Loading...
HomeMy WebLinkAboutMINUTES - 05041993 - IO.9 TO.: z BOARD OF SUPERVISORS 1.0.-9 Contra FROM: INTERNAL OPERATIONS COMMITTEE " Costa COTr''�'C °a County DATE: April 26, 1993 Uti't'{'G SUBJECT: REPORT ON STATUS OF CERTAIN COMMUNICABLE DISEASES IN CONTRA COSTA COUNTY SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATIONS: 1. ACCEPT the attached report on the status of the AIDS epidemic in Contra Costa County. and APPROVE the steps which are being taken to slow and prevent further expansion of the epidemic. rr 2 . SUPPORT AB 260 (Willie Brown) which would legalize three year clean needle exchange pilot programs in counties and cities upon request of the governing board and county health officer and with clearly established assessments to determine the effectiveness of the pilot program. EMPHASIZE that the Board's support for AB 260 is provided in order to legalize such programs, thereby opening community discussion on this issue and providing local agencies additional flexibility and discretion in the battle against AIDS. Support for AB 260 is not to be interpreted as necessarily indicating the support of the Board of Supervisors for any particular program in Contra Costa County. 3. CLARIFY that the Board's support for AB 260 is intended solely as support . for one tool in the fight against a 100% fatal infectious disease and should not be interpreted as indicating in any way that the Board of Supervisors has changed its commitment to the fight against drug abuse or that the Board of Supervisors condones intravenous drug use. The Board's commitment to, a drug-free Contra Costa is unabated. This proposed program is a step in that direction and an opportunity for outreach for recovery and rehabilitation. It is hoped that in addition to saving lives and protecting children there may be ways through this program that we may be able to have our health dollars spent more on preventing AIDS than just in treating AIDS and HIV patients . CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD gEF TE APPROVE 0 SIGNATURE(S): SUNNE WRIGHT McPEAK - H ACTION OF BOARD ON may 4 19 APPROVED AS RECOMMENDED OTHER i VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS(ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: � AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: ° A¢tLf - OF SUPERVISORS ON THE DATE SHOWN. ATTESTED 9.3 Contact: PHIL BATCHELOR.CL OF THE BOARD OF cc: See Page 3 . SUPERVISORS AND COUNTY ADMINISTRATOR BY DEPUTY I.O.-9 4 . DIRECT the Health Services Director to continue to seek the support of the private medical community, advisory boards, cities and others for AB 260 and forward expressions of such support to the Board of Supervisors for their information. 5 . ENDORSE the use of a mobile health clinic on a one day a week basis in the County, utilizing State funds and existing County staff. 6 . REQUEST the Health Services Director to make a further report to our Committee on the subject of communicable diseases on August 9, 1993 . BACKGROUND: Our Committee has been providing oversight, to the subject of communicable diseases in Contra Costa County':' for the past several years, with particular emphasis on AIDS and tfiberculosis. The Board of Supervisors last approved a report from our Committee on ,this subject February 2, 1993 . This is the most recent quarterly report on this subject. We met with Mr. Finucane, Dr. Brunner and members of their staff on April 26, 1993. Attached is a copy of the report from the Health Services Director and Director of Public Health which we reviewed, along with a set of charts and graphs which were shared with us at the meeting. It is important to note the changes in the number of reported cases of AIDS as a result of the recently revised definition of AIDS. Dr. Brunner noted that he expects 500 additional cases this year. This is a one-time increase in the caseload as cases which meet the revised definition are included. While there will be an increased caseload reported in future years as a result of the new definition, it will certainly not be anything like this one-time increase. The attached report highlights the fact that increasing proportions of injection drug users, women, African Americans, and people over the age of 40 are being seen under the new definition. The report also notes that in terms of the incidence of AIDS cases, the five cities which have the highest incidence are Richmond, San Pablo, Walnut Creek, Pittsburg and Concord. Mr. Finucane noted that added attention will be given to these cities, including meetings with the city managers in an effort to plan a joint strategy for a public education and prevention program. Mr. Finucane and Dr. Brunner also noted that Contra Costa County has a higher than average incidence of AIDS cases among injection drug users. It is believed that this is due to the fact that the County has a higher than average rate of HIV infection, rather than a higher than average number of injection drug users. The report also comments on the growing problem with tuberculosis, particularly in association with HIV infections. Additional attention is being given to directly observed therapy with non- compliant patients in the community. The report notes an upcoming program in the County's detention facilities where Public Health and Detention Facility medical staff will be testing all inmates for tuberculosis as well as offering HIV counseling and testing. Public Health staff have received a grant from the State Department of Health Services ' California Sexually Transmitted Disease Control Branch in the amount of $35,000, plus the use of a van which is equipped as a mobile clinic facility. The van will be available to the County one day a week and will be used in the Richmond/North Richmond and Pittsburg/West Pittsburg areas on alternating Fridays . The money from the State will fund the cost of a Family Nurse Practitioner and a Public Health Microbiologist on a part-time basis. Existing staff from the Sexually Transmitted Disease Program will also be working with the van on Fridays. -2- I .O.-9 Finally, Mr. Finucane strongly urged the Board of Supervisors to support AB 260 (Willie Brown) , which would legalize clean needle exchange programs in cities and counties, with the approval of the governing board (city council or board of supervisors) and the County Health officer. A copy of the bill, as amended April 12, 1993, is attached. AB 260 passed the Assembly Health Committee on March 30, 1993 by a vote of 9:4 and is scheduled to be heard in the Assembly Ways & Means Committee on Wednesday, May 5, 1993. These would be considered pilot programs, would have to be a part of a network of voluntary and confidential services and would require an assessment of the effectiveness of the program, based on a set of specified criteria. Supervisor Smith is most supportive of AB 260, believing that it is an important program and that the community must do something dramatic since otherwise we are going to have a whole group of children born with AIDS who will never have!"' had a chance for a normal life. Supervisor McPeak agreed to recommend supporting AB 260, but indicated that she would have preferred that a support network for Clean Needle Exchange Programs be developed from the private medical community, hospitals, cities and others before the Board of Supervisors was asked to support the legislation. She noted her concern that support such