Information in this appendix is from two sources. The first section briefly describes a report published in 1993 on the public health impact of needle exchange programs (NEPs) in the United States and abroad. Information on ordering the report is provided. The second section presents material from a 1993 proposal to develop the San Francisco Needle Exchange Program. The proposal describes a three-phase program for implementing street-based outreach activities targeted to injection drug users who are not in treatment and those in treatment who are experiencing relapse.
A needle exchange program (NEP) has been defined as "a facility where drug injectors can obtain sterile needles and syringes and return used injecting equipment" (Donoghoe et al., 1992). NEPs seek to reduce the harm associated with injection drug use and particularly with the sharing of injection equipment, acknowledging that many injection drug users (IDUs) continue to engage in these practices. Proponents of NEPs have argued that they could decrease the transmission of HIV by increasing the probability that IDUs use uninfected syringes, produce reductions in HIV risk behaviors, and refer IDUs to drug treatment or other public health services. Opponents have countered that NEPs condone drug use and increase drug use in the community.
In 1992, the U.S. Centers for Disease Control and Prevention sponsored an evaluation of the public health impact of NEPs in the United States and abroad. The evaluation was carried out by a multidisciplinary team of investigators at the University of California, Berkeley, and the University of California, San Francisco. The research team submitted its final two-volume report in October 1993 (Lurie et al., 1993). The following is a summary of the report's conclusions.
As of September 1, 1993, there were at least 37 NEPs operating in 30 U.S. cities. U.S. NEPs distributed more than 2.4 million syringes in 1992. All U.S. NEPs also provide condoms to clients and most distribute bleach for syringe infection, as well as health pamphlets and alcohol wipes. Most U.S. NEPs selectively refer clients for drug treatment. At least 794 NEP clients have entered drug treatment in five cities.
The median annual budget of U.S. and Canadian NEPs studied was $169,000, a sum that would support about 60 methadone maintenance slots for a year. NEPs generally reach IDUs with long histories of injection drug use who remain at significant risk for HIV infection. While some NEPs appear to have reached large proportions of the local IDU population at least once, others are reaching only a small fraction of local IDUs.
Although quantitative data are difficult to obtain, those available provide no evidence that NEPs increase the amount of drug use by NEP clients or change overall community levels of drug use. NEPs in the United States have not been shown to increase the total number of discarded syringes and can be expected to result in fewer discarded syringes. The majority of studies of NEP clients demonstrate decreased rates of HIV drug risk behavior, but not decreased rates of HIV sex risk behavior.
Studies of the effects of NEPs on injection-related infectious diseases other than HIV provide limited evidence that NEPs are associated with reductions in subcutaneous abscesses and hepatitis B among IDUs. Studies of the effect of NEPs on HIV infection rates do not and probably cannot provide clear evidence that NEPs decrease HIV infection rates, due in part to the need for large sample sizes and the multiple impediments to randomization. However, NEPs do not appear to be associated with increased rates of HIV infection. Mathematical models suggest that NEPs can prevent a significant number of infections among clients, clients' drug and sex partners, and clients' children. In almost all cases, the cost per HIV infection averted is far below the $119,000 lifetime cost of treating an HIV-infected person.1
The plan for a needle exchange program in San Francisco is contingent upon the need for an expanded vision, which would include treatment availability as well as the exchange of needles. Increased access to drug treatment programs is the foundation of a fully effective program to break the link between HIV infection and drug use. A number of recent awards have increased the capacity for substance abuse treatment for IDUs (CARE, Waiting List Reduction Grant, Waiting Period Reduction Grant, Critical Population Grant, and others). Although the number of drug treatment programs and treatment slots have been enhanced in recent years, waiting lists still exist and surveys still show many IDUs that are not enrolled in any type of treatment. Moreover, recent behavioral surveys indicate widespread use of illicit drugs and alcohol use that continues to be correlated with the spread of other sexually transmitted diseases.
Currently, the Business and Professions Code, Article 5.5 Hypodermics, section 4140, states, "No person shall furnish hypodermic needles or syringes, by sale or otherwise, without a permit issued by the board, except as otherwise provided by this article."
Health and Safety Code, section 11014.5, defines drug paraphernalia and section 11364.7 makes it a misdemeanor for any person ". . . to possess with intent to deliver, furnish or transfer . . . drug paraphernalia . . . used to inject the human body with a controlled substance."
Numerous exchange sites will be available. Street-based outreach workers will exchange needles and related paraphernalia. Street-based outreach services are the first priority and most effective way to implement a needle exchange program. Outreach workers will not work in isolation but will consist of teams. Phase I can be implemented immediately.
