The distribution of sterile needles to injection drug users IDUs began in the early s in the United States as a highly fragmented and ostensibly illegal practice initiated by drug user advocates and community organizations. In its earliest manifestations, needle distribution was framed by turns as an act of last resort or outright civil disobedience, caught within a legislative and political climate that actively stigmatized drug users and criminalized outreach efforts that purported to circulate drug use paraphernalia i.
Since the late s, needle exchange has achieved increasing yet variable levels of institutional support across the United States, receiving the official sanction of local public health and police departments, deriving funds from state and municipal governments, and becoming enshrined in public health law in certain contexts.
In turn, the practice s and discourse s of needle exchange have shifted significantly in many locales, becoming the purview of public and professionalized administration that advocates needle exchange as a necessary public health measure protecting both IDUs and the populations they put at risk for disease transmission.
This article will show how needle exchange has become implicated in and appropriated by networks of power that seek to discipline and regulate injection drug use. In particular, this article will seek to describe the encroachment of biomedicine upon the theory and practice of needle exchange, and further, how such encroachment has been rhetorically justified.
At the same time, this article will seek to avoid a characterization of needle exchange that envisions the unilateral control of drug users by governmental power, illuminating instead both its negative and productive effects for drug users. As the flip side of the biopolitical coin, a necropolitical perspective might view needle exchange as a genocidal or racist policy in the Foucauldian sense that seeks to subtly deprive certain populations of the right to life by encouraging a deadly habit.
Alternately, the long-term ban on the federal funding of needle exchange in the United States, resulting in its patchy and precarious implementation, may be cited as an evidence of a necropolitical stance toward drug users, who are left to die without sincere attempts at intervention.
While representing a primarily theoretical endeavor, this article will draw on the history of needle exchange practice and legislation in the United States, citing specific programs and policies where relevant; this work should ultimately be supplemented by an ethnography of the concrete practices that occur within needle exchange programs NEPs , and an analysis of the site-specific discourses that shape them.
In , Jon Stuen-Parker, Yale student and former heroin user, began publicly distributing sterile needles to intravenous drug users in New Haven, CT. While ejected from medical school the same year, Stuen-Parker ultimately persisted in his efforts to implement needle exchange in the United States, founding the National AIDS Brigade in , a volunteer-based outfit which would eventually offer exchange services further along the Northeast Corridor, in Philadelphia, Boston, and New York Drucker The size of such operations ranged from one man to several volunteers, often with little more at their disposal than a curbside table, cache of sterile needles, and bucket for the disposal of used works.
Citing an ethics based in pragmatism and social justice, many of the first needle exchange practitioners actively sought to contest a politics that excluded and abandoned drug users, publicizing their cause through acts of civil disobedience. Yet, in order to establish permanent and legal sites of needle exchange, these early practitioners relied upon sympathetic partners in local health departments and medical institutions, a strategy that risked the governmental appropriation of needle exchange.
Although a ruling by Congress continues to bar the use of federal funds for needle exchange, the Centers for Disease Control CDC enumerated the existence of NEPs, distributed across 36 states as well as the District of Columbia and Puerto Rico , as of November Needle exchange is offered here as a value-free, technical solution to an essentially biomedical problem; merely addressing the proximate, individual causes of disease transmission, needle exchange by itself remains conveniently mute as to the larger social, political, and economic context that drives drug use and HIV infection.
While the level of institutionalization enjoyed by NEPs has certainly increased over time, it is necessary to ask whether significant discursive shifts might also be mapped alongside changes in funding and authoritative support. The civil disobedience of early exchangers has been described as encompassing acts intended to stimulate political and public debate around the marginalized status of drug users; in advocating for the implementation of harm reduction strategies, individuals like Stuen-Parker were more broadly interested in advancing a program attuned to the larger social welfare of drug users, and the communities in which they lived.
Acts of illegal exchange have also been framed as a method of last resort, aimed at saving lives despite the political consequences and media attention entailed therein. In recent years, it has been argued that harm reduction has increasingly lost interest in addressing the broader social, political, and economic context that make drug use more dangerous.