legislation could send a confusing message to young people that would tend to undermine our work on drug abuse prevention by implying that injection drug use was an acceptable form of behavior. She noted that it is important to explain support for a clean needle exchange program as a public health effort to fight an infectious disease and that the Board is still committed to the prevention and treatment of drug abuse. With these explanations we have formulated the above recommendations for the Board's action. cc: County Administrator Health Services Director Director of Public Health Substance Abuse Coordinator Les Spahnn, Heim, Noack & Spahnn via CAO -3- t t Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Jeff Smith,2nd District �E,..s;�.c o Mark Finucane, Director Gayle Bishop,3rd District s�ir�:,• 20 Allen Street Sunne Wright McPeak,4th District Martinez, Caiifornia 94553-3191 Tom Torlakson,5th District i C'. _ (510)370-5003 510 County Administrator �;�:, FAX ( )370-5098 Phil Batchelor County Administrator coApril 26, 1993 To: Internal Operations Committee From: Mark Finucane, Health Services Director by Wendel Brunner, M.D:, C__.) � Assistant Health Services Director for Public Health Subject: Quarterly Report on Communicable Diseases THE IMPACT OF THE NEW CASE DEFINITION FOR AIDS Contra Costa County now has over 1,000 cases of AIDS diagnosed and 644 deaths since the epidemic began. As of April 19, 1993, 1,067 cases have been reported, an increase of 15% since our'last report to this committee on January 20. The increase is due to cases diagnosed under the new and expanded AIDS surveillance case definition which went into effect January 1, 1993. The new definition primarily represents cases more recently infected with HIV and indicates more current trends in the epidemic. To date 162 persons not previously diagnosed with AIDS received a diagnosis under the new definition. The first chart on the following page shows the AIDS cases reported from Merrithew Memorial Hospital and Clinics including reported mode of HIV infection and other demographic variables divided by old and new case definition. This chart graphically depicts the shifting trends highlighted under the new case definition. Only cases diagnosed at Merrithew Memorial Hospital and Clinics are included because active surveillance efforts by Public Health have initially focused there and since January 66% of the new cases are from these clinical centers. In summary we can observe increasing proportions of injection drug users (IDUs), women, African Americans, and people over 40 years of age, among the people diagnosed with AIDS under the new definition. We believe that the increasing representation of these groups among AIDS cases will continue to be observed even after gathering all the cases diagnosed by private providers. These initial data underline the sensitivity of the new AIDS case definition to detect cases emerging from secondary waves of the epidemic. In our county this second wave has especially involved injection drug users, their sexual partners, and particularly African American injection drug users. The second and third charts show the regional distribution of all AIDS cases diagnosed and reported since the beginning of the epidemic and the incidence of AIDS per 10,000 residents in the five most affected cities. Merrithew Memorial Hospital&Clinics Public Health • Mental Health • Substance Abuse Environmental Health Contra Costa Health Plan Emergency Medical Services • Home Health Agency Geriatrics n.ze� 10i0'11 Report to the Internal Operations Committee -April 26, 1993 Page 2 On Communicable Disease in Contra Costa County Figure #1 AIDS cases diagnosed at Merrithew Memorial Hospital and Clinics (1982-1993) Comparison of cases in selected populations groups - by 1987'& 1993 case definitions 60% 52.4% :::::::::::::::::::: 50% .... -._._._................................_................._......._..........-.......-._....-........_......_.....-.._._....._.........._._._._......_._..............._....................__............................... 45.7% 44.8% ......:.:.... .. 40% - -...... ........................-._.._..........._......................_.. . 39°b _._._........ ... .. . 35% ........ ........ .:: 29.2 ..:::::::.:: .::.:..: .:: 3096 ............. 20% ......._.............. ......_.:...18.1%......................._... 9.6% 10% ... asr �o ;te: :::: ::` :e4 vs :ab: 0% Women Injection Drug Over 40 years African American Users 0 1987 Definition 1993 Definition Figure #2 Contra Costa County AIDS Cases By City Cities with five or more cases, 1982-1993 Oakley a Brentwood ,o Antioch 43 Pittsburg U 124 Alamo 7 Clayton ,0 Mora a Y Lafayette 21 San Ramon 20 Danville 20 Orinda 30 1993 NEW Definition Pleasant Hill 36 Martinez 45 1987 Definition Walnut Creek ,0e Concord W 102 Rodeo7 Kensington 7 EI Sobrante ,4 Hercules ,e EI Cerrito 29 Pinole 23 j San Pablo e3 Richmond 230 0 50 100 150 200 250 300 04/20/93 Total cases since 1982-1,067 Report to the Internal Operations Committee -April 26, 1993 Page 3 bn Communicable Disease in Contra Costa County Figure ##3 Contra Costa County Cities with the Highest Incidence of AIDS Richmond o d 20.3 Pablo S P b San o17.1 Walnut Creek 15.8 t Plt sbur 9 > > '� <'>"'«i89...: 13.7.- Casesper 10.000 population Concord 3..T.... 12.3 3 0 5 10 is . 20 25 Population from.1990 census AIDS cases as of 12/31/1992 AIDS IN INJECTION DRUG USERS COMPARING CONTRA COSTA COUNTY AND THE STATE OF CALIFORNIA By December 31, 1992, Contra Costa County reported 895 cases of AIDS under the 1987 . AIDS case definition. During the same period the State of California reported a total of 47,636 cases. Only 7% of the State cases were among heterosexual injection drug users. In contrast, Contra Costa heterosexual injection drug users represent 15% of all our 1987 definition cases. Contra Costa County has approximately 2.7% of the State's population but 4.4% of the cases of AIDS in injection drug users. Our county has had a higher than average incidence of AIDS among injection drug users. HIV INFECTION AMONG INJECTION DRUG USERS IN CONTRA COSTA COUNTY This relatively high incidence of injection drug users with AIDS is not necessarily the result of proportionally higher numbers of injection drug users in the county but more likely the consequence of higher levels of infection with HIV. Different surveys over time have demonstrated persistently high rates of infection with HIV in Contra Costa County injection drug users. Unlinked surveys of methadone treatment clients have been conducted since 1989. After removing any information that could link the blood sample with a particular person, the blood of all persons entering methadone treatment programs is tested for HIV, providing a complete picture of the HIV seroprevalence among injection drug user population in methadone treatment. The seroprevalence levels for injection drug users entering into methadone detoxification programs from 1989-1992 have remained consistently high for all clients (9.3%) and even higher for African American injection drug users (29.3%). These figures represent the infection rate for injection drug users entering treatment from the street and the community. The rates for clients in methadone maintenance programs are higher, as are the rates for detoxification and maintenance combined, largely due to the policy of preferential admission into methadone maintenance programs