A "storefront" or stationary site will be utilized to distribute needles and related materials. The stationary site will also be utilized for support groups; referrals; and medical, substance abuse, or psychiatric interventions. The stationary site offers more privacy than street outreach efforts, and some clients may prefer the storefront site for referrals, counseling, interventions, etc. The stationary site will also be utilized to store the items and host community meetings and client activities. The stationary site will not be housed in a substance abuse treatment program. Phase II can be implemented within 3 to 4 months after approval of the program.
A van will be utilized for the NEP. The van will work in conjunction with the storefront and the street outreach efforts and will be used to provide all services of the needle exchange program. The van can also accommodate special requests (for instance, a rock concert). The van will provide backup to the outreach teams, can be utilized for emergencies (i.e., driving a client to a hospital), and will target high-risk neighborhoods. Phase III can be implemented within 4 months after approval of the program.
Community preference, values, and acceptance will be considered before the assignment of Phase I, Phase II, or Phase III activities. A variety of strategies will be used to announce the schedules of the team or van (i.e., cards, 24-hour recording, and posters).
Outreach will be conducted by interdisciplinary teams that will include individuals trained in areas such as substance abuse, HIV disease, community referrals, HIV testing, primary healthcare, and crisis intervention. Teams will include at least three workers, and they will concentrate their efforts in areas populated by IDUs such as the Tenderloin, the Western Addition, Bayview Hunter's Point, and the Mission. The teams will have a regular roving schedule that will be communicated by brochures, posters, word-of-mouth, and linkages with community-based organizations in high-risk areas. Determination of the initial target areas will be based on substance abuse data, community support, and the latest seroprevalence information.
It is anticipated that the San Francisco Needle Exchange Program will be able to attract clients in substantial numbers and will reach individuals often unreached by other services. Special outreach strategies will be developed to attract women, gays, young injectors, new injectors, racial/ethnic minorities, and other high-risk groups.
Coded needles will be provided to addicts on a one-for-one exchange basis. In addition, other items will be provided such as cotton balls, bandages, antiseptic solutions, etc. New, sterile needles and syringes will be provided. Syringes and needles will be provided in a puncture-proof container. An I.D. marker system may be developed.
The team will be skilled in the areas of substance abuse assessment and referral. The encounter may be brief until a trusting relationship has been established. Some encounters may last just minutes; others may last 45 minutes or more, depending upon the receptivity and needs of the client. The NEP is part of a comprehensive program to reduce HIV infection among IDUs in San Francisco. While the needle exchange program has the simple, straightforward mission to distribute clean needles and supplies to IDUs, the encounter is a unique opportunity to serve as a bridge to alcohol and drug treatment, primary healthcare, TB/STD services, mental healthcare, HIV programs, and other community services. Services will be provided free of charge.
Other items may be distributed, such as condoms, dental dams, safe-sex products, AIDS education material, resource information, coupons indicating priority status for alcohol and drug treatment, safe-sex guidelines, bleach, sterile water, clean cotton and needle use, and harm reduction and needle hygiene information.
The San Francisco Needle Exchange Task Force suggested eleven possible locations -- the Tenderloin, the Mission, Bayview Hunter's Point, the Western Addition, Polk, Haight, Outer Mission, South of Market/6th Street, South of Market/Ballpark, Visitation Valley, and Oceanview.
Prevention Point currently targets the Tenderloin, the Mission, Civic Center, and South of Market.
At the point of implementation, the target sites will be selected based upon the most recent information regarding high-risk neighborhoods, community input, and coordination with Prevention Point.
The target populations are IDUs not in treatment, IDUs on waiting lists for treatment, and IDUs experiencing relapse (may be currently enrolled in treatment). Specialized outreach, recruitment, referral, and supportive services will be provided to IDUs who are young injectors, racial/ethnic minorities, new injectors, women, and the homeless.
Services will be provided to IDUs. The IDUs will need a needle to exchange. Needles will be exchanged on a one-for-one basis. The participants may be offered other services such as referral. However, they will not be required to participate in other services in order to receive needles.
Participation in research (if applicable) or evaluation activities will be voluntary.
It is anticipated that the NEP will become a bridge to substance abuse treatment for a number of addicts. The interactions between staff of the San Francisco NEP and the clients will often result in referrals to alcohol and drug abuse treatment, HIV counseling and testing, and primary care sites. Early intervention for HIV through counseling and testing programs and alcohol and drug abuse treatment programs is the most effective way to reduce the potential for infection (or the spread of infection). The intervention of the NEP involves elements of reducing HIV transmission by decreasing the number of injections that involve contaminated equipment and actively linking drug injectors to HIV and drug treatment services.
