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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

  

Health Emergency 1999: The Spread of Drug-Related AIDS and Other Deadly Diseases Among African Americans and Latinos

http://www.harmreduction.org/

By Dawn Day, Ph.D.
With a foreword by Joycelyn Elders, M.D. - Former U.S. Surgeon General


Executive Summary

Health Emergency Among African Americans

  • In 1997, after the advances in treatment, AIDS was still the leading cause of death among African Americans between the ages of 25 and 44. Over 60 percent of the deaths were injection-related.
  • More than 115,000 African Americans had injection-related AIDS or had already died from it by June 1998.
  • Suffering disproportionately from the epidemic, African American women account for over half of all injection-related AIDS cases among women, although they are only 12 percent of the female population.

Health Emergency Among Latinos

  • AIDS was the second leading cause of death among Latinos age 25 to 44 in 1996. Over half of the deaths were injection-related.
  • More than 56,000 Latinos had injection-related AIDS or had already died from it by June 1998.
  • Suffering disproportionately from the epidemic, Latina women account for twenty percent of all injection-related AIDS cases among women, although they are only 10 percent of the female population.

What Must Be Done

We must improve drug education. We must expand drug treatment programs. We must also implement the proven public health interventions that can reduce substantially the spread of AIDS and other deadly bloodborne diseases among people who inject drugs by reforming our laws and regulations to:

  • Permit possession of sterile needles
  • Permit pharmacies to sell syringes without prescriptions
  • Permit and fund clean-needle programs


Foreword
Dr. Joycelyn Elders - Former U.S. Surgeon General

This powerful report brings home the severity of the problem of AIDS spread through dirty needles. It makes me angry!

We have got to be about preventing disease! We have better drugs, but we still donít have a vaccine or a cure for this disease. We have watched people die from this disease; now they must learn how to live with HIV/AIDS. But why canít we help prevent this disease by providing clean needles? We do not allow people to get the clean needles that would reduce the spread of HIV disease, yet we spend $155,000 or more for each person who develops AIDS to take care of them, to watch them die. That makes no sense! We have got to be about preventing problems, not fixing things after they are broken.

Our best scientific research shows that needle exchange programs do not increase drug use, but do reduce the spread of HIV. We need to speak out. Silence about the importance of needle exchange programs is causing the deaths of thousands of our bright young black and Latino men and women. Time is slipping away. Our bright young people are slipping away.

We must recognize the spread of AIDS through dirty needles as the public health problem that it is. We must accept the scientific data and stand up for needle exchange programs and begin to save precious lives!

About the Author

This report was prepared by Dawn Day, Director of the Dogwood Center, an independent research organization in Princeton, New Jersey. Dr. Day is an activist scholar with 30 years' experience as a researcher and writer on social issues.

This is the third in a series of reports detailing the impact of the injection-related AIDS epidemic on African Americans and Latinos.

Dr. Day's books dealing with racial discrimination include Adoption Agencies and the Adoption of Black Children (Lexington Books, 1979) and Protest, Politics and Prosperity: Black Americans in White Institutions, 1940-1975 (Pantheon, 1978; co-author).

As a Vice President at Response Analysis, in Princeton, New Jersey, Dr. Day led the team that provided the basic statistical data on American household energy consumption to the US Department of Energy. Her work on household energy consumption has also been funded by the Ford Foundation.

Dawn Day was a member of a team funded by the Carnegie Corporation that analyzed changes in the lives of African Americans. Holding both a PhD in sociology and an MSW in social work from the University of Michigan, she has taught at Brooklyn College and the University of Maryland.

Acknowledgment

I am particularly grateful to my husband, Reuben Cohen, for his support in many ways.

For Copies

Copies of this report are available from the Dogwood Center, PO Box 187, Princeton, NJ 08542 ď Tel: 609-924-4797 ď Fax: 609-252-1464 ď E-mail: dday99@aol.com ď Copyright ©1998 Dawn Day ď Revised March 1999 ď Reproduction and distribution with credit is encouraged ď Available on the web at http://projectsero.org/day.shtml

1. Health Emergency: The Spread of Injection-Related AIDS Among African Americans

More than 115,000 African Americans were living with injection-related AIDS or had already died from it, by June 1998. (1) Many thousands more were infected with the HIV virus.

In 1997, after the advances in treatment, AIDS was still the leading cause of death among African Americans between the ages of 25 and 44 in 1997. More than 60 percent of the deaths were related to injections with contaminated needles. (2)

More than eight thousand injection-related AIDS cases were diagnosed among African Americans in the year ending June 1998. That was more than twice the number of injection-related AIDS cases diagnosed among whites in the same year.

Among those who inject drugs, African Americans are five times as likely as whites to get AIDS. (3)

There were over eight thousand injection-related AIDS cases diagnosed among African Americans in the year ending June 1998. That was more than twice the number of injection-related AIDS cases diagnosed among whites in the same year.

The role of the legal system in the spread of AIDS

Access to sterile needles would substantially reduce the spread of HIV among injecting drug users. No research has ever shown that making needle possession illegal is effective in reducing drug use in the United States. Our needle possession laws have been effective, however, in making sterile needles scarce and in creating the circumstances in which persons who inject drugs share their infected needles, resulting in the further spread of HIV, hepatitis and other bloodborne diseases. In this way, an ineffective policy of drug control ń denying access to sterile needles ń has become a major factor in the spread of deadly disease. (4)

People can avoid arrest for possession of an illicit drug by buying the drug immediately before they plan to use it. In the many states where needle possession is illegal, those who carry their own clean needles are vulnerable to arrest all the time. (5)

African Americans are more at risk in this regard because black communities frequently have been the target of police drives to enforce drug laws. This shows up in the federal governmentís own data. Among whites, there were five arrests per year per 100 users of heroin and cocaine in 1996; among blacks, there were 20 arrests per 100 users. In other words, the arrest rate for black users was four times higher than the arrest rate for white users. (6)

We can now begin to see why the number of injection-related new AIDS cases is so high among blacks: arrests for possession are higher. This means that the legal system, via the police, is more likely to confiscate the personal needles of blacks. Also, because black users know (correctly) that they are vulnerable to arrest, these users are likely to "choose" not to carry their own clean needles. (7) Users who do not carry their own needles all too often end up sharing the needles and bloodborne diseases of others.