for HIV- infected injection drug users. Report to the Internal Operations Committee -April 26, 1993 Page 4 On Communicable Disease in Contra Costa County Street surveys of current injection drug users, mostly people who have not recently been in a drug treatment program, are a second source of information on injection drug users in Contra Costa County. The surveys were conducted in the city of Richmond by the Urban Health Study, Institute for Health Policy Studies, UCSF, directed by John Watters, PhD. Of the survey participants 90% are African American injection drug users. The first two surveys conducted in 1991 and 1992 show an HIV seroprevalence of 22.9%. The seroprevalence was higher (24.8%) when only African Americans were analyzed. The highest rate was among those who reported daily injection of drugs (29.6%). The seroprevalence rates found in Richmond injection drug users were double the rates of the other Bay Area sites which include two Oakland sites and three San Francisco sites. These figures are concordant with the unlinked surveys among injection drug users entering methadone detoxification clinics, at least for African American injection drug users. Voluntary, HIV testing data from drug treatment centers for the year 1991 show that Contra Costa County sites have the highest percentage of HIV infection among injection drug users accepting a voluntary test of the 20 counties in the State which have reported. PERSISTENT HIGH RATES OF HIV INFECTION AMONG INJECTION DRUG USERS ARE THE RESULT OF NEW INFECTIONS EVERY YEAR Injection drug users who are known to be HIV-infected are encouraged to enroll in methadone maintenance programs. In.addition to making treatment available first to those with specific needs, the intent of this policy is to limit needle sharing between those infected individuals and other injection drug users. By the end of 1992, 82% (108) of the methadone clients, tested in detoxification programs and known to be infected, had been enrolled in methadone maintenance. At least 72 Contra Costa County injection drug users have died after being diagnosed with AIDS. Of these persons 51 were African Americans. Additionally, the methadone clinics report that 21 clients infected with HIV, not all diagnosed with AIDS, have died while in methadone treatment. An additional six persons left the methadone program for jail sentences. The central factor in the persistence of the high levels of HIV infection among injection drug users in Contra Costa County, even with success in recruitment and preferential admission into methadone maintenance of those known to be HIV infected and the death of many infected persons, is the continuing occurrence of new infections. In July 1992, we reported to the Board of Supervisors that at least 16 injection drug users became infected in the previous year. These persons who tested positive were from a group of 685 methadone treatment clients who reported a prior negative status within the previous 12 months. This represented a2.3% rate of seroincidence(with a95% Confidence Interval 1.4%-3.7%). Fifteen of the 16 newly infected injection drug users were African American. For the 142 African American injection drug users with prior negative status the percent of seroconversion was 10.5% (95% CI 6.5%-16.7%). This estimate is a minimum incidence rate for new infections. The actual rate is probably higher. Report to the Internal Operations Committee -April 26, 1993 Page 5 On Communicable Disease in Contra Costa County Data for the year 1992 show a similar picture. During 1992 a total of 1,082 injection drug users accepted voluntary tests at the methadone clinics and 1,001 of these persons had negative HIV status in the previous 12 months. There were 102 positive tests, including 21 persons who tested positive and reported a prior negative test within the previous 12 months. This indicates new infections in 2.1% (95%CI 1.4%-3.2%) of the injection drug users in methadone treatment. All 21 new infections were among African American injection drug users, clients at both the Richmond and Pittsburg clinics. African American injection drug users with a history of a recently preceding negative status who tested positive for the first time were 11.3% (95% CI: 7.5%-16.7%). Again this is an estimate of the minimum infection rate. We are observing a cycle of high rates of infections among injection drug users, especially African Americans, followed by some exclusion of the infected persons from circulation through enrollment in treatment or by death, followed by new infections which maintain the overall prevalence at a consistent level. The policy of preferential admission to treatment of the infected and the natural history of the disease with probably shorter survival times for injection drug users is slowing the cumulative effect of the new infections. Observing this cycle is not enough; we need to prevent it. INTENSIFYING PREVENTION EFFORTS AMONG INJECTION DRUG USERS Community education efforts do appear to be increasing knowledge about HIV/AIDS and its prevention. Counseling and testing are widely accepted by injection drug users in treatment programs. Many injection drug users are experiencing directly the impact of HIV/AIDS either in their own lives or among their friends or family members. The Health Services Department AIDS Program has recently been informed that education and prevention funding from the State Department of Health Services Office of AIDS will double in the next fiscal year. Intensified prevention efforts are clearly necessary in conjunction with community education. We know that drug addiction places extreme limits on the addict's ability to act on what has been learned about prevention. When an addict needs his/her drug, s/he is likely to use whatever is available to inject that drug. Often a syringe or needle has been used by someone else. With new infections among African American injection drug users at 10.5% in 1991 and 11.3% in 1992, we are observing how HIV is year after year literally decimating this population. We are facing a critical situation which requires intensified action. Our first choice would obviously be for all injection drug users to stop taking drugs and to choose independent, productive lifestyles. We all know that the solution is unfortunately more complicated than that. The route of detoxification and rehabilitation is not always available, even for those ready for recovery. It is possible to survive addiction for a time until recovery is an option, it is not possible to survive AIDS. We need to prevent HIV disease, AIDS, and all the additional pain brought into people's lives, and the lives of their loved ones and children. Report to the Internal Operations Committee -April 26, 1993 Page 6 On Communicable Disease in Contra Costa County Prevention also makes sense financially. The lifelong cost for medical treatment for HIV disease, in most cases covered by Medi-Cal, is estimated at up to $100,000. The total cost of medical care for the 20 new infections we observed last year and the additional 60 infections we might expect among injection drug users in our county would be 2 to 8 million dollars. The cost is covered by Medi-Cal or would be born by the county's new Health First plan. Preventing even some of these infections would be a substantial savings in both lives and money. COMPREHENSIVE PREVENTION INCLUDING CLEAN NEEDLE PROGRAMS Part of a comprehensive