Accessing the publicly funded alcohol and drug treatment system can be confusing. Available slots change on a day-to-day basis. The team will work closely with the staff of Community Substance Abuse Services (CSAS) in terms of referrals, placement, priority admissions, and identification of available slots. Clients will receive coupons that indicate a priority status in the publicly funded substance abuse system. Clients who do not wish treatment may continue to receive needles. An additional attempt to recruit them into treatment may occur at a later date. Because addiction is a chronic relapsing disorder, there will be no limit as to the number of times an individual may utilize the program.
The team will also work with the network of HIV and primary care providers. They will triage and assess the needs of the client and provide an effective link to the appropriate level of care, be it HIV anonymous or confidential testing or primary healthcare services.
Most of the programs in San Francisco have a waiting list for treatment. Because of the new management information system, CSAS will have the capability of identifying available slots in all modalities in any given week. CSAS will assign a staff person to the NEP and this assignment will help with referrals into substance abuse treatment and referrals between modalities (i.e., from outpatient to residential care). This person will assist prioritized clients entering substance abuse treatment (pregnant addicts, adolescents, IDUs, and HIV-infected individuals).
Referrals will be provided to drug and alcohol programs, HIV testing sites, primary healthcare programs, STD clinics, youth programs, TB programs, etc. It is important that referral information be written in simple, easy-to-understand language. Incoming referrals will be accepted from multiple sources such as individual requests, community-based organizations, police, and treatment/prevention programs.
It is an anticipated outcome that some individuals, no matter how much outreach and intervention is directed toward then, will never enroll in a drug treatment program. In a New York City pilot program for needle exchange, 57 percent of people targeted entered a substance abuse treatment program. Because the rate of transmission of the HIV virus, especially within the IDU population, continues to increase exponentially, the fact that there will be unsuccessful interventions should not hinder the implementation of this program. Denial is always present in individuals with substance abuse problems and often complicates the referral and intervention process.
Young IDUs and new injectors. Because of their risk of HIV infection, young IDUs will be served by the program, as will be new injectors of any age. The teams will need specialized training and skills in regard to youth services in areas that are frequented by young IDUs, and specialized referrals will be provided to youth and young adult services.
Women. Women and pregnant women may be served by this program. Women need these services for the same reasons male IDUs need services. The perinatal transmission of the virus is a concern. The teams will include women and will cover the areas of San Francisco frequented by female IDUs. The teams will provide specialized interventions and referrals for women and pregnant women. Pregnant women are a priority admission in the publicly funded substance abuse treatment system.
Training will be provided for the outreach teams and will include information on AIDS prevention, needle hygiene, team building, safety precautions, stress management, and support options. This training will be extensive Racial/ethnic minorities. Outreach teams will be multicultural and sensitive to the needs of racial/ethnic IDUs. Specialized referrals will be provided that are respectful of cultural values.
Gay IDUs. Outreach will be provided to gay IDUs. The teams will provide services in areas requested by gay IDUs. Specialized referrals will be provided when an IDU prefers a gay-sensitive organization. The outreach teams will include individuals who are heterosexual, homosexual, or bisexual.
Homeless. Outreach will be provided to homeless IDUs. The teams will provide services in areas that are commonly utilized by the homeless. Outreach teams will be familiar with a range of referrals, including shelter, food, and entitlement programs.
Training will be provided for the outreach teams and will include information on AIDS prevention, needle hygiene, team building, safety precautions, stress management, and support options. This training will be extensive before the delivery of service, then ongoing throughout the course of employment with the needle exchange effort. Team members will also receive training on referral options to primary medical care, legal services, HIV services, housing, drug and alcohol treatment, and social services. Topics will include AIDS education, HIV counseling and testing, and client advocacy with the drug treatment community. Specialized support groups will be provided for employees working on this project.
Disposal of needles will be conducted consistently with the Department of Public Health (DPH) Body Substance Precautions Policy as it applies to the disposal of infectious waste. Workers will be provided with an orientation to this policy and will be provided with all the necessary equipment and resources in this regard.
Employment issues/hazardous incidents. Employee safety is an important issue. A specialized training program will provide classes in teamwork building, emergency referrals, assessment of potential dangers, and drawing limits. Since recovering IDUs may be readily accepted by the out-of-treatment population, their involvement as employees in the program is suggested. Individuals should not work in isolation. The team may enter "shooting galleries," confront drug dealers, or confront individuals meeting the 51/50 criteria. Employee Assistance Services should be provided to employees and may be helpful in terms of relapse prevention, assessment, and referral for burnout and stress-related disorders. Nurses may be part of the multidisciplinary teams to assist with medical referrals. Protocols will be developed to deal with potential hazardous incidents such as a needle stick, violence, overdose, etc.
