Funding ban repeal a step forward for needle exchange: Support could bolster HIV prevention =========================================================================================== * Kim Krisberg Needle exchange in Bangor, Maine, is a portrait of public health success and struggle: After years of building inroads and gaining the trust needed to turn around disease rates among some of the city’s most vulnerable residents, tenuous funding puts up a roadblock even the most steadfast health worker cannot always overcome. With an ailing economy affecting both public and private funding, successful needle exchange programs like Bangor’s are facing cuts or even closure. Such programs are no stranger to walking the fine line between the evidence of prevention, changing political sensibilities and dwindling resources. However, this year could be a critical turning point. ![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/2/1.2/F1.medium.gif) [Figure1](http://www.thenationshealth.org/content/40/2/1.2/F1) Hazel Smith, a worker with the Washington, D.C., needle exchange program PreventionWorks!, looks over supplies in August 2008. The repeal of a ban on using federal funding for needle exchange may offer opportunities for such programs. Photo by Lauren Victoria Burke, courtesy AP Images In December, members of Congress passed and President Barack Obama signed a budget bill that lifted the 21-year ban on using federal funds for needle exchange programs. The move could bring much-needed funds to the work to prevent HIV and hepatitis as well as efforts to connect those struggling with substance abuse to treatment. The ban’s repeal stipulates that federal funds will not be available for needle exchange programs whose locations are deemed inappropriate by local law enforcement or public health officials. The repeal was not accompanied with specifically appropriated funds, however needle exchange advocates are gearing up to compete for overall federal prevention dollars from agencies such as the Centers for Disease Control and Prevention. Intravenous drug users account for 16 percent of new HIV infections and 20 percent of the 1.1 million people living with HIV in the United States, so the payoff could be substantial. “We’re incredibly optimistic that being able to access federal dollars will help us grow our programs,” said Patsy Murphy, executive director of the Eastern Maine AIDS Network, which operates Bangor’s needle exchange program. “A number of needle exchanges (around the country) have already had to close, and we’re all in the same boat until we get a steady, committed revenue stream. Sustainability is about having dedicated resources. The needles cost cents, the diseases cost millions — this is not rocket science.” ![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/2/1.2/F2.medium.gif) [Figure2](http://www.thenationshealth.org/content/40/2/1.2/F2) AIDS activists call for an end to the funding ban for exchange programs during a July 2009 protest in Washington, D.C. Photo by David S. Halloway, courtesy Getty Images Created in 2002, Bangor’s needle exchange program offers not only clean needles, but free HIV and hepatitis C testing, referrals for further treatment and care, and help obtaining housing assistance and mental health care, among other services. The program operates on a one-to-one exchange — a clean needle for a used needle — exchanging more than 4,600 needles in December 2009 alone, Murphy said. Working with local partners, including local law enforcement, the Bangor program has been successful in helping reduce the spread of HIV and hepatitis, facilitating entry in drug treatment programs and in reducing the numbers of discarded needles in public spaces. Currently, the Bangor needle exchange relies exclusively on private foundation grants, and Murphy said the lifting of the federal funding ban could be a significant boost for a program that has always had to struggle to “squeeze a dollar out of a nickel.” “It’s a huge step forward and it acknowledges that helping to ensure that those who use drugs have clean needles is critical in stopping the HIV epidemic in America,” said Rebecca Haag, executive director of AIDS Action. “This is a battle we’ve been fighting for many years, and it’s an important step. Now we have to work to make sure it gets implemented and make sure it leads to additional syringe access programs across the country.” According to the North American Syringe Exchange Network, there are now more than 200 reported needle exchange programs in 34 states, Washington, D.C., Puerto Rico and American Indian nations. While opponents of needle exchange claim the efforts encourage drug use, research on the topic has shown just the opposite. As early as 1994, a study published in the *Journal of the American Medical Association* concluded that “our data did not support the hypothesis that a syringe exchange program would stimulate increased drug abuse in terms of frequency of injection or recruitment of new or younger users.” A 2005 article in the *New England Journal of Medicine* that was co-authored by current CDC Director Thomas Frieden, MD, MPH, noted that “making clean needles available to people who inject illicit drugs” is an evidence-based way to reduce the high-risk behaviors that lead to HIV infection. ![Figure3](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/2/1.2/F3.medium.gif) [Figure3](http://www.thenationshealth.org/content/40/2/1.2/F3) George Ducheli, who drove a van for a New Haven, Conn., needle exchange program in March 2007, shows some of the program’s supplies. There are now more than 200 reported needle exchange programs in 34 states, according to estimates. Photo by Douglas Healey, courtesy AP Images “For so long, patients who had acquired HIV through injection drug use or still had active use were purposely victimized and stigmatized,” said Michael Horberg, MD, a member of the Board of Directors of the HIV Medicine Association. “At least (the repeal of the funding ban) shows that we’re going to deal realistically and with respect for the members of the HIV-active community.” In Washington, D.C., home to the nation’s worst HIV rates, the lifting of the federal funding ban is much-welcome news. For years, Congress had prevented the city from spending its own funds on needle exchange, but in 2007, federal policy-makers repealed the D.C.