Where subsequent sections of this article will attempt to further mine the concept of governmentality to discern the positive, or at least productive, effects of needle exchange, it is here necessary to both concede and question a history of needle exchange that envisions its progressive ideological cleansing by the neoliberal state. In the United States, early advocates of needle exchange undoubtedly disputed the stigmatization of IDUs within a political climate that focused intensely upon their criminalization, a stance that further decried the social, political, and economic climate that promoted drug use within certain communities.
Further, it is valid to assert that the codification of needle exchange within public health law has led to its increasing relegation to a domain of biomedical expertise, which concentrates upon the creation of regular protocols and the production of statistics seeking to portray the public health benefits of needle exchange in relatively limited terms.
It appears obvious that contemporary proponents of needle exchange invoke new logics hardly envisioned by its early supporters. From its grassroots origins to institutional investment, the major concern addressed by needle exchange may be the preservation of the biological integrity of IDUs, and by extension, the general population. Needle exchange attempts to establish injecting drug users as legitimate members of the national body, and further allows this group to demonstrate their qualifications through the uptake of risk-conscious health practices.
Whether disseminated by street-level activists or public heath bureaucrats, all discourses of needle exchange, and perhaps harm reduction at large, illuminate the entrenchment of such programs within a still-existent biopolitical regime of power. Here it is necessary to qualify the relationship between needle exchange and biopolitics, a paradigm of power that some scholars have already relegated to the past Rose Public hygiene is highlighted as a major field of biopolitical intervention, wherein increasingly rationalized mechanisms are employed toward the medicalization of bounded populations.
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This does not affect your statutory rights under English Law. All the information and images on this site are protected by copyright and commercial organisations may not use any image or text without permission. Unauthorised use may result in charges being applied, and court action. More sophisticated, multivariate models were also used, with similar results. Although drug behaviors and gender remained statistically constant over time, Kaplan and colleagues Heimer et al.
Because white participants are less at risk, the change in HIV prevalence might be due to the change in the composition of the population served, but, as the authors note, this does not appear to be a viable plausible explanation for the decline in the infectivity of needles. The decline occurred in the first days and then stabilized. The number of white participants steadily increased throughout the duration of the project. The magnitude of the change in composition is also not great enough to explain the reduction in HIV seropositivity.
Specifically, the authors state Heimer et al. If needle exchange were without effect, then However, Also, Heimer et al. As noted by the authors, because of the manner in which the exchange operated, it is not possible to know with certainty whether discordant needles i. Finally, Kaplan and others Kaplan, a; O'Keefe et al. Although the status of those who dropped out was not always clear, as noted above, a small fraction of these participants were known to have entered drug treatment.
Kaplan a argues that even short-term exposure to the needle exchange program could contribute to its aggregate impact.
The pattern of evidence surrounding the New Haven needle exchange program involves a set of models, driven in large measure by empirical data gathered from participants and the needles they exchanged. Although the estimates of relative and absolute reduction in HIV incidence are based on mathematical models, Kaplan and his colleagues have explored the computational implications of a range of parameter values. These varied models provide estimates that are not dramatically different, lending credibility to the methods.
Nevertheless, the models are not infallible. The most compelling evidence from this set of evaluation studies is the direct evidence from the actual testing of syringes for the presence of HIV positivity. Here the empirical results of monthly assessments show about a one-third reduction in the rates of infected needles. These empirical results are consistent with those produced by the models underlying Kaplan's circulation theory. Furthermore, evidence about the actual operation of the needle exchange program reveals that the mechanisms necessary for change were in place.
A substantial number of needles were exchanged removed from circulation , the frequency of exchanging increased, and the mean circulation time of needles declined. Had these changes not occurred or had there been observed changes in the composition of the study population, the plausibility of the observed effect i.
Evidence about the program processes strongly suggests that the reduction in the rate of infected needles is plausibly due to the program.