Spreading HIV among African Americans who inject drugs is not the deliberate policy of any state government or police department. But, by restricting the sale of sterile needles and by targeting black drug users for arrest, that has been the result.

When needle possession is illegal, those who carry their own clean needles are vulnerable to arrest all the time. African Americans are more at risk in this regard because black communities frequently have been the target of police drives to enforce drug laws.

Ronald Hampton, executive director of the National Black Police Association, drawing on his 23 years as a police officer in the District of Columbia, expresses his support for needle exchange programs this way: "I have seen the devastation that drugs have brought to our community; AIDS from dirty needles has further destroyed our community. If people are going to use drugs, donít condemn them beyond the adverse effects of the drugs themselves."

Needle exchange programs also provide police officers with protection from accidents. With infected needles removed from circulation, and sterile needles covered by their protective caps, a police officer frisking an arrested person is less likely to be stuck with an HIV-infected needle.

The infamous Tuskegee syphilis "experiment"

In our society, medical intervention goes far beyond the use of pills, bandages, and surgery; in the name of public health we remove asbestos and lead-based paint and treat water. Given the medical consensus that has emerged on the effectiveness of sterile needles as a way to avoid the spread of injection-related AIDS, it is difficult to see the denial of access to sterile needles as anything other than the denial of access to a lifesaving medical intervention.

In the history of modern medicine in the United States, there is only one other instance where a lifesaving medical intervention involving the spread of a deadly infectious disease was deliberately denied a group of people. (8) That instance is the infamous Tuskegee syphilis "experiment." The originators justified themselves by saying they wanted to study the course of untreated syphilis. The unfortunate victims of this study were 400 black men from Alabama, who were denied medical treatment for their syphilis from 1932, when the study began, until their deaths or, if they lived, until 1972, when the "experiment" was exposed and stopped. (9)

It is difficult to see the denial of access to sterile needles as anything other than the denial of access to a lifesaving medical intervention.



2. Health Emergency: The Spread of Injection-Related AIDS Among Latinos

More than 56,000 Latinos living in the United States and Puerto Rico had injection-related AIDS or had already died from the disease, by June 1998. Thousands more were infected with the HIV virus. (1)

AIDS was the second leading cause of death among Latinos in the United States age 25 to 44 in 1996, the latest year for which data are available. More than half of those deaths were injection-related. The AIDS death rate for Latinos age 25 to 44 was more than double that of whites in the same age group. (2)

Injection-related AIDS represents a significant portion of the Latino AIDS epidemic. Over half of all AIDS cases among Latinos are injection-related compared with less than a quarter for whites.

Among those who inject drugs, Latinos are at least one and a half times as likely as whites to get AIDS. (3) The true figure could be substantially higher. (4)

Puerto Ricans, living on the island of Puerto Rico and in the United States, have a higher incidence of injection-related AIDS than do other Latino groups living in the United States.

More than 56,000 Latinos living in the United States and Puerto Rico had injection-related AIDS or had already died from the disease, by June 1998. Thousands more were infected with HIV.

Migration between the United States and Central and South America is probably affecting the spread of HIV/AIDS and the statistics on HIV/AIDS in a variety of ways. For example, it is possible that Latino AIDS deaths are understated in US statistics because some migrants, after becoming HIV infected in the United States, return home to be cared for by relatives. It is also possible that some men, migrating to the United States in search of work and isolated from their families, start injecting drugs; then, because of the absence of clean needles, they become infected with HIV and ultimately carry the AIDS epidemic back home.

 

    

3. Preventing Injection-Related HIV

The injection-related HIV/AIDS epidemic is not going away. Every day, 33 more people are infected with HIV as a result of intravenous drug use, according to federal officials. (1)

AIDS treatments are extending life for about half the patients being given the new combination therapy. The therapy is not easy, however. Patients must swallow at least eight, and often 16 or more, anti-HIV pills a day (along with any other needed medicines, such as those meant to prevent specific opportunistic infections or to control pain). They must also remember which pills have to be consumed with food, which on an empty stomach, and which must be taken alone.

Combination treatment can include unwanted side effects such as rash, nausea, diarrhea, headaches, anemia, neuropathy (painful or numb feet), hepatitis, and, possibly, diabetes. (2)

AIDS doctors and AIDS patients alike are convinced that prevention is by far the better path. So what can be done to prevent further spread of HIV among people who inject drugs?

Prevention is key. Every day, 33 more people are infected with HIV as a result of intravenous drug use.

Secretary of Health and Human Services Donna E. Shalala, AIDS czar Sandra Thurman, National Institutes of Health director Harold Varums, Surgeon General David Satcher, the American Public Health Association, the American Medical Association, President Clintonís Advisory Council on AIDS and the National Institutes of Health Consensus Panel ń all strongly recommend needle exchange as a way of slowing the spread of HIV. (3)

Medical experts recommend clean needle programs because they work. A study of needle exchange in New York City, for example, found that use of a needle exchange resulted in a substantially reduced hazard for HIV infection. (4) A study in New Haven found needle exchange associated with a 33 percent reduction in HIV incidence. (5)

A worldwide study found that HIV infection among drug users fell an average of 6 percent a year in 29 cities with needle-exchange programs and rose by 6 percent a year in 51 cities that had no needle-exchange programs. (6) When needle exchange programs can be expanded to cover more users, an even greater decline in new HIV infections among injecting drug users will occur.

In 1989, Congress declared that no federal money could be spent to support clean-needle programs until the federal government could provide scientific evidence that such programs both reduced the spread of HIV and did not encourage drug use. In April 1998, after a meticulous review of the scientific evidence, Health and Human Services Secretary Donna Shalala certified that the congressional mandate had been met. The research unquestionably showed that needle exchange programs do slow the spread of HIV and do not increase illegal drug use. (7)

At the same time the Clinton administration publicly concluded that needle exchange works, it continued the prohibition on the use of federal HIV prevention dollars for needle exchange.

"At best [the prohibition on federal funding of needle exchange] is hypocrisy," said Dr. R. Scott Hitt, head of the Presidentís Advisory Council on HIV and AIDS. "At worst, itís a lie. And no matter what, itís immoral." (8)

The Congressional Black Caucus called on the administration to reverse its wrongheaded decision on financing and permit federal funding of clean needle programs. "This is a life-and-death issue." said Representative Maxine Waters, chair of the Caucus. "We can save lives with needle exchange as we try to work at getting rid of drugs in our society." (9)

For some time the chair of Congressional Hispanic Caucus, Representative Xavier Becerra, has championed federal funding for needle exchange. (10)

The NAACP has taken a stand in favor of needle exchange. (11) The National Black Caucus of State Legislators strongly supports needle exchange.

