DAMAGE CONTROL

Needle-exchange program aims to stem spread of disease without forcing
addicts into treatment

Peter Fishburn, left, an outreach worker with the New Mexico Health
Department's mobile clinic, questions a man about his recent sexual
activity before he is tested for STDs. The clinic's program also
distributes condoms and provides a needle exchange every Monday in
Albuquerque. Editor's note: In 1997, the New Mexico Legislature passed the
Harm Reduction Act authorizing needle-exchange programs to prevent
drug-related diseases. Five sites opened in Albuquerque on Feb. 2, 1998.
Since then, 6,327 people have exchanged more than 3 million needles. Now
there are 23 sites including ones in Santa Fe, Las Vegas, Hernández and
Chimayó. New Mexican health and social issues reporter Deborah Davis
recently visited a couple of these sites and talked with health officials
and addicts about the program and how the state is educating drug users to
prevent illness. She writes about her experience today in this paper.

Jason, a thin 28-year-old with blond, spiked hair, knows he can come to the
Health Department's RV for honest advice about how to care for the abscess
on his arm, where heroin ate his flesh when he missed his vein.

He knows the nurse, Tani Davis-Cave, won't scold or judge him for injecting
heroin, a four-times-a-day habit for the Albuquerque man. He also feels
comfortable exchanging his dirty needles for clean ones and getting packets
of sterile water to dilute his heroin, cookers to mix heroin with the water
and dental cotton to filter the impurities in the heroin before he injects
the drug.

Jason, who has been married for three years, has taken advantage of the
free HIV and hepatitis tests offered at the RV. State health officials
estimate that most addicts contract hepatitis within their first year of
injecting drugs, but Jason tested negative for hepatitis C, the deadliest
of the three hepatitis viruses, six months ago.

They ask him, as they always do, if he's interested in drug treatment. He's
been coming to the New Mexico Health Department's needle-exchange site off
Central Avenue in Albuquerque for six years, and he doesn't want treatment.
But he hasn't shared any needles in the past month, and that's one of the
main goals of the Harm Reduction Act and the needle-exchange programs it
authorized.

Unlike many substance-abuse programs that operate under abstinence-only
rules, harm-reduction programs accept that people use drugs and choose to
minimize the harmful effects rather than ignoring or condemning that drug use.

"In some organizations, it's either black or white, you're a user or not,"
Davis-Cave said. "There's no reduced-risk model in place. Public health has
more acceptance and tolerance for what people go through in life.
Organizations that are black or white don't have tolerance for them being a
failure. It's not that way with us."

These programs try to reduce the spread of disease, a crucial concept in
the United States, where almost one-third of all HIV infections are related
to injection-drug use, according to the federal Centers for Disease Control
and Prevention.

Drug use is the major risk factor identified in new cases of AIDS,
hepatitis C and tuberculosis in the nation, and a growing number of cases
are reported among the partners of intravenous drug users, according to the
National Institute on Drug Abuse's 2001 report to Congress. In addition,
the majority of HIV-infected newborns have mothers who were infected
through their own drug use or by having sex with a drug user.

"Our goal is to prevent disease from destroying lives and communities,"
said Phillip Fiuty, the Health Department's harm-reduction coordinator.
"That's not the same thing as saying we're going to help solve the drug
problem. That's an important distinction. We're here to help people stay
alive. If they don't stay alive, they'll never have an opportunity to
change their minds."

In New Mexico, almost 83 percent of addicts have hepatitis C, according to
a statewide street-based study from 1994 to 1997. The study, which also
showed that less than 1 percent of addicts have HIV, helped win support for
a needle-exchange program from AIDS activists and former Gov. Gary Johnson,
said Steve Jenison, the Health Department's medical director of the
infectious-disease bureau.

"The rationale was if HIV has not reached critical prevalence you could
potentially keep it from happening so it will not become a problem in that
population," Jenison said.

The harm-reduction program also gives people like Jason a safe place to
seek care. Jason didn't go to a doctor even when his abscess turned black.

"People are so afraid of persecution," Fiuty said. "They don't have medical
assistance and only show up in the ER when it's completely out of control.
Having access to the type of services offered through needle-exchange
programs reduces the cost to hospitals and communities."

Fiuty, who used to work at Albuquerque's Health Care for the Homeless,
passionately believes that people don't deserve to die just because they
are addicts. And that's the philosophy underlining the state's 23
syringe-exchange sites in towns such as Santa Fe, Chimayó, Las Vegas and
Hernández.

"Fear and a lack of access to information and services causes the most
problems for addicts," Fiuty said. "If someone can talk about drug use and
not be scolded, judged or persecuted, if they don't have to lie, that's
part of the healing. When you empower people with good, basic information,
they make changes beneficial to themselves and beneficial to us."