Similarly, reduction in the rate of infected needles strongly suggests but does not directly test that there should be a reduction in HIV incidence on the order of magnitude projected by Kaplan's models. In the panel's view, the empirical data clearly indicate that needles used by program participants have a lower probability of being infected and, consequently, program participants are less likely to become infected.
The first legally authorized needle exchange program in the United States was implemented in Tacoma, Washington, in There are several reasons for examining the research on the Tacoma needle exchange in some detail. The needle exchange was the dominant HIV prevention effort in the local area, so there is less confounding with other simultaneous HIV prevention efforts than in other geographic areas.
Also, several studies have been conducted on the Tacoma needle exchange program, making it possible to assess consistency across different outcome measures and study designs. The importance of the Tacoma studies on needle exchange programs is the fact that they provide direct evidence of the incidence of a blood-borne viral disease, spread by needles and sexual contact, among individuals who attended and those who did not attend a needle exchange program.
In Tacoma, the prevalence of HIV infection among injection drug users was low, indicative that incident HIV infections would be expected to be rare. The Tacoma needle exchange program began operating "unofficially" in August After informing city officials that a needle exchange would be opening, a community-based organization set up a folding table on a sidewalk in an area of downtown Tacoma where there was a visible concentration of drug users and began exchanging syringes.
The unofficial program was officially sanctioned and funded by the local health department beginning in January A few months later, the health department filed a lawsuit to settle the issue of the legality of the program in view of existing drug paraphernalia laws. In early , a Pierce County Superior Court judge declared that needle exchange was legal in the county. During the past 6 years, the needle exchange has developed into a broad public health program of prevention and education for injection drug users.
At present, the Tacoma needle exchange program consists of two fixed outdoor exchange sites, one located two blocks from the original location and another in a Tacoma neighborhood.
Both fixed sites are located near shelters or food kitchens that provide services to homeless persons and operate in areas of the city where there are many injecting drug users. The fixed outdoor sites are open 5 hours per day, 5 days per week. In addition, a community-based organization also operates a mobile needle exchange that can be accessed by phoning exchange workers and arranging to meet and exchange syringes at a mutually agreed-on location within the county.
The mobile exchange can be reached during business hours weekdays and Saturdays; exchanges are arranged before or after the fixed sites' hours of operation.
A van is used to transport supplies and staff to each of these exchange sites. Syringe exchange is also available within the local public health department clinic pharmacy for 8 hours each weekday. There are few regulations governing the Tacoma needle exchanges. Participants do not need to register or show identification or proof of drug injection to participate in any exchange program. However, all programs operate on a strict one-for-one basis, and participants must return a syringe for each new syringe they receive.
At the pharmacy exchange, a maximum of 20 syringes may be exchanged at any time. At the fixed outdoor and mobile exchanges, there is no maximum number of syringes that may be exchanged at any time, and single exchanges of more than 1, syringes have been recorded. The purpose of imposing no limit on the number of syringes is to encourage injection drug users to build up a large reserve of clean syringes to perhaps enable them to better avoid high-risk situations when they have exhausted their supply.
It is estimated that , syringes were exchanged in Tacoma needle exchange programs in 90, from the pharmacy, the remainder from the fixed outdoor and mobile programs. Assistance from injection drug users willing to act as "secondary exchangers" is encouraged, and several have been identified via the mobile exchange program.
They have included representatives from groups of gay and bisexual injection drug users and other injection drug user groups who report they are fearful of being exposed as drug injectors if they come to the fixed sites.
With each of the secondary exchanges, there is an explicitly stated expectation that syringes will not be sold. Although for a few months in the pharmacy exchange asked needle exchange participants for donations, at present there is no cost for syringes or any services provided directly by any exchange.
The Tacoma needle exchange program has been the primary source of AIDS education for injection drug users in the county. Exchange workers spend time each day talking with individuals about their own and other injection drug users' behavior in relation to risk of exposure to HIV and other pathogens and about specific prevention strategies. When it was apparent that the exchange was a better setting for one-to-one education than were ad hoc encounters on street corners, the local health department's small-scale "bleach and teach" outreach campaign moved to the needle exchange site.