plan to prevent the spread of HIV among injection drug users is to provide clean needles or needle exchange services along with access to treatment, health education, and support for change of risk behaviors. Currently, only 11 states have criminal laws against the furnishing, possession or use of hypodermic needles and syringes without a prescription. Four of these have enacted legislation or waived the prohibition administratively to permit the development of clean needle programs. In the United States needle exchange or distribution programs have been established in New York City, Tacoma, Seattle, Boston, Portland, Philadelphia, Boulder, San Francisco, Santa Cruz, Redwood City and Berkeley. Programs abroad include England, the Netherlands, Australia, Switzerland, and Sweden. There is evidence that needle exchange programs, when well designed and conducted, have the capability of reducing new infections. A recent study from the Yale University Medical School reports that in New Haven, Connecticut, the HIV infection rate fell by one-third in just eight months after sterile hypodermic syringes were distributed to drug users. A public health survey in Tacoma, Washington, indicates that nine out of 10 addicts no longer share needles. In Liverpool, England, data on the first three years of their needle exchange programs show that not a single one of more than a thousand addicts receiving clean needles got infected with HIV. Last year legislation passed the State legislature (Assembly Bill 2525/Senate Bill 1418)which would have allowed the State Department of Health Services to authorize clean needle and syringe exchange pilot projects in jurisdictions requesting such programs. The bills passed by the Legislature were not signed into law by Governor Wilson. Legislation has been reintroduced this year (Assembly Bill 260) and it is currently moving through the legislative process. The purpose of the bill is to slow the spread of HIV disease and AIDS by permitting the development of needle exchange programs, thus reducing the use of injection equipment contaminated with HIV. The bill establishes a three-year Clean Needle and Syringe Pilot Project. Assembly Bill 260 specifically: • Allows a local health jurisdiction to request authorization from the State Department of Health Services to establish a 3-year clean needle exchange pilot program. • Requires each pilot project to be part of a local comprehensive HIV prevention program. • Requires that projects be linked to voluntary HIV testing, counseling, partner notification and early intervention programs. fleport to the Internal Operations Committee -April 26, 1993 Page 7 On Communicable Disease in Contra Costa County • Requires community involvement, including the involvement of law enforcement officials, in developing and assessing each local project. • Contains language that requires the local health officer to terminate the project if he or she finds that it is increasing drug use or the spread of HIV infection. • Requires a one-year progress report and a final report to the Director of the Department of Health Services, the Legislature and the Governor on measures of the project's effectiveness. The following list of organizations were among those endorsing the Clean Needle and Syringe Pilot Project legislation in 1992: • County Supervisors Association of California • California Conference of Local Health Officers (CCLHO) • Association of Bay Area Health Officers (ABAHO) • California Association of County Drug and Alcohol Program Administrators • California Medical Association • California Nurses Association (CNA) • California Pharmacists Association • California Association of AIDS Agencies (CAAA) • American Civil Liberties Union • Planned Parenthood Affiliates • San Francisco Health Commission • San Francisco Board of Supervisors • Marin County Board of Supervisors • Alameda County Board of Supervisors • San Mateo County Board of Supervisors • City of Berkeley • Contra Costa HIV/AIDS Consortium We are requesting that the Internal Operations Committee recommend to the Board of Supervisors endorsement of Assembly Bill 260. We believe that needle exchange programs should be legalized and added to the arsenal of public health agencies combatting this disease. Report to the Internal Operations Committee -April 26, 1993 Page 8 On Communicable Disease in Contra Costa County TUBERCULOSIS The link between HIV infection and tuberculosis is well established. Since 1985 there has been an increase in cases of tuberculosis throughout the United States which the Centers for Disease Control (CDC) attribute primarily to the AIDS epidemic as well as drug use. Some of the evidence the CDC used for that assessment was developed by the Contra Costa Communicable Disease Program and reported in the CDC's journal Mortality and Morbidity Weekly Reports. In 1992 there were 117 cases of tuberculosis reported in Contra Costa County. This represents an increase of 71% in the rate of tuberculosis since 1985 but approximately the same as 1991 (108). Of these 1992 cases, 61% of the people reside in West Contra Costa and 12% were children under 18 years of age. The increase in tuberculosis is occurring nationwide for many of the same reasons that we are seeing here in Contra Costa. These factors include substance abuse with poor attention to medical needs, combined with lack of access to medical care; increased non-compliance with medical regimes in persons diagnosed with tuberculosis; and concurrent HIV infection leading to more rapid progression from infection to disease. Six patients are currently being treated for Tb which is resistant to multiple medications. However, the issue of drug resistance, although a concern, has not increased extensively yet as it has in New York. We have treated three to six drug resistant patients each year for many years. We need to remain alert for the development of Multiple Drug Resistant Tuberculosis through the expansion of directly observed therapy (DOT) with non-compliant patients in the community. TB Incidence Rates in Contra Costa Co. 1985-1992 .................................... . .............. .... .......................120............. ....................................................... ....117 Cases per year 1o0 103 108 (95% Increase) 80 .................................._................................ .. .............. ................... ................... 60 ............ ........._............................................ .............. ................ .................... ................. ...... 48 .......... ....__............. .................... . ....._..... .................... .................... .................. .............. ...... 2 64 1 .5 .............1 9 ...........1 .2 ............1. 