Williams and Metzger (2010) demonstrated that the behavior of injection drug users (IDUs) was dependent on geographic and socioeconomic variables such as racial clusters and economic endowment in neighborhoods. Injection-related HIV risk was higher for drug users who used public spaces like vacant properties and parks because of the likelihood to engage in risky behaviors in such settings. Such public places lacked access to unused needles, and clean water and bleach for rinsing. Also, people in affluent neighborhoods were less likely to inject drugs in public places. As such, unhygienic sharing of needles was more likely to occur in public places than in the privacy of homes. Another study reported by Williams and Metzger (2010) revealed that African Americans has a higher HIV incident rate and prevalence compared to white Americans despite engaging in less risky behavior. This is because African Americans tended to live and operate in neighborhoods with higher HIV prevalence than those of their white counterparts. Therefore, targeting at-risk populations that injected drugs in public places or engaged in risky behavior reduced the risk of transmitting HIV by needle sharing (Williams and Metzger, 2010).
The needle exchange programs were more cost-effective compared to the lifetime treatment of hepatitis B or C or HIV/AIDS. For instance, 1 dollar used in needle exchange programs saved at 6 dollars needed for HIV treatment (Frakt, 2016). The proponent use the financial statistics to urge the government for support because of the benefits in reducing the taxpayers burden in healthcare.
However, the needle exchange programs have suffered various setbacks because of their unintended consequences. Contaminated needles are prevalent in the streets because users do not always return them to the program administrators (Elkins, 2017). Access to new syringes is no longer pegged on returning the used ones, which served as an incentive for their proper disposal through the program channels. Associated Press (2018) reported that the parks and streets of San Francisco were polluted visibly with discarded syringes despite the city having 13 syringe return sites. The compactness of the city, which covered 12,950 square hectares, high level of homelessness and the increase in heroin use worsened and made the problem visible. The city’s mayor in 2018 had hired 10 people to collect the disposed syringes, indicating that the needle exchange program was unable to avoid the accumulation of needle litter (Associated Press, 2018). This conforms to the findings of Wenger (2011), which indicated that 13% of used needles and syringes were disposed improperly by injection drug users in San Francisco.
The programs have also been associated with high infection rates among participants (Elkins, 2017). This was true especially among African Americans who resided and operated in areas with high HIV prevalence and where needle-sharing was a normal practice of preventing suspicion and displaying trust (Williams & Metzger, 2010). Moreover, in neighborhoods dominated by African and Latino Americans, needle sharing prevailed despite the easy access of sterile syringes because these groups tended to source them from non-syringe exchange program sites to avoid publicizing their drug behavior (Williams & Metzger, 2010).
The programs are perceived negatively by those who feel that promoting needle exchanges using public funds normalizes the drug problem by supporting drug use. Indeed, some counties in California continued to criminalize the possession and distribution of syringes while many programs lacked public funding, therefore relying on the meagre resources from private donors. Moreover some studies indicated that although mobility and homelessness of the injecting drug users was associated with needle sharing, in San Francisco, the presence of syringe exchange program sites did not guarantee their utilization by drug addicts (Martinez, Lorvick & Kral, 2014). Such contradicting research findings were used by opponents of the needle exchange programs to discourage free access to sterile syringes and needles to drug users.
The needle exchange programs are not accessible equally in all locations where injectable drug users are found because most of them are administer in cities and especially in neighborhoods with known high prevalence of drug use. This leaves out rural areas where drug users exist, albeit in few numbers (Elkins, 2017). Martinez, Lorvick and Kral (2014) revealed that the syringe exchange programs were concentrated in downtown San Francisco where commercial activity and population density were high while the affluent areas were underserved.
Locations for needle exchanges are prone to crime because they bring together many hard-drug users (Elkins, 2017). The high concentration of injectable drug users at needle exchange program collection and disposal sites presents a high possibility of violent conflict among the injecting drug users who are usually under the influence of drugs and easily irritable. The fear of exposure and contact with law enforcement causes the drug users to be apprehensive when collecting or disposing syringes at the program centers, particularly when they meet strangers.
Altogether, the disadvantages of the needle exchange programs were associated with the injection of drugs in public places, the avoidance of needle collection sites by certain members of the community and the inaccessibility of the programs in some locations. These promoted risky behavior among drug injectors exposing them to HIV infections.
In conclusion, needle exchange programs have reduced the spread of HIV/AIDS among intravenous drug users. These programs provide for the safe disposal of used syringes, thus removing them from the community and reducing the chances for their reuse. As such, the chances of contracting HIV/AIDS from a used or shared syringe are minimized, thus combating cross-contamination among drug users. However, improper disposal of used syringes persists because of the lack of punitive measures and inefficient syringe collection mechanisms. Since access to new syringes is no longer pegged on the one-on-one exchange of used ones, there is no incentive to deliver used syringes to the program administrators. Nonetheless, the benefits of needle exchanges outweigh the detriments in combating HIV/AIDS as well as injectable drug use. The misconceptions and myths surrounding these programs alongside inconclusive and negative findings from research prevent the adoption of the needles exchange approach in many communities and its universal application in the country.
Associated Press (2018). San Francisco’s streets are littered with free syringes. New York Post. Retrieved from https://nypost.com/2018/05/11/san-franciscos-streets-are-littered-with-free-syringes/.
Elkins, C. (2017). Benefits and risks of needle exchange programs. DrugRehab. Retrieve from https://www.drugrehab.com/2017/11/06/pros-and-cons-of-needle-exchange-programs/.
Frakt, A. (2016). Politics are tricky but science is clear: Needle exchanges work. The New York Times. Retrieved from https://www.nytimes.com/2016/09/05/upshot/politics-are-tricky-but-science-is-clear-needle-exchanges-work.html.
Leslie, K. M. (2008). Harm reduction: An approach to reducing risky health behaviours in adolescents. Paediatrics & Child Health, 13(1), 53-56.
Martinez, A. N., Lorvick, J., & Kral, A. H. (2014). Activity spaces among injection drug users in San Francisco. International Journal of Drug Policy, 25(3), 516-524.
Riley, E. D., Kral, A. H., Stopka, T. J., Garfein, R. S., Reuckhaus, P., & Bluthenthal, R. N. (2010). Access to sterile syringes through San Francisco pharmacies and the association with HIV risk behavior among injection drug users. Journal of Urban Health, 87(4), 534-542.
San Francisco AIDS Foundation (2020). History of health: Needle exchange in San Francisco. Retrieved from https://www.sfaf.org/resource-library/needle-exchange-in-san-francisco/.
Takács, I. G., & Demetrovics, Z. (2009). The efficacy of needle exchange programs in the prevention of HIV and hepatitis infection among injecting drug users. Psychiatria Hungarica: A Magyar Pszichiatriai Tarsasag tudomanyos folyoirata, 24(4), 264-281.
Tookes, H. E., Kral, A. H., Wenger, L. D., Cardenas, G. A., Martinez, A. N., Sherman, R. L., … & Metsch, L. R. (2012). A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug and Alcohol Dependence, 123(1-3), 255-259.
Wenger, L. D., Martinez, A. N., Carpenter, L., Geckeler, D., Colfax, G., & Kral, A. H. (2011). Syringe disposal among injection drug users in San Francisco. American Journal of Public Health, 101(3), 484-486.
Williams, C. T., & Metzger, D. S. (2010). Race and distance effects on regular syringe exchange program use and injection risks: a geo-behavioral analysis. American Journal of Public Health, 100(6), 1068-1074.