Eventually, needle exchange staff assumed responsibility for providing one-to-one education and counseling to local injection drug users, primarily because regular and frequent visits to the exchange by their clientele offered an opportunity for follow-up contact and counseling.
From January to November , a monthly average of one-to-one contacts were made range , which consisted of individualized education, counseling, and referral to other services. Condoms and sexual risk reduction education have been included among the basic services since the program began. The fixed outdoor exchange sites are both within police-defined areas of prostitution in the city, and there are many female and male sex workers among needle exchange participants.
In the first 11 months of , approximately 2, condoms range from 2, to 3, were distributed each month at the exchange sites.
The fixed needle exchange sites have become the primary locations in the county for bringing health and social services to local injection drug users. Since , a public health nurse has been stationed at the fixed outdoor sites to administer tuberculosis screening tests the PPD skin test. Those who are given the screening test return to the exchange to have their results read, and further medical workup is arranged for those with positive skin tests.
Patients who require antituberculosis medications are scheduled to receive directly observed therapy at the needle exchange. Tuberculosis prevention education is provided to all needle exchange participants through one-to-one counseling and a small-media approach.
An average of tuberculosis screening tests are administered to exchange participants each year Hagan et al. HIV testing has also been provided to exchange participants to a limited extent; full implementation has been hindered by the physical setting of the exchange. The support services given to case management clients provide stability in housing and health care access. The needle exchange has also become an important source of referral to drug treatment programs in the community.
In the first 11 months of , an average of 65 persons were referred to treatment each month. Methadone drug treatment programs, in particular, noted that recruitment at the exchange resulted in enrolling a higher proportion of injection drug users with no previous history of treatment.
Furthermore, in and , the needle exchange was the largest single source of recruitment to methadone treatment programs in the county Hagan et al. Since that period, referrals to methadone treatment from the exchange have increased, but program capacity has not kept up with the demand as the number of low-cost, publicly funded treatment slots has plateaued.
In the Tacoma community, the exchange's function of safe disposal of contaminated injection equipment has been considered important. In fact, the local police chief cited public safety and protection of his officers from accidental needlestick injury as the basis for his support of the exchange program affidavit of Raymond Fjetland, in Tacoma Pierce County Health Department v.
City of Tacoma. In addition, a maintenance supervisor responsible for keeping public areas in the vicinity of one of the fixed outdoor sites free of trash and litter noted a dramatic decline in the number of discarded syringes picked up by his crews affidavit of James Burgess, in Tacoma Pierce County Health Department v. In , a sample of returned syringes was collected from the exchange and tested for HIV Hagan et al.
The virus was detected in 1 percent of 1, syringes tested; 2 percent of syringes with visible blood or dirt were HIV-positive. That year, approximately , used syringes were collected and safely disposed of by the needle exchange. In Table 7. We consider these studies in the order shown there. A nonlinked design was used in accordance with the CDC unlinked survey protocols, with all eligible clients being enrolled so that an unbiased estimate of seroprevalence is obtained.
Eligible clients included those who were not coming to the methadone clinic solely for HIV testing and who had not been previously admitted during the survey period, which corresponded to the calendar year. Demographic and risk behavior information was abstracted from data routinely collected for client records. From June through December , 1, drug treatment clients were enrolled in the seroprevalence survey.
HIV seroprevalence remained between 2 and 4 percent during each year of the 5-year period. The continued maintenance of such a low HIV seroprevalence in a population of injection drug users cannot be unequivocally attributed to the needle exchange program and its many program components. However, this stands in sharp contrast with experience in many places, where no systematic prevention programs were in place and seroprevalence among injection drug users was observed to rise rapidly from low to high levels.