Record keeping. In order for this program to be utilized by IDUs, a degree of trust must be established. Information recorded will be number of contacts; client (case) demographics; number of needles exchanged; number of items distributed, such as condoms; return rates; and referral information. Client confidentiality will be assured. A unique fictitious name code may be utilized to control needles issued and return of needles (i.e., was the needle returned by the same person to whom it was issued?).
Advertising. Innovative methods, such as word-of-mouth, coupons-for-treatment services, posters, handouts, handbills, tee-shirts, announcements at events, television/radio, etc., will be used to advertise the program. A telephone number will provide a recorded message with the location of the program and information on how to access the street outreach workers. Comic strips, bus ads, and cooperative ventures may also be helpful in advertising the service.
Needle exchange programs can potentially slow the spread of HIV through a reduction of needle-sharing behavior, injection drug use, or high-risk sexual behavior -- a reduction that can be attained through the provision of clean needles and health education to IDUs participating in a NEP. However, opponents of needle exchange maintain that the provision of clean needles removes at least one barrier to drug use and thus may actually promote that behavior.
Because of this controversy, it is important that a needle exchange program be submitted to a rigorous evaluation that attempts to answer the questions above. Behavioral surveys regarding the effectiveness of NEPs have accumulated over the past several years, with most studies showing that NEPs have led to a reduction of injection equipment sharing and served as bridges to treatment for many IDUs. However, critics have cited the methodological flaws in many of these studies and stood by their claims that no study has yet proven that NEPs reduce HIV infection.
In August 1991, Yale University announced the results of an innovative evaluation of the New Haven Needle Exchange Program in which a tracking system was devised to assess sharing behavior. Using a mathematical projection model, researchers concluded that the program reduced new HIV infections by 33 percent. The findings led the National Commission on AIDS to endorse needle exchange programs as a component of an overall strategy.
Prevention Point in San Francisco has undergone considerable evaluation. The Prevention Point Research group has collaborated with investigators from the University of California at San Francisco (UCSF) Center for AIDS Prevention Studies as well as the Institute for Health Policy (see Prevention Point section). A street-based survey of needle exchange clients has been included in the Urban Health Study of out-of-treatment IDUs in San Francisco.
These studies have illustrated the following: 1) a strong association between frequent use of the syringe exchange and not sharing syringes; 2) no evidence for increased frequency of drug injection among current needle exchange users or recruitment of new drug users because of needle availability; 3) tendency for HIV-positive IDUs, as opposed to those who are HIV negative or who do not know their antibody status, to use a NEP; 4) great interest among IDUs using a NEP to be HIV tested onsite; and 5) strong evidence that the current NEP in San Francisco has become the principal source of clean needles for IDUs.
The San Francisco Department of Public Health (SFDPH) supports a continuing and comprehensive evaluation of San Francisco's NEP, especially in the following areas:
More concrete and valid measurements of its contribution in reducing HIV among IDUs
Effectiveness in referring IDUs to drug treatment
Effectiveness of providing IDUs with onsite HIV testing and health services.
It should be noted that the evaluation recommendations above are not intended to precede funding support for a NEP in San Francisco but rather to be implemented with the NEP simultaneously.
The contract will be a collaborative venture between Community Substance Abuse Services and the AIDS office via a contract with the Department of Public Health.
The delivery of services will be conducted by a competitively selected community-based organization (CBO). Oversight of this pilot program will be provided by a Needle Exchange Committee that will advise both the SFDPH and the CBO. The committee could consist of representatives from the city government; local and State public health officials; treatment providers; public health professionals; recovering addicts; substance abuse provider groups; volunteers from Prevention Point; the San Francisco Police Department; researchers/evaluators; CBOs; the legal, religious, and scientific communities; women's groups; and others.
In a study done by the Public Research Institute of San Francisco State University in 1989, it was found that 70 percent (n=406) of San Francisco registered voters were supportive of the distribution of needles as a method of AIDS prevention. The question was put on the ballot in 1990 as Proposition O, and 62 percent of the voters responded "Yes" to the policy question:
Shall it be the policy of the people of San Francisco to call upon the State Legislature to eliminate all criminal and civil penalties on the manufacture, use, sale or distribution of hypodermic needles?
This study, as well as ongoing inquiries to the various AIDS service providers in San Francisco, support the premise that the recruitment of volunteers and solicitation of donations would be an additional component to the program. Volunteers could not only work with the outreach and publicity for the project but could also be trained in the intervention techniques necessary to work with the clients of the program. Recovering addicts will work with the program. Additionally, donations will be accepted and utilized for equipment and educational materials. A speakers bureau may be established.
The San Francisco Needle Exchange Program will begin if legislation is changed to allow it. The law enforcement agencies will be members of the Advisory Committee in order to plan and monitor the implementation phase of the program.
Special protective carriers may be distributed to participants of the needle exchange program that will protect police from needle-stick injuries at the time of arrest.
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