8 ................1 1 8 Ca e p f' ; O 7 % Increase) 1985 1986 1987 1988 1989 1990 1991 1992 Report to the Internal Operations Committee -April 26, 1993 Page 9 On Communicable Disease in Contra Costa County NEW EFFORTS IN RESPONSE TO HIV/TUBERCULOSIS • HIV/TB Project in Detention Facility Public Health and Detention Facility medical staff will be testing all inmates for tuberculosis as well as offering HIV counseling and testing. Screening will include a chest X-ray and examination by a physician with preventive therapy for all those who do not have active tuberculosis. The unique aspect of this project is that all inmates requiring preventive medication will be.observed (actually watched while taking their pills) during their time in detention. When they are released, a field worker from Public Health will visit them at home and deliver directly observed therapy (DOT) until the six month course of therapy is completed. • Mobile Clinic Contra Costa Public Health staff will utilize a mobile clinic facility provided by the State Department of Health Services each Friday beginning April 30. The clinic will be in Richmond/North Richmond twice a month and in Pittsburg/West Pittsburg twice a month. The target population is women who are prostitutes, women who trade sex for drugs, and their partners. We will also target the substance abusing population and their partners. The mobile clinic will diagnose and treat sexually transmitted diseases (STD). There will also be testing for tuberculosis and HIV with referrals to care, counseling and education as an integral part of the services provided. We are working with community organizations including Cal-PEP and Neighborhood House of North Richmond to do outreach and follow- up for persons served by the mobile clinic. v ro � o � •° USO -+-a c k ro k -c o .c O O U .0 cz 4-0 = (13 oLO CO o h CO.. y N L O a--0 C L 0 O a� C O �+- v >C U C a� L '\ CO O O •- �0a -+ p O �C +.. U a� (� cri a) O ,cz .=' cl) Q ro O �L � CO cz U 0 N O O O Q i O T OR O O C Q r N t� 'C V tCL to co dwo co co '- a c U N N v 0 N O O N � Q O O T v v +r \ T C Q O O O LCO :: >:> >: CO p : r p � QCO ` o U a� c� czLO o � rz co U � c c� V, CDL Q � L � • O CO -0 �r o Q� �... N U IQ) o N O O Q C ca o U a •L Cl) C �t b a� E 0 Q �C .�..� lA co C> CD cr). -L ccs CO ccs � _ Q O L a� Q� ......... '......... < > 0 ...<: E co O Cf) M 0 O ti C 'L T U C 3` L S ❑ L ++ w .�.+ L C L .0 co O CD O 'Q U N = O N ,CZ Cf) N c O �C CO C co t .L T o :... a . ...... C a'^) co O K\ T co CF) E V/ O [� Uco N COCV 0 CO Q T OO O O O O O co lA C7 N r ti Q � Y+ N N G O .G G .� O Q "r Q U z � co '�- rn rn N CD � a � o e o r N � co T �o N cl) C ZN N 10 1p V N N N 0,0 V r O �".�► fl) O 0 o ca H 46 ' o (1) O p 00.0 .• td"� v� „O � O o� 0 O tZ p N'y c r Hca x" �� 2 o S�0 cA o- Qo o) a. V v LO N o CIL OO N {� .� y N .. T .� a COTco rn T v/ W YJ ■i MM T OT U N n, T W U C 0 T ■_ ;;...:::. �;::::::::: :::::::::: :. C�. :::::::: .:t�.::::: �1.:< . >Q1 :. CCS :; �., v; ao O U ._ TT N N ..i. 1 c r 0 r U �-+ i I I I � O � N U as = a L y c o w cd U c Cl) cc c U 5 c CL C, o — a ¢ O V) 0 -v tl1 AT ca o o 0 30 cl' CO - -Cf CA Cf gT to 0 c y ... fid? ` �.+ p° •, 3 b -fitn d V no U td U , C U cn o i V 'Soo t t Crl oN (� 00 To ;v O C\j °C ._ cz U ccs -. N O N r ti \\� �\ � T cz 1 m ti v C) co co cz CZ 0 co CD LL ORco _ .a? CDLJL co � LL ZRI 4: ZRR a ,a a a cn a C7 N N l N N CY) ".. U o w ^, W �O N C SI. L L N -211 O o C/ .c: VCD Z a� c: .� -c co O 3 N U oN _ cz O O o O � � o T O W N T _ Q �., C u •— o N C _ o _ j y � 0 0 U) U) N a U) '' C O u o O C r MDQ 3 U c °? >1 •` v •O L -&-a Z3 . c O .� Cn .2c)� 1 Ucz .c \\ ' In .� C/) LO 0 cu00 N cU � co � T N o > N o O •� O CY) Q Q U (Y r O -� a? r L 11 N cz a) .� O n U O •— U i CO c N Flu rz . _ •+-� 3 Z O •— •— U O O ` ) V) Q1 ' a v C . O I� N T:. Cl) �. . O M T V o rn T L Q -♦-+ M O r O N o T T o rn T N 00 LD ■ ^' 1 Cl) LO +(1) co O 00 O rn 00 cz ccT T L � U o� co co CL �. 00 V v c0 � � c mO CO F N CO CCU co0) AMENDED IN ASSEMBLY APRIL 12, 1993 AMENDED IN ASSEMBLY MARCH 1, 1993 CALIFORNIA LEGISLATURE--4993-94 REGULAR SESSION ASSEMBLY BILL No. 260. Introduced by Assembly Members Willie Brown, Archie-Hudson, Bates, Valerie Brown, Burton, Cortese, Escutia, .Farr, Lee, Martinez, Murray, Solis, Speier, and Vasconcellos (Coauthors: Senators Dills, Hayden, Hughes, Killea, Marks, Rosenthal, and Torres) January 28, 1993 An act to amend Section 4146 of the Business and Professions Code, and to add and repeal Chapter 1.18 (commencing with Section 199.83) of Part 1 of Division 1 of. ,t the. Health and. Safety Code, relating to AIDS. LEGLV A=.COUNSEL'S DIGEST AB 260, as amended,.W. Brown.. AIDS: Clean Needle and . Syringe Exchange Pilot Project. Existing law authorizes pharmacists and physicians to. furnish. hypodermic needles and syringes without a prescription or permit for human use in the administration of insulin'.Or adrenaline. This :.bill would establish the Clean Needle and Syringe Exchange Pilot Project, and would authorize pharmacists, physicians, and certain persons authorized under the pilot project to furnish hypodermic needles and syringes without a prescription or permit as prescribed through the pilot project: . This 'bill would state the findings and declarations of the Legislature regarding infection with the human 97 80 AB 260 — 2 — immunodeficiency virus (HIV), and development of acquired immune. deficiency syndrome (AIDS) among injection drug users. This bill would require the State Department of Health Services to authorize a pilot project in the City and County of San Francisco upon the request of the San Francisco County Board of Supervisors, the Mayor of San Francisco, and the local health officer. This bill would permit the department to authorize additional counties, cities, or cities and counties to.develop a pilot project upon the prescribed request of that j county, city, or city and county and local health officer. This bill would. enumerate the components of the pilot project, and would require that the pilot project be part of a network of voluntary and confidential services where available. This bill would require.that the county, city, or city and county participating in the pilot project assess the project using certain criteria, and submit a progress report and a final report that take into consideration.data from the assessment to the State Director of Health .Services, the Governor, and t the chairpersons of both health.. committees of the Legislature. This bill would provide`. that. if the local health officer determines the pilot project has a detrimental effect on drug use and the increased spread of HIV, the project is to be terminated. This bill would repeal the pilot project on January 1; 1997. Vote.:. majority. Appropriation:. no. Fiscal committee: yes. State-mandated local program: no. The people of the State of California do enact as follows:. 1 SECTION 1. The Legislature hereby finds and 2 declares all of the following: 3 ' (a) The rapidly . spreading acquired . immune 4 deficiency syndrome (AIDS) epidemic poses. an 5 unprecedented: public health crisis in California, and 6 threatens, in one way or another, the life and health of 7 every Californian. 8 (b) Injection drug users are the second largest group 9 at risk of becoming infected with the human 97 100 i — 3 — AB 260 .nt of 1 immunodeficiency virus (HIV) and developing AIDS, among .2 and they are the primary source of heterosexual, female, 3 and perinatal transmission in California, the United Health 4 States, and Europe. county 5 (c) According to the State Office of AIDS, injection Mcisco6 drug use has recently emerged as one of the most :!0,, and 1 7 prevalent.risk factors for new AIDS cases in California. rtment 8 (d) Studies indicate that the lack of sterile needles )unties 9 available on the streets, and the. existence of laws of that 10. restricting needle availability promote needle sharing, er. 11 and consequently the -spread of HIV among injection e...pilot 12 . drug users. The sharing of contaminated needles is the in of a 13 primary:means of HIV transmission within the injection where . 