Pierce County has been one of four U. All confirmed and suspected cases are reported to the local health department's hepatitis surveillance clinic. Public health nurses at the clinic conduct the case investigations and, using a standardized questionnaire, they interview cases and collect demographic and risk-factor information in accordance with the sentinel county study protocol. Hepatitis serologies are performed to specify type of infection. Hepatitis C cases were presumptively classified as non-A non-B hepatitis until hepatitis C virus antibody anti-HCV assays were introduced to diagnose acute illness.
The majority of both hepatitis B and hepatitis C cases were symptomatic at the time they were reported. An outbreak of hepatitis B was observed among injection drug users in Pierce County beginning in 43 incident cases as of December Figure 7.
The incident cases of hepatitis B among injection drug users persisted until several months after the needle exchange opened i.
That is, incident cases peaked in December 43 incident cases among injection drug users were reported, declining to 39 incident cases in December , and further declining to 9 cases as of December A similar pattern was observed among cases whose source of infection was not identified, whereas the incidence of those cases for which sexual exposure was identified as the primary mode of exposure remained relatively stable over that time period ranging between 12 and 20 incident cases per 6-month interval between June and December Hepatitis B incident cases by 6-month intervals, between January and December The fact that the reduction of new HBV cases coincided with the introduction of the needle exchange program suggests a plausible positive impact of the exchange.
These ecological data alone are subject to alternative explanations. However, when combined with other data from Tacoma, the data support the pattern of evidence suggesting that the abrupt rather than gradual reduction in new hepatitis B infections among injection drug users following the opening of the needle exchange program could be in part due to the exchange.
Injection drug users who reported to the sentinel hepatitis surveillance system in Pierce County from January to December and who met the hepatitis B or hepatitis C case definition see the previous section were included in the case series Hagan et al. Male cases who reported sexual contact with another male were excluded from the study because they may have acquired hepatitis as a result of sexual rather than parenteral exposure to the virus.
Cases reporting other risk factors for hepatitis B or C blood transfusion, health care employment with frequent blood contact, hemodialysis, or sexual or household contact with a confirmed case of hepatitis B or C were also excluded.
In addition to items included in the surveillance questionnaire, a supplemental question was asked about previous use of the needle exchange Hagan et al. Control subjects were injection drug users from either of two other health department services, including those attending the HIV-testing center or enrolling in a methadone drug treatment program.
Controls were enrolled during the time the cases were being reported. As with the cases, potential controls who were males reporting sexual contact with another male were excluded, and those referred to either health department service by the needle exchange program were also excluded.
Similarly, hepatitis C controls had to have an absence of any serologic evidence of exposure to hepatitis C anti-HCV negative. Demographic and behavioral data and serum specimens were collected for routine purposes and recorded on client records. Data were abstracted from client records by study personnel. A total of 28 injection drug users with acute hepatitis B and 20 with acute hepatitis C who met study eligibility criteria were reported to the sentinel surveillance system in Pierce County during the time period to Hagan et al.
Controls were 38 injection drug users with no serologic markers of exposure to hepatitis B and 26 with no markers for hepatitis C who were attending health department services during the same calendar period and met all study criteria.
For both hepatitis B and C infections, there were no differences between cases and controls in the distributions of gender or race. Injection drug users with hepatitis B were somewhat younger and had injected for fewer years than hepatitis B controls. For hepatitis C, there were no differences between cases and controls in relation to age or duration of injection. Adjusted for gender, race, age, and duration of injection, the odds ratio for the association between nonuse of the exchange and hepatitis B was 5.
For hepatitis C, the adjusted odds ratio was 7. These case-control studies indicate a powerful retardant effect of needle exchange program attendance on infection with two blood-borne viral infections, offering support to the wholly independent indications from the New Haven study.
The first interview study with injection drug users in the county was carried out between November and December A systematic random sample of injection drug users attending the needle exchange was drawn and asked to participate in a brief interview Hagan et al.
Subjects were asked about their behavior during the month prior to their enrollment into the needle exchange program and their behavior during the most recent month following their enrollment. Pre-versus postexchange behavior was compared for individual study subjects. In the pre-versus postexchange comparison of behavior among exchange users, there were no changes in the rate of injection. However, there were statistically significant declines in the frequency of unsafe injections.