With about $700,000 in state funds this year, the harm-reduction program
represents a sliver of the department's $25 million budget for
substance-abuse treatment and prevention. When people enroll in the
program, they answer a two-page questionnaire about their drug use, HIV and
hepatitis tests, source of needles and interest in drug treatment. This is
one opportunity for health workers to learn about people's risky behavior
and develop a relationship with them.

"It's all about trust," said Tony Escudero, a Health Department worker who
helps enroll new clients and assists in needle exchanges in Santa Fe. "If
they find someone in the system that doesn't judge them, it helps them feel
like it's a useful resource, one they'd feel comfortable telling their
friends and family about. And once they know there's no judgment, they feel
better about themselves."

The health workers always offer treatment without making it a big issue.

"If we're trying to coerce them into treatment, people won't come back or
will lie to us," Fiuty said. "We try to be ready for them when they want it."

When enrolled, addicts receive 30 clean needles and a card that allows them
to legally carry them. It is otherwise against state law to possess needles
without a prescription.

After the first 30, people receive one clean needle for each used one they
bring to the exchange site. Needles are later discarded by a
waste-management company on contract with the Health Department.

Each year, people must renew their card. Workers then resurvey them about
their drug use to see if behaviors have changed.

Of 734 New Mexicans who were resurveyed between 1999 and January 2003, 64
percent said they didn't share needles as much as they had. One client had
reduced his shared needles from 50 a week to none, according to department
records.

In that same survey, 15 percent of respondents said contact with the
needle-exchange program helped them seek treatment.

But treatment is hard to come by in New Mexico, health workers say. Twenty
five percent of all participants said they tried to get treatment and
couldn't for various reasons.

"If you've got money, there's access," Davis-Cave said. "There's not many
options available to you if you don't have money, and that's the population
I deal with."

Overcoming resistance

Albuquerque's needle-exchange programs quickly gained momentum, but the
Health Department has struggled to start programs in underserved, rural
communities where entire families are addicted and isolated from outside help.

"We need more people who are activists to rally around this," Fiuty said.

Bob Parkins, the department's disease-prevention program manager, exchanges
1,500 needles some days and barely any on other days in an RV he parks at
El Duende Liquors off Highway 74 in Hernández.

"People have to trust you," Parkins said. "They are doing illegal stuff so
it's very difficult to convince them that this is legal."

Parkins relies on addicts in the area to tell other users about the program
so they know when to expect his RV in the area.

"It can be real hard to figure out how to gain their trust and be there at
the right time when you're not part of that community," Parkins said. "You
have to be there every single time. What happens is people all their lives
made promises to them that they didn't keep so you don't want to be another
guy who told them something and didn't follow through."

Since the exchange sites opened, only one neighborhood association has
complained, fearing that the programs would lure addicts to the area. "That
doesn't make sense," said Peter Fishburn, a Health Department outreach
worker. "Any outreach program goes to where the population already is."

Outreach workers typically find support once people understand the program.

"People have some far-fetched ideas of the program," Parkins said. "They
think we're handing out needles, and a lot of people believe it encourages
drug use, that needles found around the area will increase, that disease
will increase. The opposite happens.

"You're placing a value on a syringe. It lessens the amount (that are)
lying around in the arroyos and parks."

Discarded needles are a public-health menace as people can be injured or
infected by them.

Albuquerque Police Department Capt. Sonny Leeper teaches officers around
the state about the Harm Reduction Act and the needle-exchange programs.
Once officers learn about the needle exchanges, many visit the sites and
talk with workers.

"I think they understand the significance of it and the importance," Leeper
said.

Gaining momentum

The federal government won't invest in syringe-exchange programs, but it
has spent millions studying their effectiveness. Numerous studies in the
1990s found that needle-exchange programs increase the likelihood people
will seek treatment, do not encourage drug use and reduce the spread of
disease.

The National Institute on Drug Abuse, which conducts 80 percent of the
world's research on drugs, told Congress in its 2001 report that
comprehensive programs including community-based outreach, needle exchanges
and drug treatment are the most cost-effective and reliable strategies for
averting new HIV infections.

The popularity of exchange programs has continued to grow over the years
from three sites in 1988 to 127 in 2000, according to a 2000 survey by the
North American Syringe Exchange Network and Beth Israel Medical Center.

The survey found the largest number of exchange sites in four states - New
Mexico, New York, Washington and California. New Mexico, which ranked third
in the number of sites in 2000, has added 10 sites since the survey.

New Mexico plans to expand needle exchanges in Taos, Española, Rio Arriba
County and the southwest part of the state, which has only two exchange
sites in Las Cruces and Anthony.

The program has prevented a second wave of HIV infections and decreased the
spread of hepatitis, the Health Department's Jenison said. If addicts
shared needles as much as they used to, the rate of hepatitis and HIV
infections would be greater, he said.

"It's also offered us unique access to a population that is in great need
of public-health education and attention," Jenison said.