Congressional critics of needle exchange, though pleased by the administrationís decision not to use federal funds to finance clean needle programs, were unable to offer any scientific evidence to support their opposition to such programs.

So, here is the situation: federal officials estimate that as a result of intravenous drug use, 33 more people are infected each day with the HIV virus. Our best scientific advisors, both inside and outside government, agree that clean-needle programs would help slow the epidemic. The federal government is in the absurd position of spending billions to provide medical treatment as people die, while refusing to spend any money for the most effective prevention technique available ń needle exchange programs.

The federal government is in the absurd position of spending billions to provide medical treatment as people die, while refusing to spend any money for the most effective prevention technique available ń needle exchange programs.



4. Saving Lives and Saving Billions of Dollars

Each AIDS illness and death exacts an uncountable cost in human pain and suffering. Each AIDS illness and death has a very countable cost in dollars.

The high cost of treating AIDS

It costs an estimated $155,000 to treat a person with AIDS from the time of initial diagnosis until that personís death. For those fortunate AIDS patients for whom the new combination AIDS medications are effective, and who are able get regular supplies of the medications, either through their own insurance or a government program, (1) the cost of medications alone is about $12,000 a year. (2)

The cost to society of treating the 19,300 cases of injection-related AIDS that were diagnosed in just one year, 1997, will be almost $3 billion, a sum beyond the comprehension of most of us. (3)

There is no question that needle exchange programs are a tremendous bargain compared with the cost of treating HIV/AIDS.

The low cost of clean-needle programs

Making it possible for people to avoid getting HIV obviously would save lives. It would also save money. The sale of syringes through pharmacies costs taxpayers nothing. Needle exchange programs are not free, but they cost much less than AIDS treatment. Using sophisticated mathematical models, a University of California team of investigators estimated that, over a five-year period, it costs between $4,000 and $12,000 in needle-exchange program expenses for each HIV infection averted. (4) The cost of medicine for combination therapy for that same five-year period would be $60,000. If we added in doctorsí fees and hospitalization, the cost difference between prevention and treatment would be even greater. There is no question that needle exchange programs are a tremendous bargain compared with the cost of treating HIV/AIDS.

5. Hepatitis C ń Another Deadly Disease Where Sterile Needles Can Save Lives and Dollars

Hepatitis C is a bloodborne virus that spreads rapidly when people share needles. It can also spread, though less rapidly, through intimate sexual contact. Difficult to treat, hepatitis C can result in death. There is no vaccine available to prevent its spread.

People who inject drugs acquire hepatitis C infection rapidly through shared needles, with 50 to 80 percent of users testing positive within 6 to 12 months of beginning injection drug use. Injection drug use accounts for half of all new hepatitis C infections and perhaps greater than 50 percent of chronic infections. (1)

Some people with hepatitis C live a normal life span without the virusís significantly damaging the liver; other people develop irreversible scarring and distortion of the organ, resulting in fatal liver failure or liver cancer. After two decades, up to a third of those infected with hepatitis C are predicted to develop cirrhosis. Within five years of diagnosis, half the patients with advanced cirrhosis caused by hepatitis C are dead.

Hepatitis C is now the leading reason for liver transplants in the United States. Each liver transplant costs an average of $300,000. It is estimated that, short of transplant, standard care for a person with advanced cirrhosis of the liver or liver cancer costs $20,000 a year.

Persons infected with both HIV and chronic hepatitis C experience a faster progression of HIV disease than those infected only with HIV.

Prior to 1990, when an effective test for the presence hepatitis C in donated blood was developed, people who had blood transfusions were at risk for hepatitis C. That risk is now very low, in the range of 1 in 100,000 units transfused.

Up to 20 percent of hepatitis C cases are attributable to sexual exposure involving blood passed through semen or vaginal secretions.

Thus, as with AIDS, we have a deadly epidemic of a bloodborne disease where exposure through blood transfusion has been almost eliminated and where a major factor in the spread of the disease ń infected needles ń could be brought under control if we permitted people who inject drugs access to sterile needles. (2)

Because hepatitis C is also spread by intimate sexual contact, protecting those who inject drugs protects their sexual partners at the same time.

Prevention of hepatitis C in the form of needle exchange costs relatively little. Without prevention, there can be pain, suffering, death ń and expensive medical bills.

6. Health Emergency: African American and Latina Women and Their Children

The crisis for African American women

  • Over 34,000 African American women had injection-related AIDS or had already died from it, by June 1998. (1) Thousands more were infected with HIV.
  • AIDS was the second leading cause of death among African American women age 25 to 44 in 1997. In that year, the AIDS death rate for African American women age 25 to 44 was twelve times higher than the AIDS death rate for white women those same ages. (2)
  • African American women account for over half of all injection-related AIDS cases among women, although they are only 12 percent of all women. (3)

The crisis for Latina women

  • More than 13,000 Latina women had injection-related AIDS or had already died from it, by June 1998. Thousands more were infected with HIV.
  • AIDS was the second leading cause of death among Latina women age 25 to 44 in 1996, the latest year for which data are available. (4) In 1996, the AIDS death rate for Latinas age 25 to 44 was more than four times higher than the AIDS death rate for white women those same ages.
  • Latina women account for twenty percent of all injection-related AIDS cases among women, although they are only 10 percent of all women.

Over 34,000 African American and 13,000 Latina women had injection-related AIDS or had already died from it by June 1998. Many thousands more were infected with HIV.

The orphans

As women become infected and die of AIDS, they leave children behind. In 1998, there were 67,000 American children under the age of 18, mostly children of color, who had lost their mothers to the AIDS epidemic. More than half these children were 12 or younger. (5)

Most of these orphans were not infected with HIV. Some were born before their mothers became HIV-positive. Others were born free of HIV, even though they were born after their mothers were infected.