Study subjects reported a mean of injections per month before first use of the exchange compared with injections per month while participating.
The number of injections with rented or borrowed syringes declined from 56 per month pre-exchange to 30 per month while participating. The number of occasions when a used syringe was given to another injector also declined from a mean of times to 62 times per month Hagan et al. The number of times when bleach was used to disinfect syringes also increased from 69 to times per month.
The proportion of exchange users reporting any unsafe injections also decreased, pre-versus postparticipation, from 58 percent to 33 percent Hagan et al.
From to , a referent group of Pierce County injection drug users not participating in the exchange nonexchangers was enrolled in a cross-sectional study Hagan et al. The systematic sampling scheme used in the pre-versus postexchange study was used to select exchange users for the referent group study. Nonexchangers were recruited from health care and social service agencies and street locations in areas where the exchange did not operate. In addition, chain-referral sampling was used to increase the sample size of nonexchangers.
Data were collected from both exchange users and nonexchangers through interview and HIV testing. Analysis compared recent behavior reported by exchange users while participating in the program with recent behavior reported by nonexchangers during the same calendar period.
In their second interview study, exchange users were compared with 93 nonexchangers. Significantly fewer exchange users 21 percent reported any unsafe injections than nonexchangers 45 percent Hagan et al.
And 2 percent of exchange users versus 7 percent of nonexchangers were HIV positive. A larger proportion of exchange users were living on the street or in shelters 20 percent than nonexchangers 8 percent Hagan et al. There have been no HIV seroconversions detected in either exchange users or nonexchangers in follow-up HIV testing 67 person years follow-up for nonexchangers, person years for exchange users Hagan et al.
We now discuss one or more alternative explanations for the results in each of the separate studies Table 7. First, it should be noted that the magnitude of the observed effects in each of the studies is relatively large, and that the findings are consistent across different potential outcome measures and methodological approaches. HIV seroprevalence has remained low and stable in the area, implying low community seroincidence.
HIV seroincidence in a cohort of injection drug users enrolled in the needle exchange program is low, less than 0. Incidence of acute hepatitis B among injection drug users in the county abruptly declined by 75 percent shortly following the opening of the needle exchange program, whereas incident cases attributable to sexual exposure remained relatively constant. The case-control studies of incident hepatitis B and C among injection drug users show use of the exchange to be a strong protective factor, and this finding persists after controlling for other potential confounding variables.
The comparison of self-reported risk behavior before and after beginning to use the exchange shows a reduction of almost half. Injection drug users attending the exchange report substantially fewer unsafe injections than those not using it.
Those using the exchange also have a substantially lower prevalence of HIV infection. Although there is at least one alternative explanation for each of the findings from the Tacoma studies, there is no single alternative explanation that could consistently explain the findings across the different studies. Indeed, the possible alternative explanation for one study is often contracted by findings from another study.
For example, low community HIV prevalence and the low incidence of HIV infection in the needle exchange cohort study might have been found simply because the conditions for rapid HIV transmission did not exist in Tacoma even before the needle exchange was implemented. This alternative explanation would not explain, however, why the community rate of hepatitis B virus infections among injection drug users fell dramatically after the implementation of the needle exchange or why the exchange users reported large reductions in risk behavior.
Syringe access in San Francisco is certainly at the top of the list. Acting against the law, they created Prevention Point — an all-volunteer, street-based operation. The program provided sterile syringes as well as other safer injection supplies such as bleach, cotton and alcohol wipes. It also offered condoms and referrals to drug-treatment programs and social services. At the time, Californians were not legally permitted to possess syringes without a prescription. So in the beginning, syringe access operated as an act of civil disobedience.
The founding members of Prevention Point were willing to take that risk to save lives, and in doing so they created a legacy of better health on the streets of San Francisco.
For nearly four years, Prevention Point operated totally underground.
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