14 drug user population. or city . . 1.5. (e. ) . As of.September 1992, 33 percent of the 242,146 project 16 reported cases of AIDS in the United States were a final 17 associated with injection drug use. Of the 15,221 cases of 5sment 18 AIDS.presumed to be transmitted through heterosexual )r, and0 sex, 53 percent of the cases occurred among the sexual )f the 20 partners of injection drug users. Of the 3,480 pediatric 21 AIDS .cases related to a mother with or at risk for HIV officer 22 infection...67 percent were related to injection drug use. n drug 23 The number of reported AIDS cases reflects only a to be 24 fraction of the total number of persons infected with HIV. ' 2.5. (f). An estimated 11.7 percent, 6.2 percent, and 5.5 1, 1997. 26. percent of injection drug users entering methadone :e: yes. 27 treatment programs between 1989 and 1991 in Contra 28 Costa, San Mateo, and Alameda Counties, respectively, .29 were infected.with HIV. Public health officials .generally . 30 consider the seroprevalence rates of those entering 31 treatment to be significantly lower than the true rate of Is and 32 HIV infection among the injection drug user population J. 33 as a whole. For example, in San Francisco where data was ;zmune 34 collected over.the same period, the seroprevalence rate es. an . 35 of those entering treatment was 8.3 percent compared to .a, and 36 15 percent among the estimated 16,000 injection drug -alth of 37 user :population. 38 :'(g) Most injection drug users use a variety of drugs: group 39 mainly heroin and cocaine. Recent federal drug abuse human ;� I .40 surveys indicate.that cocaine has replaced heroin as the i 97 100 97 120 AB 264 —4- 1 -4-- 1 injection drug user's drug of choice. Because 2 cocaine-injecting drug users inject more frequently than .3 heroin users, their risk for HIV infection is higher. 4 (h) Studies of injection drug users in New York,.New 5 York; San Francisco, California; Tacoma, Washington; 6 .Boulder, Colorado; Portland, Oregon; and other cities in 7 the United States indicate that injection drug users are .8 concerned about AIDS and do change their behavior 9 when offered, in a nonjudgmental setting, reasonable I 1 10 strategies to protect.themselves. A San Francisco study,of 1 11 injection drug users found that the percentage of drug 1. 12 users who reported using bleach to sterilize .their 1, 13 equipment increased from'3 percent to 61.percent after 1. 14 :a street outreach.program was in operation for six months 1 15 and to 86 percent after two years: 1r 16 (i) A study. by Yale University of a needle exchange 1' 17 program in New Haven, authorized by the Connecticut 1� 18 Legislature in .1990, estimates that in the first eight 1� 19 months of operation, .the program reduced new . HIV 2( 20 infections by 33 percent. 2J1 21 (j) California is one of 10 states that criminalizes the 22 furnishing; possession, or use of hypodermic needles or 2 23 syringes without a prescription. Of these 10 states, three 24 24 have either passed legislation or waived the prohibition r- 2, 25 through administrative action over the last several'yearn 2E 26 to permit the development of needle exchange 2? 27prograrris: California has the highest seroprevalence rate . 28 28 of.HIV infection of any .state, .that has not waived the 29 29 prohibition or adopted a statute to permit needle , 30 30` exchange: programs. 31 31 SEC. 2. Section 4146 of the Business and Professions 32 32 Code is amended to read: - 33 33 4146. (a) Notwithstanding any other provision of `. 34 34 law, a pharmacist or physician may, without a . 35 35 prescription or a permit,furnish hypodermic needles.and 36 36 syringes for human use in the administration of insulin or 37 37 adrenaline; a .pharmacist or veterinarian may, without a 38 38 prescription or permit, furnish hypodermic needles and 39 39 syringes for use on poultry or animals; and a person may, 40 40 . without a prescription . or , permit,. obtain hypodermic �'7 140 -5 — AB 260 1 needles and syringes from a pharmacist or physician for .use 2 human use in the administration of insulin or adrenaline, han 3 or from a pharmacist,veterinarian, or permitholder, for 4 use on poultry or animals; if all of the following few 5 requirements are met: :on; 6 (1) No needle or syringe shall be furnished to a person s in 7 who is unknown to the furnisher and unable to properly are 8 establish his or her identity. rior 9 (2) The furnisher, at the time furnishing occurs,makes Me 10 a record- of the furnishing in the manner required by y of . 11 Section 4147, rug 12 (b) ,,Notwithstanding any other provision of Maw, a leir 13 pharmacist, physician, or other person designated under ler 14 the' operating procedures developed pursuant , to .ths 15 paragraph (1) of subdivision -(4-} (a) of Section 199.84 of 16 the Health and Safety Code may furnish hypodermic ige17 needles and syringes without a prescription or permit cut 18 when :operating under the pilot project established ght 19 pursuant to Chapter. 1.18 (commencing with Section. [IV 20 199.83):. of Part 1 of,Division 1 of the Health and Safety 21 Code. the .22 SEC,. 3.. Chapter 1.18 (commencing with Section or 23 199.83) is added to Part:1 of Division l of the 'Health and ree 24 Safety Code, to read; ion 25 .airs ' 26 CHAPTER 1.18. CLEAN NEEDLE AND SYRINGE ige 27 EXCHANGE PILOT PROJECT ate 28 the 29 199.83. (a) The Legislature finds and declares that dle .30 scientific data from needle. exchange programs in the 31 United States and in Europe have, shown that the . ans 32 exchange of used hypodermic needles and syringes for 33 clean hypodermic needles and syringes does not increase Of ; ;t : 3.4 drug use in the population, can serve as an important a 35 bridge to treatment and recovery from drug abuse, and Lnd . 36 can curtail the spread of human immunodeficiency virus t or 37 . (HIV) infection among the intravenous drug user It a 38 population. end 39- (b) . In order to attempt to reduce the spread of HIV ay, ;:-� 40 infection among the intravenous drug user population nic 97 160 140 i AB 260 —6- 1 6-1 within California,,the state department shall authorize a 2 one-for-one clean needle and syringe exchange pilot i 3` project pursuant to this chapter in the City and County i 4 of San Francisco upon the request of the San Francisco ?. 5 -County Board of Supervisors, the Mayor of.San Francisco, 6 and the local health officer. 7 (c) The state department may authorize additional ' r 8 one-for-one clean needle and syringe exchange pilot 9project sites upon the request ofa county board of 10 supervisors and the local health officer.of that county, or 11 - upon the request of the city council, the mayor, and the 12 local health officer of a .city with a health department. 1 13 (d) -Authorization by the state department shall be 1 14 based upon -a proposed project as described. in Section 15 199.84. 16 199.84, (a) A city and county, or a county, or a city i 17 with a health department that receives the department's ! 1 18 authorization pursuant to this chapter shall, in 1 19 consultation with the state department,. the . State 1 20 Department of Alcohol and Drug Programs; the local 21 ' alcohol and drug administrator, . and the University of ' ' 2 22 California,, conduct a pilot project on.. the one-for-one # 2 23 exchange of clean hypodermic needles and syringes as 2 24 part of a network of comprehensive services, including 2 25 treatment services,to combat the spread of HIV infection 2 26 among injection drug users. The pilot project shall 2 27 include, but not be. limited to,.all of the following. 