Throughout the period of the HIV/AIDS epidemic, the majority of babies born to mothers with HIV have not been born infected with HIV. In the absence of any medical treatment, about 75 out of 100 infants of HIV-infected mothers are born free of HIV. Given appropriate medical treatment during pregnancy and birth, an infantís chance of being born free of HIV disease rises to more than 90 in 100. (6)

Most of these 67,000 childrenís mothers died from AIDS, infected either directly or indirectly from contaminated needles. About a quarter of the mothers never injected drugs themselves but were unfortunate in their relationships, infected because their husbands or sexual partners at one time injected drugs with an HIV-infected needle.

About two-thirds of the mothers of these now-orphaned children became HIV positive because the mothers themselves injected drugs. (7) We should not assume that, if these mothers had lived, they would not have been good parents. Women who inject drugs at one point in their lives are not necessarily drug users for life. Some experiment for only a short time. Others use drugs for longer periods and then successfully stop.

Children need their parents. We need to be following policies which ensure that as few children as possible are orphaned by AIDS.

In 1998, there were 67,000 American children, mostly children of color, who had lost their mothers to the AIDS epidemic.

Prevention through safe sex and sterile needles

Because HIV/AIDS spread first among gay men in the United States, some Americans do not realize how pervasive and devastating HIV can become in a heterosexual population. To see that, we need only look to Africa where, in 15 countries, 10 percent or more of pregnant women visiting clinics in urban areas have HIV or AIDS. (8) Virtually all these African mothers have been infected through heterosexual sex.

Persuading men to use condoms during sex is not a simple task. (9) The Centers for Disease Control has spent millions of dollars researching this topic and has yet to find an easy approach.

Because so many heterosexual men are already infected with HIV, women, to protect their own health, will need to continue to persuade their men to use condoms for many years to come. Given the sexual attitudes of substantial numbers of American men, many women are going to fail in these efforts.

To protect women ń and men ń who do not use drugs, we need to do everything we can to keep the number of HIV-positive people as small as possible. We need sterile needle programs to save the lives of non-drug-injecting women and men, as much as we need sterile needle programs to save the lives of persons who inject drugs themselves.

The inescapable conclusion

With thousands of motherless children and about 90 percent of all AIDS cases among women caused directly or indirectly by HIV-infected needles, the case for clean-needle programs to save the lives of women and children and prevent the destruction of families could not be stronger.



 

    

7. The Legality of Saving Lives

How needle exchange programs began

Not long after researchers discovered the link between dirty needles and the spread of HIV, a few people began saying we must find a way to get clean needles to people who inject drugs.

Uninfected men and women who inject drugs need sterile needles so they can avoid becoming infected. HIV-infected persons who inject drugs need sterile needles so they will not borrow the needles of others, spreading the HIV virus further.

With few resources besides their own courage and convictions, the early leaders in needle exchange took action. (1) They went into the neighborhoods where drug use was heavy and handed out clean needles. They collected used, dirty needles to get them out of circulation and out of the neighborhood. They distributed condoms to prevent the spread of HIV by sexual means. They referred individuals who wanted to stop using drugs to drug treatment. They were sometimes able to get medical volunteers to provide on-site treatment of immediate medical problems. Few in number, these brave activists were almost always volunteers, working with little or no financial support and often in a hostile legal environment.

The early volunteers, as well as those who followed, had only one goal: to save lives.

The needle exchange volunteers have only one goal: to save lives.

Early AIDS prevention organizations were often called needle exchanges because an important part of their work was giving out clean needles and collecting dirty ones. Another name, now commonly used, is harm-reduction organizations.

Without calling it that, we, as a society, practice harm reduction all the time. We reduce the harm of riding a motorcycle by requiring riders to wear helmets. We reduce the harm from car accidents by requiring people to wear seat belts. We reduce the harm to nonsmokers by requiring that smoking be done only in designated areas. We reduce the harm from excessive drinking at parties and bars by encouraging the use of a designated driver who does not drink. The goal of needle exchange is to reduce the harm from injecting drug use.

Heroes or Criminals?

By slowing the spread of AIDS, harm-reduction activists are saving the lives of those who inject drugs, their non-drug-injecting spouses or sexual partners, and their newborn children. Harm-reduction activists see themselves as health workers; others sometimes see them as criminals.

The highly variable legal status of clean-needle programs originates in local interpretations of two different sets of laws: those dealing with public health and those dealing with drug use. (2) When the situation is defined as a health emergency in which public health authorities must act in order to stop an epidemic, the state laws giving broad authority to public health officials are applied. The distribution of sterile needles is seen not only as a legal but as a vital service to the community.

The courts traditionally have viewed the exercise of public health powers with considerable deference, and health measures aimed at controlling communicable disease have rarely been overturned.

When the situation is not defined as a health emergency, the state laws restricting access to sterile needles apply, and persons distributing clean needles are subject to arrest under those laws. (3)

The question of whether public health law or drug paraphernalia/needle prescription laws apply to needle exchange programs is not being resolved without a struggle.

There are two important ways that access to clean needles is restricted: needle prescription laws and drug paraphernalia laws. Needle prescription laws require a prescription from a medical doctor before a pharmacy can sell clean needles. (4) Drug paraphernalia laws make it illegal to possess clean needles and the equipment needed to clean and use the needles.

The question of whether public health law or drug paraphernalia/needle prescription laws apply is not being resolved without a struggle. (5) As of August 1998, activists had charges pending against them for their needle exchange work in at least two states ń New Jersey and California. The governors of both New Jersey and California (states with high rates of injection-related AIDS) actively oppose clean-needle programs.

It seems clear that the trials of harm-reduction workers have been a vehicle for activists to gain publicity and win support for their cause. It is probably also true that activists have been more willing to take risks in communities where activists feel they have a good chance of winning. From anecdotal material, we know that arrest or the threat of arrest has been effective in preventing harm-reduction activities in some cities where there is great need.

By restricting the growth of needle exchange programs and preventing pharmacy sales of syringes, the laws limiting access to sterile needles have been an important factor in the spread of injection-related HIV/AIDS.

The laws limiting access to sterile needles have been an important factor in the spread of injection-related HIV/AIDS.

Needle exchange programs today

Since the first needle-exchange program was started in Tacoma, Washington, in 1988, the number of programs has been slowly increasing. By 1997, there were 113 programs. The exchanges were operating in 80 cities in 30 states, the District of Columbia and Puerto Rico. Chicago, Detroit, Honolulu, New York City, Philadelphia and San Francisco all had needle exchange programs.