-specific ban. For PreventionWorks!, Washington, D.C.’s oldest and largest needle exchange program, the 2007 move was critical, allowing it to expand from one program to four in less than a year, according to Mary Beth Levin, MPH, director of programs and services at PreventionWorks! With only city and private funds to rely on, a possible infusion of additional federal funds could mean even more lives saved and the ability to respond to increasing demands, Levin told *The Nation’s Health.* “States and cities now have the ability to use their federal dollars to say ‘yes, the life of a drug user is worth saving, the life of a husband, wife, girlfriend or boyfriend of a drug user is worth saving, the life of a child of a drug user is worth saving,’” she said. “In these tough economic times, the lifting of the (federal) ban cannot only expand existing efforts but preserve efforts as well.” In a city home to 9 percent of the nation’s pediatric HIV cases and where 17 percent of the HIV rate is linked to intravenous drug use, PreventionWorks! is making vital inroads. In 2009 alone, the organization distributed more than 166,000 clean needles, received and disposed of almost 147,000 used needles, conducted about 1,300 HIV tests, distributed more than 29,000 safer sex kits and almost 2,900 wound care kits, and referred almost 200 people to further treatment and care, Levin reported. That year, the organization achieved a needle return rate of 88 percent, she said, showing that “we’re getting dirty needles off the streets, and making our neighborhoods safer for our children and safer for law enforcement as well.” Across the country in Seattle, years of needle exchange support has resulted in a low and stable rate of HIV infection among injection drug users of about 3 percent over the past 18 years, even while other metropolitan areas witnessed rapid and unfortunate growth, according to Michael Hanrahan, manager of HIV education and prevention services at Public Health Seattle-King County. King County’s public health department began its needle exchange program in 1989, and is now exchanging about 1.6 million needles per year. Offering treatment has long been central to the program, with the department issuing vouchers redeemable for drug treatment since 1990, said Hanrahan, who noted that the program placed about 450 people into treatment in 2008 and about 400 people in 2009. The needle exchange program relies on a mixture of city, county and state funds, which Hanrahan said have been very stable until this year. State budget shortfalls mean the department’s needle exchange could be facing a funding cut of up to $5 million — a gap that could be helped with the lifting of the federal funding ban, Hanrahan said. Without an accompanying expansion of federal prevention funds, it may be difficult to begin diverting money to needle exchange, he cautioned, especially when there are other populations facing rising HIV rates. “The irony is that we’ve been pretty effective at containing HIV in this population, and when you’ve got something under control, it’s difficult to justify more resources at a time when resources continue dwindling,” he told *The Nation’s Health.* “(Repeal of the federal ban) opens the possibilities, but embodies some very tough choices and has the potential of pitting populations against each other in a way that has some undesirable outcomes.” While freeing up federal funds creates possibilities for some, it does little for those working in states where needle exchange is illegal, such as Florida. Self-described “one-man show” George Gibson is the founder and executive director of Flashlight of Hope Inc. in Miami, an underground needle exchange he operates out of his home. Using his own funds — he also received a grant in 2000 from the North American Syringe Exchange Network — Gibson helps about a dozen people every month, exchanging needles, providing prevention education, referring people to treatment agencies, and safely disposing of used needles with hospitals and health departments. But unless Florida policy-makers change state law, the community Gibson serves will not benefit from the possibility of federal prevention money. “I’m helping people from all different walks of life,” Gibson told *The Nation’s Health.* “This work is so vital. (Changing the law) is well overdue.” Time will tell if repealing the federal funding ban translates into the support advocates are hoping for, but they caution that the repeal will likely need defending in coming years, noting that it is up to health workers to continue to demonstrate the effectiveness of needle exchange. “This is a huge public health victory, but the fight is far from over,” said APHA member Jirair Ratevosian, MPH, deputy director of public policy at amFAR, an AIDS research foundation. “We must rely on effective implementation because if there are any problems, our opponents will certainly be watching carefully.” For more information on needle exchange programs or the repeal of the federal funding ban, visit [www.nasen.org](http://www.nasen.org) or [www.amfar.org](http://www.amfar.org). ## Footnotes * *Editor’s note: This article was corrected post-publication.* * Copyright The Nation’s Health, American Public Health Association