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Local D.C. Lawmakers Could Help Shelve the Morality Debate About Needle-Exchange Programs

Washington, D.C., is getting on board with the truth about needle exchange. Will the rest of the country follow?
 
 
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Two days into 2008, Washington, D.C., Mayor Adrian Fenty called a press conference to reintroduce local funding for needle-exchange programs. Freed from a nearly decade-long congressional ban on D.C. financing of needle exchange, Fenty responded with a $650,000 investment.

"We know that [needle exchange] is a best practice," Fenty said during his remarks. "Here in Washington, D.C., with one of the highest HIV/AIDS rates anywhere," funding for needle-exchange programming "goes right where the rubber meets the road on this very serious health crisis."

But D.C. health officials and needle-exchange advocates aren't content to just reintroduce needle exchange. They want to reconceptualize it.

Rather than engaging in the ethical go-round over whether government-funded needle exchange officially, if tacitly, sanctions illegal injection drug use, local advocates are sticking to the scientifically proven bottom line: Needle exchange reduces the transmission of HIV/AIDS without increasing injection-drug use.

They're more interested in talking, instead, about what needle exchange can become. To wit, successful needle exchange sites provide an obvious bridge to a range of holistic treatment and care options for an otherwise isolated population.

The standard conception of needle exchange as a place, either mobile or concrete, to exchange used, potentially infected needles for new, clean syringes is incomplete. A comprehensive needle-exchange site can offer a host of services to historically underserved populations of injection drug users: substance-abuse treatment, primary medical care, rapid HIV counseling and testing, mental health linkages and referrals, and information on safer sex practices.

Needle-exchange programs should be "about the people and not the paraphernalia," said Dr. Shannon Hader, Washington's new director of the HIV/AIDS administration, in a neat summation of the approach. "It's really about how we keep [people] safe, get them to all the services they need."

It's a medically responsible move that has the added benefit of being politically strategic.

When the new Democratic Congress unshackled D.C. from the local-funding ban, the city suddenly found itself with both the opportunity and the political will to implement holistic needle-exchange programming almost immediately. If successful -- both in helping combat a citywide reemergence of HIV/AIDS and providing sustainable care and treatment for injection-drug users -- Washington might just shelve the irresponsible morality debate for good.

Though Hader and other local proponents have largely moved beyond that debate, there still exist politicians willing to disregard scientific evidence in their continued assault on needle exchange. They spin funding bans to an uninformed public as an ethical stand against illegal drug use. Their efforts have cost both time and lives, especially in D.C., which has no autonomy over its own budget. That right is reserved for Congress, which, beginning in 1998, instituted the local-funding ban on needle exchange.

It mirrors a federal funding ban, enacted in 1988, a ban President Bill Clinton refused to lift in 1998, despite the recommendation of his Department of Health and Human Services Secretary Donna Shalala and a host of reputed medical organizations, including the American Medical Association. President George W. Bush has maintained the ban.

While this prohibition has stymied the development of needle exchange nationwide, many cities and counties have been able to call on enlightened local legislatures and councils for funds.

In Washington, only the local organization PreventionWorks!, which is buoyed by private funding, has been able to sustain a stable needle-exchange operation. In 2007, before the ban was lifted, PreventionWorks! distributed 183,803 clean syringes with a more than 95 percent disposal rate for used syringes and served 1,982 clients. But the organization is unable to reach all of the D.C.'s injection-drug users, a population estimated to number at least 10,000.

"The message was zero tolerance," explained William McColl, the political director of AIDS Action, a vocal proponent of needle exchange based in D.C. "People who were deeply involved with zero tolerance were saying [needle exchange] was sending the wrong message.

"The United States needs to understand that that message of toughness, at least in this instance, really worked against what is the best way to respond to the [HIV/AIDS] epidemic."

The federal government's shortsighted legislation coincided with a stunning and complex reemergence of HIV/AIDS in Washington since at least 2001.

Weeks before the lifting of the funding ban, local health officials released a sweeping statistical study detailing the spread of HIV/AIDS in D.C. between 2001 and 2006. Headlines accompanying the release blared, "A Modern Epidemic," and the articles spotlighted an AIDS case rate that is currently the highest in the country: 128.4 cases per 100,000 people.

Though the study showed injection-drug use to be only the third most frequent mode of transmission for HIV/AIDS, dirty needles are still responsible for 20.8 percent of all D.C. HIV/AIDS infections. And from 2001 to 2006, the most AIDS-related deaths were attributable to people who became infected through injection-drug use.

The $650,000 in funding means, for the first time in recent history, D.C. has the tools it needs to reduce those numbers.

It also has the opportunity to shift the national discourse around needle exchange, which could be equally as important. The local-funding ban may have been lifted, but not before 208 members of the House voted for a failed amendment to keep the prohibition. And the federal-funding ban is still in place.

While the two remaining Democratic presidential contenders -- Sens. Hillary Clinton and Barack Obama -- have announced a willingness to overturn the federal funding ban if elected, all progressive presidents and lawmakers should be able to point to Washington when future attempts to stymie needle exchange arise. Politicians who vote against needle exchange on ethical grounds will have to publicly confront the morality of denying not just clean needles, but also treatment for drug abuse, HIV/AIDS and hepatitis, additional medical care and information on safer sex practices.

Ken Vail heads PreventionWorks!, which is set to receive $300,000 of the local funding Fenty announced on Dec. 2. His vision for the agency's future offers the best window into what comprehensive care and treatment in the D.C. can look like. (The remaining $350,000 in funding will be divided among up to four existing service programs. They must go through an application process detailing how they will rapidly integrate needle exchange into their other programming.)

Vail's commitment to needle exchange is inked across his back. A tattoo of two needles atop a list of all the cities where he has set up or worked for needle-exchange programs: Santa Cruz, Calif., Boston, Cleveland, Los Angeles, San Francisco, and New York, as well the Central Asian country of Kazakhstan. He's waiting to add D.C. to the list. But there's some work to do first.

"Our primary goal is to make [PreventionWorks!] a model for the rest of the country," he said.

Despite years providing a host of services beyond needle exchange, PreventionWorks! is now able to really transcend its status as D.C.'s only syringe-exchange option.

He diagrammed his idea for what he calls a Treatment Adherence Resource Center. One building that would combine prevention services, like needle exchange, with community outreach, case management and clinical support. Basically a one-stop shop to help treat and care for injection-drug users whatever their level of need. The centers would also offer laundry services and locker storage for medications.

Vail's vision for these centers makes sense intuitively. As he explained: "If I were on the streets and I was HIV-positive and injecting drugs, and I was having a hard time taking my meds, if you gave me a place I could wash my clothes, if you gave me a place I could store my meds, if you gave me a place where there's a consistent person there meeting with me from a harm-reduction perspective ... A friendly face. A cup of coffee. I'd go."

That cup of coffee might lead to a discussion about drug-abuse treatment, safer sex practices or medical referrals.

PreventionWorks! plans to staff and operate at least one, and maybe two centers if it gets funding from a Ryan White Part B Funding Grant.

"There are a lot of people doing a lot of good work" on needle exchange around the country, Vail said. "But I think doing really comprehensive syringe exchange, harm reduction, treatment adherence ... there's only a few agencies around the country who are doing that kind of stuff." He specifically highlighted the program at Tenderloin Health in San Francisco, which serves as a model for his vision of PreventionWorks!

"But I'd like to see a model program working out of [D.C.]," he said.

 
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