Half the needle exchange programs were located in four states: California, New York, Washington, and Connecticut. (6)

Most needle exchange programs are funded from private sources. However, the states of Connecticut, New York, Hawaii, and Washington do provide financial support to needle exchange programs.

In 1997, most needle exchange programs, despite limited resources, provided other public health and social services. Virtually all provided instruction in the use of condoms and dental dams to prevent sexual transmission of HIV and other sexually transmitted diseases. Over 90 percent of these programs referred clients to drug treatment programs. Health care services on site at needle exchange programs included HIV counseling and testing (64 percent); tuberculosis skin testing (20 percent); sexually transmitted disease screening (20 percent); and primary health care (19 percent). More exchanges would have provided these services if they had had the resources to do so.

By 1997, the number of needle exchange participants was about 120,000. (7) A substantial number, it is still far from the estimated 1.1 million who inject drugs in the United States. (8)

With 33 people in the United States being infected every day with HIV as a result of intravenous drug use, it is clear we must do more. We need to expand drug treatment opportunities. We need to continue to educate people to the harms of drug use, particularly injection drug use. And we must listen to the expertise and wisdom of our public health officials and support clean-needle programs.

Along with improved drug education and expanded drug treatment, the ultimate goal must be to persuade the federal government as well as state and local governments to:

  • fund clean needle programs in all the cities where they are needed
  • eliminate the drug paraphernalia and drug prescription laws so that there will be no ambiguity about the legality of harm-reduction organizations and so that drug users can purchase and carry their own clean, safe needles without fear of arrest

As a humane society, we must reach the point where injecting drug users in every state have an opportunity to protect themselves from HIV and other bloodborne diseases and where harm-reduction workers in every state are treated not as criminals but as the public health workers they are.

As a humane society, we must reach the point where injecting drug users in every state have an opportunity to protect themselves from HIV and where harm-reduction workers in every state are treated not as criminal but as the public health workers they are.



8. The Next Steps

Every day, according to federal officials, 33 more people are infected with HIV as a result of intravenous drug use. Our medical experts, after careful research, have concluded that needle exchange works to slow the spread of HIV, as well as hepatitis C and other bloodborne diseases, and that it does not increase drug use.

Needle exchange programs prevent human suffering and save money. It costs much less to prevent HIV with sterile needles than it does to treat HIV/AIDS.

Needle exchange programs are an important link to drug treatment. When someone who injects drugs is ready to seek help, exchange workers are there with information on how to get into treatment.

Because used needles are returned to the exchange, clean needle programs effectively remove infected needles from communities. (1)

Without clean needle programs, African Americans and Latinos are suffering disproportionately. Among those who inject drugs, African Americans are five times as likely as whites to get AIDS. Among those who inject drugs, Latinos are at least one and a half times as likely as whites to get AIDS.

As early as 1993, the number of European countries with needle exchange programs stood at 17. Needle exchange programs now enjoy national government support in Canada, Australia, the United Kingdom, and the Netherlands. (2)

Needle exchange programs send the message that human life has value.

Each of us can play a role in making change happen as rapidly as possible. We must improve drug education. We must expand drug treatment programs. We must recognize the spread of HIV/AIDS as the public health problem that it is. In the words of former Surgeon General, Dr. Joycelyn Elders, "We must accept the scientific data, stand up for needle exchange programs, and begin to save precious lives!"

Needle exchange programs send the message that human life has value.



9. Endnotes

1. Health Emergency: The Spread of Injection-Related AIDS Among African Americans

1. Injection-related AIDS cases are a count of persons with AIDS in the following Centers for Disease Control and Prevention (CDC) exposure groups: injecting drug users, men who have sex with men and inject drugs, and heterosexual sex with an injecting drug user. Unless otherwise specified, all statements about AIDS cases in this section are taken from CDC, HIV/AIDS Surveillance Report, for cases reported through December 1997; see pp. 11-12.

2. CDC, "Report of Final Mortality Statistics, 1997," Monthly Vital Statistics Report. Hyattsville, MD: National Center for Health Statistics, forthcoming. Since more than 60 percent of all AIDS cases among African Americans are injection-related, it is reasonable to conclude that more than 60 percent of all AIDS deaths are also injection-related.

3. Based on the number of AIDS cases reported in 1997, according to the CDC and an analysis by Day and Cohen of household and nonhousehold drug use as reported by the Substance Abuse and Mental Health Services Administrationís National Household Survey on Drug Abuse: Population Estimates for 1991-1994. See Dawn Day and Reuben Cohen, Race and the Spread of HIV/AIDS Related to Injection Drug Use, Princeton, NJ: Dogwood Center, April 1996, 11 pp. Confirming support for this relationship comes from a CDC survey of HIV seroprevalence among persons in drug treatment in 1991 and 1992. In that study, the median HIV seroprevalence for blacks was 18.4 percent; for whites it was 3.8 percent. CDC, National HIV Serosurveillance Summary: Results through 1992, vol. 3, p.19.

4. Peter Lurie and Ernest Drucker, "An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA, Lancet, 1997, vol. 349, March 1, 1997, pp. 604-8. Discrimination by pharmacies plays a role in preventing African Americans from getting access to sterile needles. There is evidence from St. Louis, for example, that drugstores will not always sell syringes to African Americans even when selling syringes is legal. University of California. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Summary, vols. I and II, by Peter Lurie, Arthur L. Reingold, et al., San Francisco: University of California, 1993.

5. In neighborhoods with heavy injecting drug use, laws prohibiting the possession of drug paraphernalia are a major reason needles are sometimes seen lying around in public areas. People who inject drugs have discarded the needles in haste, as they have tried to avoid being arrested. A study in Ohio in 1993 found that 73 percent of the 276 active drug injectors interviewed feared carrying needles because of drug paraphernalia laws. See R. G. Carlson, H. A. Siegal, J. Wang, and R. S. Flack, "Attitudes Toward Needle ëSharingí Among Injection Drug Users: Combining Qualitative and Quantitative Research Methods," Human Organization, 1996, vol. 55, pp. 361-69.

