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Southern States Outlaw Syringe Exchanges Used to Prevent Disease

Southern syringe exchange programs struggle with little funding, limited supplies and unfavorable public opinion.

In the pale light of early morning, a mobile unit sits curbside in Atlanta, Georgia’s most notorious crime zone. A woman in a tattered coat shuffles up to the vehicle. She’s diabetic and carries a bag of over 300 used syringes. The people in the mobile unit are happy to accept the needles, and they offer her clean insulin syringes in exchange. Mostly volunteers, they have braved the cold to bring public health services to the neighborhood’s residents. In doing so, they are breaking the law.

Syringe exchange, the act of exchanging a used syringe for a clean one, is an accepted practice for reducing bloodborne disease transmission in much of the northern United States. Not so in the South, which has steadfastly refused to endorse syringe exchange, and the practice is more or less prohibited in all Dixie states. But despite a legal situation that is ambiguous at best and often outright hostile, 13 syringe exchange programs exist in the South. Scattered across nine states, the programs and the people who run them are as colorful as they are unexpected. A program in New Orleans runs a clandestine exchange through volunteers on bicycles, advertising their services through a circus and the local music scene. In South Carolina, a doctor, two reverends and an atheist formed an unlikely alliance to create the first syringe exchange program in their state. In North Carolina, a former drug user living with HIV and hepatitis C distributes needles from the back of his van to help others avoid his fate.

The exchange programs are diverse in size, scope and methodology, but they share a common goal to reduce disease in their communities and to offer services to a population both stigmatized and ignored by traditional health providers. 

“Just because you suffer from the disease of addiction does not exclude you from basic medical services and equipment,” says Jeff McDowell, executive director of the Atlanta Harm Reduction Coalition, which operates an exchange. “It costs $680,000 to treat a person with HIV and 9 cents to prevent it with a clean syringe.”

AHRC runs the largest and most comprehensive syringe exchange program in the South. Three times a week, outreach workers from AHRC visit fixed locations in a mobile unit. The unit is equipped with an examination room where clients are offered nonemergency medical care, HIV and hepatitis C testing, overdose prevention education, and referral to drug treatment if the client requests. Clients may also receive brown-bagged meals and access to a shower.

Unlike most syringe exchange programs in the South, and despite Georgia law prohibiting the distribution of hypodermic needles for nonemergency purposes, AHRC operates right under the nose of the Atlanta police department.

“We have an unspoken agreement with the police because a lot of officers recognize the benefits of syringe exchange,” explains Jeff McDowell. Benefits include lower rates of HIV and hepatitis C in the community, the collection of used syringes that might otherwise be discarded in public parks or bathrooms, and fewer accidental needle-sticks to law enforcement. AHRC distributed approximately 61,000 syringes last year and collected 60,000 dirty needles off the streets. Mutual respect between Atlanta law enforcement and AHRC has allowed the syringe exchange to operate effectively for nearly two decades.

Interestingly, local law enforcement policy toward syringe exchange seems to determine program operation more than state law. AHRC’s cooperative relationship with local police is unusual in the South. Miami offers a more characteristic example of how exchanges adapt to a murky legal environment. No official exchange program exists in Miami, just one man who believes in the public health benefits of syringe access. Fernando (an alias) collects extra syringes from local diabetics and disperses them to drug users who might otherwise share dirty needles. He operates as a volunteer and is discreet in his deliveries so as not to attract the attention of a police force tough on paraphernalia laws. Similar programs operate in Little Rock, Arkansas, Jackson, Mississippi, and Nashville, Tennessee, among others. In most cases, drug users are provided a phone number to call when they need supplies, and a volunteer performs a clandestine delivery.