6. According to unpublished tabulations provided by the FBI, in 1996 there were 150,000 arrests for possession of heroin and cocaine among whites, and 127,000 arrests for possession of heroin and cocaine among blacks. In 1996, there were 3,106,000 whites who used heroin or cocaine in that year and 638,000 blacks. This makes for an arrest-to-possession ratio of about 5 in 100 for whites and 20 in 100 for blacks. The drug use data are from U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse: Population Estimates 1996, July 1997, Tables 4B, 4D and 18. See also Ricky N. Bluthenthal, Alex H. Kral, Jennifer Lorvick, and John K. Watters. "Impact of Law Enforcement on Syringe Exchange Programs: A Look at Oakland and San Francisco," Medical Anthropology, vol. 18, 1997, pp. 1-23. Also, Ricky N. Bluthenthal, Alex H. Kral, Elizabeth A. Erringer, and Brian R. Edlin. "Drug Paraphernalia Laws and Injection-Related Disease Risk Among Drug Injectors," in press, Journal of Drug Issues.

7. Sameul L. Groseclose, Beth Weinstein, T. Stephen Jones, linda A. Valleroy, Laura J. Fehrs, and William J. Kassler, "Impact of Increased Legal Access to Needles and Syringes on Practices of Injection-Drug Users and Police Officers ń Connecticut, 1992-1993," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, vol. 10, pp. 82-29. Alice A. Gleghorn, T. Stephen Jones, Meg C. Doherty, David D. Celentano, and David Vlahov, "Acquisition and Use of Needles and Syringes by Injecting Drug Users in Baltimore, Maryland," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, vol. 10, pp. 97-103. Jean-Paul C. Grund, Douglas D. Heckathorn, Robert S. Broadhead, and Denise L. Anthony, "In Eastern Connecticut, IDUs Purchase Syringes from Pharmacies but Donít Carry Syringes," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, vol. 10, pp. 104-5.

8. Dawn Day, "Do you support a government-sanctioned needle exchange program?" New Jersey Medicine, August 1996, vol. 93, no. 8, pp. 55-59. New Jersey Medicine is the journal of the Medical Society of New Jersey. J. H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, New York: Free Press, 1981, 263 pp. In May 1997, President Clinton apologized to the survivors and their families for the Governmentís 40-year role in creating, funding, and running the experiment. Carol Kaesuk Yoon, "Families Emerge as Silent Victims of Tuskegee Syphilis Experiment," New York Times, May 12, 1997, p. 1.

9. Writing about the continuing aftermath of the Tuskegee syphilis experiment as well as other more recent events, Sandra Crouse Quinn of the School of Public Health at the University of North Carolina comments that "belief in genocide, accompanied by distrust of government reports on AIDS, may be contributing to continuing transmission of HIV by maintaining a social environment steeped in denial and contributing to lack of social support for use of condoms, needle exchange programs, and participation in clinical trials. Sandra Crouse Quinn, "Belief in AIDS as a Form of Genocide: Implications for HIV Prevention Programs for African Americans," Journal of Health Education, November/December Supplement 1997, vol. 28, no. 6, pp. S6-S11. See also Sheryl Gay Stolberg, "Eyes Shut, Black American Is Being Ravaged by AIDS," New York Times, June 29, 1998, p. A1.

2. Health Emergency: The Spread of Injection-Related AIDS Among Latinos

1. Unless otherwise specified, all statements about AIDS cases in this section are taken from CDC, HIV/AIDS Surveillance Report for cases reported through June 30, 1998; see pages 16-18.

2. CDC, "Report of Final Mortality Statistics, 1996," Monthly Vital Statistics Report, Hyattsville, MD: National Center for Health Statistics, forthcoming. Since more than half of all AIDS cases among Latinos are injection-related, it is reasonable to conclude than more than half of all AIDS deaths are also injection-related.

3. This figure comes from a study of injecting drug users in drug treatment, done in 1991-92. CDC, National HIV Serosurveillance Summary, Results Through 1992, vol. 3, p. 19.

4. Using an index based on injection drug use as reported in the National Household Survey on Drug Abuse, the incidence of AIDS among Latino injecting drug users could be as high as six times the incidence of AIDS among white injecting drug users. This estimate is based on the CDCís count of AIDS cases in 1997 for whites and Latinos and on the average number of injection drug users among whites and Latinos as reported for the four years 1991-1994 by the National Household Survey on Drug Abuse: Population Estimates, 1991 (revised 1992) p. 106; 1992, p. 106; 1993 p. 104; and 1994, pp. 107 and A-26. See Dawn Day and Reuben Cohen, Race and the Spread of HIV/AIDS Related to Injection Drug Use, Princeton, NJ: Dogwood Center, April 1996, 11 pp.

3. Preventing Injection-Related HIV

1. The 33 persons per day includes people who use drugs, their sexual partners and their children. Sheryl Gay Stolberg, "Clinton decides not to finance needle program," New York Times, April 21, 1998, p. A1.

2. Almost identical results from clinics at San Francisco General Hospital and the Johns Hopkins Medical Institutions reveal that approximately 50 percent of patients given triple-drug therapy achieved the goal of viral loads below 500 copies per milliliter at 6 to 52 weeks after the start of treatment. John G. Bartlett and Richard D. Moore, "Improving HIV Therapy," pp. 89, 91; and John W. Mellors, "Viral-load Tests Provide Valuable Answers," p. 91, both in the Scientific American, July 1998. There are several reasons why not all patients benefit from combination therapy. Many cannot tolerate the side effects. Others cannot follow the complex drug regimen. And some have developed drug-resistant HIV, usually because their disease is in an advanced stage or because they have already been treated extensively with antiviral drugs. David D. Ho, "Too Much Pessimism on AIDS Therapies," New York Times, June 27, 1998, p. A15.

3. For a statement by R. Scott Hitt, MD, chair of the Presidential Advisory Council on HIV/AIDS on the need for federal funding of needle exchange, see his article in the June 9, 1998 issue of The Advocate.

Early on, it was thought that sterile needles were not necessary for AIDS prevention among injecting drug users. It was thought that used needles could be disinfected with bleach. However, field studies have shown that bleach is not effective in killing the HIV virus. In 1993, the Centers for Disease Control, the National Institute on Drug Abuse, and the Center for Substance Abuse Treatment issued a joint bulletin warning that bleach-disinfected, previously used syringes are less safe than sterile, never-used syringes. HIV/AIDS Prevention Bulletin, US Department of Health and Human Services, Public Health Service, April 19, 1993.

4. Don C. Des Jarlais, Michael Marmor, Denise Paone, Stephen Titus, Qiuhu Shi, Theresa Perlis, Benny Jose, and Sam Friedman, "HIV Incidence Among Injecting Drug Users in New York City Syringe-Exchange Programmes," Lancet, October 12, 1996, vol. 348, pp. 987-91.

5. E. H. Kaplan, "Probability Models of Needle Exchange," Operations Research, 1995, vol. 43, pp.558-569.

6. Susan F. Hurley, Damien J. Jolley, and John M. Kaldor, "Effectiveness of Needle-exchange Programmes for Prevention of HIV Infection," Lancet, June 21, 1997, vol. 349, pp. 1797-1800.

7. Research shows needle exchange programs reduced HIV infections without increasing drug use. Press release, April 20, 1998, U.S. Department of Health and Human Services. Between 1991 and 1997, the federal government funded seven reports on clean-needle programs for persons who inject drugs. The reports were unanimous in their conclusions that clean needle programs reduce HIV transmission and DO NOT increase drug use:

  • National Commission on AIDS, The Twin Epidemics of Substance Use and HIV, Washington, DC. 1991.
  • General Accounting Office, Needle Exchange Programs: Research Suggests Promise as an AIDS Prevention Strategy, Report Number GAO/HRD-93-60, Washington, DC: US GPO, 1993.
  • University of California, The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Summary, vols. I and II. Peter Lurie, Arthur L. Reingold, et al., San Francisco: University of California, 1993; available from the National AIDS Clearinghouse, PO Box 6003, Rockville, MD 20848-6003.
  • Centers for Disease Control. D. Satcher. Note to Jo Ivey Boufford. December 10, 1993, The Clinton Administrationís Internal Reviews of Research on Needle Exchange Programs, 1993; available from the Drug Policy Foundation, 4455 Conn. Ave. NW, Suite B-500, Washington, DC 20008.
  • National Research Council and Institute of Medicine, Jacques Normand, David Vlahov, and Lincoln E. Moses, eds., Preventing HIV Transmission: the Role of Sterile Needles and Bleach. Washington, DC: National Academy Press, 1995.
  • Office of Technology Assessment of the US Congress. The Effectiveness of AIDS Prevention Efforts, 1995, PB96107529. Springfield, VA: National Technical Information Service.
  • National Institutes of Health Consensus Panel, Interventions to Prevent HIV Risk Behaviors, 1997, Kensington, MD: NIH Consensus Program Information Center.
  • Studies of needle exchanges in Vancouver and Montreal revealed inefficiencies in those programs that had to be corrected, but the authors of the studies in the two cities continue to strongly favor needle exchange as a way of slowing the spread of HIV, and the health departments of Vancouver and Montreal have both expanded their needle exchange programs as a result of the studies. Julie Bruneau and Martin T. Schechter, "The Politics of Needles and AIDS," New York Times, April 9, 1998, p. A27.

8. Sheryl Gay Stolberg, "Clinton Decides Not to Finance Needle Program," New York Times, April 21, 1998, p. A1.

9. Paul Bedard, "Black Caucus Targets Drug Czar," Washington Times, April 25, 1998, p. 1.

10. Letter from Representative Xavier Becerra and Representative Maxine Waters to Secretary of Health and Human Services Donna Shalala dated February 9, 1998.

11. The chief executive of the NAACP recently wrote: "The NAACP has taken the bold stand to support needle-exchange programs as part of comprehensive drug treatment programs." Kweisi Mfume, "Letter to the Editor," New York Times, July 11, 1998, p. A10. See also Imani Woods, "Needle Exchange from an African American Perspective," African American Community Education Project, Drug Policy Foundation, 4455 Connecticut Avenue NW, Suite B500, Washington, DC, 20008.

4. Saving Lives and Saving Billions of Dollars

1. A 1997 study by the National Alliance of State and Territorial AIDS Directors and the AIDS Treatment Data Network showed that 22 states had imposed restrictions that limited either the number of people served by AIDS-drug-assistance programs or the availability of medications themselves or both. Laurie McGinley, "States, in Midst of Cash Crunch, Restrict AIDS-Drug Programs, Report Finds." Wall Street Journal, July 11, 1997, p. B12.

2. David R. Holtgrave and Steven D. Pinkerton, "Updates of Cost of Illness and Quality of Life Estimates for Use in Economic Evaluations of HIV Prevention Programs," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, vol. 16, no. 1, pp. 54-62. B. E. Perdue, P.J. Weidle, R.E. Everson-Mays, and P. S. Bozek, "Evaluating the Cost of Medications for Ambulatory HIV-infected Persons in Association with Landmark Changes in Antiretroviral Therapy, Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, April 1, 1998, vol. 17, no. 4, pp. 354-360.

3. CDC, HIV/AIDS Surveillance Report, cases reported through December 1997, pp. 11-12.

4. National Research Council and Institute of Medicine, Jacques Normand, David Vlahov, and Lincoln E. Moses, eds., Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington, DC: National Academy Press, 1995, pp. 86-88.

5. Hepatitis C ń Another Deadly Disease Where Sterile Needles Can Save Lives and Dollars

1. See the National Institutes of Health Consensus Development Statement, Management of Hepatitis C, March 24-26, 1997, 30 pp.; and Jerome Groopman, "The Shadow Epidemic," New Yorker, May 11, 1998, pp. 48-60. For further information on hepatitis C, contact the HVC Global Foundation, 1406 Madison Avenue, Redwood City, CA 94061-1550, tel: 650-369-0330 or fax: 650-369-0331.

2. Although not as widespread as hepatitis C, hepatitis B is another virus infecting the liver that spreads through sharing infected syringes or unprotected vaginal, anal, or oral sex. Most people recover from hepatitis B within six months and afterward develop immunity. Some 5 to 10 percent of the people who get hepatitis B remain contagious for the rest of their lives and develop chronic liver disease, with all its attendant problems. "Hepatitis Facts for Injectors," distributed by the University of California, San Francisco, and the Department of Epidemiology and Biostatistics, San Francisco, General Hospital, March 1997.

6. Health Emergency:African American and Latina Women and Their Children

1. Unless otherwise noted, all HIV/AIDS data in this section are taken from the CDCís HIV/AIDS Surveillance Report through June 30, 1998.

2. CDC, "Report of Final Mortality Statistics, 1997," Monthly Vital Statistics Report. Hyattsville, MD: National Center for Health Statistics, forthcoming.

3. The AIDS data are cumulative for the entire epidemic. "Women" refers to females age 13 and over. Since the CDC has included new AIDS cases among women living in Puerto Rico in the U.S. AIDS statistics, the population estimate of women age 13 and over in 1997 has also been adjusted to include women living in Puerto Rico. U.S. population estimates are from the Census Bureauís Current Population Reports, series P25-1139, pp. 46-47. Puerto Rican population estimates are based mainly on Eduard Bos et al., World Population Projections, Baltimore: Johns Hopkins University Press, 1994, p. 410.

4. CDC, "Report of Final Mortality Statistics, 1996," Monthly Vital Statistics Report. Hyattsville, MD: National Center for Health Statistics, forthcoming.

5. The estimate takes into account the deaths to AIDS-infected children, as well as other child deaths; so the estimate refers only to children alive in 1998. Personal communication from David Michaels based on his article, "Estimates of the Number of Motherless Youth Orphaned by AIDS in the United States," Journal of the American Medical Association, December 23/30, 1992, vol. 268, no. 24. UNAIDS reported an estimate of 70,000 orphans for the United States for 1997. UNAIDS, Report on the Global HIV/AIDS Epidemic, New York City: UNAIDS, June 1998,p. 66.

6. E.M. Connor, R.S. Sperling, R. Gelber, et al., "Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 With Zidovudine Treatment," New England Journal of Medicine, 1994, vol. 331, pp. 1173-80.

7. Based on cumulative AIDS cases among women reported through 1997. The remaining women for whom the exposure group is known (about 10 percent) were infected through infected blood products or through heterosexual sex with a man with hemophilia.

8. The countries are Botswana, Burundi, Central African Republic, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. Michael Specter, "Breast-feeding and HIV: Weighing Health Risks and Treatment Costs," New York Times, August 19, 1998, p. A14, and corrected maps published August 21, 1998, p. A7.

9. D. Worth. Self-Help Interventions with Women at High Risk of HIV Infection, New York City: Montefiore Medical Center, 1988. D. Worth. "Sexual Decision-Making and AIDS: Why Condom Promotion Among Vulnerable Women Is Likely to Fail," Studies in Family Planning, 1989, vol. 20, no. 6, pp. 297-307. Kathleen Sikkema, Timothy G. Heckman, Jeffrey A. Kelly, Eileen S. Anderson, et al., "HIV Risk Behaviors Among Women Living in Low-Income, Inner-City Housing Developments," American Journal of Public Health, August 1996, vol. 86, no. 8, pp. 1123-28.

7. The Legality of Saving Lives

1. At least two people were actively trying to get clean needles to persons who injected drugs as early as 1986. Glen Craddock of Baltimore, after he was diagnosed with AIDS, distributed needles and condoms to friends and family members on a monthly basis from 1986 until 1988, when his health deteriorated. Jon Parker, the first person to distribute drug injection equipment publicly in the United States, in November 1986, distributed needles in New Haven and Boston. The information on Glen Craddock is from his widow, Inez, who continues his work, doing HIV prevention in Baltimoreís SHIELD program. The information on Jon Parker comes from the CDC publication, The Public Health Impact of Needle Exchange Programs in the United States and Abroad, Summary, vols. I and II, Peter Lurie, Arthur L. Reingold, et al., San Francisco: University of California, 1993.

2. Scott Burris, Davis Finucane, Heather Gallagher, and Joseph Grace, "The Legal Strategies Used in Operating Syringe Exchange Programs in the United States," American Journal of Public Health, August 1996, vol. 86, pp. 1161-66.

3. As of 1996, forty-six states and the District of Columbia had laws restricting the possession or delivery of drug paraphernalia. Only four states--Alaska, Iowa, North Dakota, and South Carolina--were without a form of the drug paraphernalia law. Ibid. p. 1161.

4. The phrase "needle prescription laws" in the text refers to both laws passed by state legislatures and pharmacy regulations. Pharmacy regulations are enforced by state pharmacy boards. A pharmacy selling needles in violation of state pharmacy board regulations risks losing its license to operate. The role of pharmacy regulation in restricting access to clean needles is detailed in Lawrence O. Gostin, Zita Lazzarini, T. Stephen Jones, and Kathleen Flagherty, "The Dual Epidemics of Drug Use and HIV/AIDS: A National Survey and Law Reform Proposals on the Regulation of Sterile Syringes and Needles," Journal of the American Medical Association, January 1, 1997, vol. 277, no. 1, pp. 53-62.

5. Scott Burris, Davis Finucane, Heather Gallagher, and Joseph Grace. "The Legal Strategies Used in Operating Syringe Exchange Programs in the United States," American Journal of Public Health, August 1996, vol. 86, pp. 1161-66.

6. "Update: Syringe Exchange Programs ń United States, 1997," Morbidity and Mortality Weekly Report," August 14, 1998, vol. 47, no. 3, pp. 652-55.

7. Denise Paone, Don Des Jarlais, Jessica Clark, Qiuhu Shi, Donald Grove, and Diana De Leon, "United States Syringe Exchange Program Survey 1997," presentation at the North American Syringe Exchange Conference, Baltimore, MD, April 1998.

8. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse: Population Estimates 1997, 1998, table 19.

8. The Next Steps

1. Meg C. Doherty, Richard S. Garfein, David Vlahov, Benjamin Junge, Paul J. Rbathouz, Noya Gaali, James C. Anthony, and Peter Beilenson, "Discarded Needles Do Not Increase Soon after the Opening of a Needle Exchange Program," American Journal of Epidemiology, 1997, vol. 145. no. 8, pp. 740-47. Kathy J. Oliver, Samuel R. Friedman, Hugo Maynard, Linda Magnuson, and Don Des Jarlais, "Impact of a Needle Exchange Program on Potentially Infectious Syringes in Public Places," Journal of Acquired Immune Deficiency Syndromes, vol. 5, no. 5, p. 534.

2. University of California. The Public Health Impact of Needle Exchange Programs in the United States and Abroad, vol. I, by Peter Lurie, Arthur L. Reingold, et al., San Francisco: University of California, 1993, p. 165.

 

 

 

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