2 28 (1) The development of a set of operating procedures 29 by the local health officer for the furnishing and one for 2! 30 one exchange of hypodermic needles and syringes for 3( 31 injection drug users and. the approval of the operating x 3' 32 procedures by.the state department. 31 33 (2) The development of a database and collection of 34 data relating to the furnishing and one-for-one 3` 35 exchanging of clean hypodermic needles and syringes to 30t36 injection drug users by persons designated in the 3E 37 operating procedures developed pursuant,to paragraph 34 38 .(1): 3f 39 (3) The provision of community outreach . and. 3I 40 preventive education that is culturally sensitive and 4( 97 180 -7 — AB. 260 .e a linguistically appropriate to reduce project participants' ilot 2 exposure to HIV infection, my 3 (4) A demonstrated effort to secure treatment for sco 4 drug addiction.for participants upon their request. ;co 5 (5) The involvement of the community in the ' 6 development of the program and assessment design.. nal 7 (6) .The involvement of local public safety officials in dot the development of the program and assessment design., of 9 (7) Accessibility of the project to the target population or 10 while being sensitive to community concerns. :he 11 (8) Appropriate levels of staff expertise in working it. 12 with . injection drug users and diverse cultural be 13 populations; and adequate staff training in providing ion 14 community referrals, needle hygiene, and safety 15 precautions. pity 16 . (9) Enhanced treatment capacity, insofar as possible, it's 17 for injection drug users. in - 18 (10) Treferential acceptance, insofar as possible, of ite 19 HIV-infected drug users into drug treatment programs. cal 20 (b) The pilot project authorized pursuant to this of - 21 chapter shall be part of a network of voluntary and ,ne 22 confidential HIV services, where available, including,but as 23 not limited to, all of the following: ng 24 (1) .Anonymous HIV antibody testing and counseling. on 25 (2) Notwithstanding Section 199.25, voluntary,. 26 anonymous, or confidential partner notification. Lim 27 (3) Early intervention and ongoing primary medical res 28 care followup for infected persons and their partners. For 29 (4) .Social services to support families of HIV-infected for .30 drug users. ng 31 (c) Components of the pilot project authorized 32 - ursuant to this chapter. shall be assessed as to their P. P of 33 effectiveness by the participating city. and county; 34 coun or city. Participants . may individually or as a ne . .� tY�' to 35 group contract with the University of California to assess he 36 the pilot.project. Assessment shall include, but not be ph 37 limited :to,,at least four of the following measures: 38 (1} Incidence of HIV among the subject population to nd 39 the:extent the. data is available. nd 40 (2) Needle exchange rates. 180 97 200 AB 260 1 (3) Change in level of drug use. 2 (4) Change in level of needle sharing. 3 (5) .Change in use of condoms. 4 (6) Change in use .of bleach. 5 (7) Program participation rates. 6 (8) The. number of. participants entering treatment. 7 (9) The status of treatment and recovery of. those 8 . entering substance abuse treatment programs. 9 (d) All components of the pilot project authorized 10 pursuant to this chapter shall. be voluntary. . Where 11 ..persons are provided services as a part of the pilot-project 12 other than the furnishing or exchange: of needles, 13 including; : but not limited to, antibody testing, . 14 counseling, or medical or social services, those provisions 15 of law governing the con$dentiality and anonymity of 16 that information shall apply. All information obtained in 17 the course of implementing the pilot project that 18 personally identifies any. person . to whom needle 19 furnishing and exchange services are provided shall 20 remain confidential and shallnot be released to any 21. person or agency not participating in the pilot project 22 without the person's.written consent. 23 (e) If the local health'officer determines that the pilot 24 project has.a detrimental, effect in terms of increased 25 drug use and` the increased spread of HIV, the project ?; 26 shall be. terminated. 27 (f) :No .provision .of this section shall apply to the 28 University of California unless the Regents of. the 29 'University o£California by resolution enacted.by January. 30 31, 1994, make that provision so applicable. 31 ., ..:(g) A city and county, county, or city with a health 32 department entering into the pilot project, shall submit 33 a progress report oneyear from the project's inception, 34 and a final report on or before April 15, 1996. The reports 35 shall . take into consideration available. data on factors 36 listed in subdivision (c).,The report shall be submitted to 37 the State Director of Health Services, the Governor, and 38 the.chairs of both health committees of the Legislature. 39 199.85. This chapter shall remain in effect only until 40 January, 1, 1997, and as of that date is repealed, unless a- 97 M . . —9- ASB 260 1 later statute, which is enacted on or before January 1, 2 1997, deletes or extends that date. se sd re ct ;s g, 1S of in at Ie X11 iy a 2t A o • ,d ie to :y a h it 1 tS rs :o .a n -i} a J Y 97 220 20 , DATE: REQUEST To SPEAK FORM (THREE (3) MINUTE LIMIT 0/ Complete this form and place it in the box near the speakers' rostrum before addressing the Board. NAME: 1 4 1 s 0.r� PHONE: %-1j , 3�9 ADDRESS: CITY: 1kJ I am speaking formyself OR organization: Check one: (NAME OF ORGANVkTION) I wish to speak on Agenda Item # My comments will be: general for against I wish to speak on the subject of e, O_UkQe, NF2 Z420 I do not wish to speak but leave these comments for the Board to consider. i DATE: REQUEST TO .SPEAK '' ORM ``�� (THREE (3) MINUTE LIMIT) (i Complete this form and place it in the box near the speakers' rostrum before addressin a Board. X2i PHONE: 02 ADDRESS: CITY: I am speaking formyself OR organization: C- Check one: (NAME OF RGAN17 10,) I wish to speak on Agenda Item # �- My comments will be: general for against I wish to speak on the subject of I do not wish to speak but leave these comments Mr the Board to caer, DATE: REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT) C-3 Complete this form and place it in the box near the speakers' rostrum before addressing the Board. I NAME: T I I� PHONE. SIO Q ADDRESS: c e CRY: P bi I am speaking formyself OR organization: Check one: (NA11 of ORGANIZNTIONt&- /J I wish to speak on Agenda Item # 7-0 9 My comments will be: general for against I wish to speak on the subject of f IF I do not wish to speak but leave these comments for the Board to consider. DATE: REguEsr To SPEAK FORM (THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. NAME: hr�� L y)s PHONE: t�/ ADDRESS: )--)40n �,h�� 5 � Crnt: A tls byr�) I am speaking formyself OR organization: Qi fits 6-)j2� Q6 :5(' G a)I Check one: (NAME bF ORGANIZ-\TIOM) I wish to speak on Agenda Item # My comments will be: general for I/ against I wish to speak on the subject of C (1i nWe Ido not wish to speak but leave th a 9g69erMf9 or he Board to consider. DATE: REQUEST .TO SPEAK '' ORM (THREE (3) MINUTE LIMrr) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. NAME: PHONE: ADDRESS: T/ y71L�1 �2 e . CITY: I am speaking formyself OR organization: V. Check one: (NAME OF ORGANVNTION) I wish to speak on Agenda Item # /y , 9 My comments will be: general for against I wish to speak on the subject of ✓ I do not wish to speak but leave these comments for the Board to consider.: APCC: 5109325153 P. 02 c AIDS PROJECT' OF CONTRA COSTA rlav RrSOURC.E5+S[;PI'0RT•F-DUCA TOIL •'GK(:E;gg5 May 3, 1943 Tom Torlakson, Chair Contra Costa County Board of Supervisors 651 Pine .Street Martinez, CA 94553 "`'""""CT d-.FNCY OF VVTIED VA Dear Supervisor Torlakson: 1N:riIk iMMEr On behalf of the AIDS project of Contra Costa, I am writing to express our strong support for AB 260 (brown) , a bill to establish a clean needle and syringe exchange pilot project in order to halt the spread of HIV among injection drug users in California. We hope the Board of Supervisors in Contra Costa County will also lend its endorsement to the legislation. When viewed as part of a comprehensive HTV prevention program targeting injection drug users, needle exchange is an effective HIV prevention intervention. Just last year, after reviewing numerous studies of needle exchange programs in the U.S. and abroad, the National Comission on AIDS urged the elimination of regulations and laws that block implementation of needle exchange. According to the Commission, "fears that needle and syringe exchange and distribution programs might encourage drug use and a new class of drug injectors have not materialized. " Needle exchange is supported by most of the major public health groups in California, including the California Medical Association, the California Conference of Local Health officers, County Drug Program Administrators, the California Pharmacists association, and numerous HIV service organizations across the State. we hope that the Contra Costa county Board of Supervisors will be among them. As a local option hill - only those communities with significant local support would be able to apply for authorization from the Department of health services - AB260 represents a modest, but significant step forward. ,in our ' State's fight against RIV. 2326 BCRJLFVARD CIW—I.E•WALNUT QME&CAIJf ORNTA,94595--II53•7ELEXaRONE jz0,931 AIDS+FACSIMILE 510,'932-5153 APCC 5109325153 P. 03 c y Page 2 Board of Supervisors I hope that you will support this measure when it comes before the Bard on Tuesday, May 4. Sincerely, Dick Eastwood Secretary, Board of Directors ' �.rr{ aN t .�-- rte'• -.�� _�i .•�c. ? �. � _t. �,,� rs r 5t r ` .,, - [ a. ��,�'��1�n,A. I x-S• i ".` 1� � A •a 4 3p��} :'° •,{? r - .f�,,,?j-f". 3Y .a> r t-- .y i, y,Fr -y� it<•x ` 'r� ! i5 y •.�y{ + �'r m ` w�. 1 rtiZy 9 =g' 71, 1�� ?rt` 115, -'N'7.�£ Ci�' ..p. e,W �T' �,� �y'''y,.4+`�'!"k• a PfSa xq. s �" `;�4.r'2Tf'"q„ ��& 9,�r,.�r�...e" �'w��til „�t;5.:�.. . �, X�v.-„,tx��;.�5. +t'• -�=ya_,r�r, i,� ��:g.��` ,,.��n'+{`a„ �' G�x,�`�•,{�,.,, s �r. � �,-,3��"Js.,,.'sr. .spa �f.. 4,.•.''�y±+c� �.�`7'�'�f�' #,, 't-a 'Y�x_•'71F[_:i �k��y.,�. :l �.t-v3`t,;,�i��n t c�a..,�YJ,.0��iv'.,�,�s�"�,�1cw�,_��:� ��tJ}t^�-}'ey�`"9•,J.•i,h'” {��ln.:+ •e'r�'�F�� J�3== ,rf' ,y'}"` nia+4�i 1`��. '1r ���"J`��,'rl��Y.r1r�y r Zk������ aF '� fir. : . � -r='' a�' tY y�s..-�'".�. -. 9 � .xY t J 'h. -Y�lt•.4!•. �f a1 '�J., '?i:„f .�,a-:is .r :�•;' .v,�,, Ae>r.u,4',�.' .t_ T ,�+-n <( .Sr:F. .4 :rv. �yr,ti•. £ *'''� it X-�,✓tr.'\�' �. -•!:;/s c y 4 .�•y y � w+,W.yr�''i'... ff:.il�..aY 'x ham'- y.'-..•u •ic e `,�r''M.r'"c'�?f yy,_t 'x ,lnl. -L` S�; q iL ?��.`°�°i fir r'°?�,,. +�•-.rf�1{ ''4 �'F'3+,:;;�s ''i`S•+s'•ay e i�.;,1..] a \"s• �t'tT, .�.s, 4' r d_: �rJ-.. "v{i,�.x.,;ate. d .:£t . �;„4:• Y-' 'r•n`i (t.> {Ft"r � ice"., c�. 6 4''�,v-•s�,' ys'�, t . r G >L_;�'- .y}i§,� • ����' ,� '` .r`�6'�h. �$,I x ,�a �.5. �• w � c .'� c�i�,�'h t t�r`'�' �:`�,�,r�,,`!"� >, �.�z' ,5��"�'i .y�F•� :�3 3. r '_�., 'kF �� t: '� ..� � :}'.`:4. -v � c. 'Lii, �.�K- 1'ci;�r Y-y x 4 ah_ 5� n'"•, F;� r� •��' - -vw1'� x:� � i�fi�r�r�Y `a.� ,Hs • t � r � a r ' m s2i"t2 r'�Ik:a.."`t� h.4s-fa:�R�`�` " �S�•• .:"rt., 3'a t r 1�'1 f r � .9"1d..�.�c, �q r �. 1r i,a t.-1� t�y' 1 �'?{-✓x •` .i. !��{.. :F -,� !i•'.{.�-+^. 3� �.> �.n t �J rtfi `��4.` `+� s. S.fi' .dna t' w � =y✓, b '�^r ^'•" _ ,.><-: :`' 2i73,'L<�.a. t -+:�•+.•, l v Fi.' x ,khrF .''.-- { '#,.fes F'-54'7 3 s: .5'+O .' ? ■ , .r•:���,",�..` �'�tr,. .fir i`[ :4S-iily°Ytf Sz .3'<.. x Y.5 ^� X-.tjL �.�':f.,a"7' t ,n.,.s 3 { '�a' �F� x yy?'+'•. .c+l:. '.'.. .,.,y+F•ap'�� ..J,F JcY.9���c,�+ •FI.. " ter,.,fiiw '17tf' +{Y.t vis} t, ,`sC ti: r*•';3♦; ` .��;;qq �' 'v�A`}.:rcj,YiJ•``'p^"�y'.^+'=l ,M -;.`�,•?-f',ci•`''.. �•'�: ,t .✓. e5: p rt s r nZ•� i GCK-.;'..� `7iZ:'F';•n�Pryy.Pic Wit'yt4. -.���,!5ye•',tr'�'^,"rr;3.{-5t`J" i?.w tr_..t5¢+'.Y,lr •.�� ff oLa': ,ri'F'. fi• .i.y ,r�-<tyy'� ',. ty ,�: 3�'t •u,}yi5, �, '•""S � ;�.-� f3'.•HY,',"�ryt+.. .;icr?;rt';.•d?;:'SJr" y. ' '!`'ti:rl ,`.K. 1 r J`'Yia 3 :.tr r ..va...i''r` a �5.. - " Ft r`'1'I••'.;�t. ci' '7•r �!` >•;.1-.1h .+i' gYxtr^;. ..tli rr,c-,- a(1` -,•.FY' 4:.a`(s''�ii ,.:y�,:,,,k r!�,tr��rF -cam .i...,.,n- ,rte=E `:�7n"l;+' n:.�i `•xc:-y�.r� •ar}, .at -`d •>(tr.,�..f . �.�a➢ri�;;5';'S°� �.,,t 7 }...'1>� P v' -�+i�t_ •„9 r 7 r''S�,_1+,. ` � .,�,r�Yy^.- h... a'�,( •.y5c3.ia �` 1,.lr.t �r.B' uMi 4;•Gv ,�r x k,•..r -`r.....:;-� c•.. .,; •c - .. tr-`1c`.. '.✓ ,r n''7 •fi': t FL ,�i�IS.vc�. „14:A :Nh:�r i a• w.. Y c R � K, 1g, J � r j ;r`Y. � i+� .&3, yr.�s .2':�3r'AfA-•��i. 'q+. xf,l.. �' :q.; x{��,rYYx. � .ip E ray', _•Y'} � �,Y•{�' :-t'1;:� a•' >fY e a' a a , A 5Yr rrk ? 4^'?3,_ -uJeX „i a. ��w au. aa`•. tr` !.i:. `c;... "`-1't..�' a ;�s•f. .r.v+.;z -. �'p.- ,r ,;'nom, -St, _ it•; <YI i`��`' ry"i`,�•',ti'?y`.= .' 1 Srvp. Y ,�: 'Y"• 9.'�` It'^ l`hi„ •.•.nV4 .�. a .tF\ a -r _y,:+- t r ,�e.�.+,L .�{.pC-S,f'... {ps r1' - ""•• �"x'" �vo. ?" �!� � iv r �, .�r'R }�1.� 4 >,1'k� -• �L t.7 r 3„i�','-r2' .e-i� ��" -;s; �s'ra',ry�= r� ?` r �Z�r''3"�t t•v rR�a fryy-r3r�.�'Y•� K�;,t-?� T.3a'�..'rtC�+a`ti'.�•.� '" Ali:•r. ''uu,, 'fid� y :,f-�;�;�':'`i.��F"'.-t1�-.i��v:,r� -? �t� r.� M r �+�' rz e:. 151 1R�k rY.rt t4w5 �¢x -1^dtSa�� F ' t�^ irR'fit Y"t r 4 i 4 a `a'- 4 '¢ riy `%�y[hky/ 'r ..y rJ�';5•`S`3.>FJZ'a r '+ 7 h> i " t.,�r•s=:.0 �":.' 5 i C'C�F• _a' 11� iL rY"' ` 4�6T`' 1 it-*f,.,s .r,�+ 3.'k°'3`t✓-\ -t, ,. r�tz-„'�'-•rr�-.r�'t�''a-at;� ;+•_t-� o--,e•�y _ir a Y .t .,y^b, .Ar l:i^ c• -., .a. 2 :,_3,Patz; .c.�Es,' '.•it•`L/!'.fi"•r3,r-•� a �Y. ., xiY t��.:u f�''i"'„w.F.txs. F�f. ::` �lf b'ur,-�'_ �e IMWO +• � rky. .t: `r-_ st i>. ,r�«w �i queer �t� int•.!'. a1i •dsx�� 4`+ t rirr P �+ : .1; �� C `'jfir. !,.T�/°-.f c-t''•• t.x_yi^J-N �_„4'Z.,{f.E'`�tlL q- _art `i+1'< <Y.k'..c t.Fj,y}',.lair•- Y f SY-.it F{° �.1=; .* "9+`.CrY`., "�f} "•l b�-,;�.� :? K:tA{ N:i•1 . xY ,�G"ar 'F r "v'S.,, rw',Fr tisU' `�i✓ �.� -.-"Fr eil- El M � '' � ' tai k �� " c f�r �t ``>f' � 7 '9P11. �('�+i .r 'r 3;.; +'r' .},5 :,C T'_ „xF�. . 7�•�,��+..3.,:rL�����;���,,.�ra�.Y'i*�V,'�' of r�;.`��.t t�]:ri. Vy. T�, �.,.,''_f,'�( •��a?J:.. i Fi �::ylF -,t * 3■ k,r 'y ttti } `2, �h '' ah' 3 rY 33 r a ry 1”, � { J t r Y <.tre ¢��1�•:-}y F •'`:: �Y. 1e - i7 +: i' 'f� .- •x' b4 ¢¢ c,iSfi > '; h Y.,"»r. `.4'c-X.-.i't"'" rsydrq,-.. ' {% tu�:- r'}'r..`-isr,s�' i."'''1 '>-t i' S d jt :.,ar• e .�•t�J.JJ " w Lr',t' 4i yc•+,`72,` fir. A,.. i' a,+-t r r �. '� /'2gcY.3 p i.,.. vtk•. s - r L 't'F c!s % - w.i'\'`s' .r• { n• i ,}i., s ,r�J N.F� k=.«ei -'�Y'� J•;".�.�t5t�"a`,{,�� y.�as5 i'k.x�t t -�x`'rti �`;t%��� '�"''� + .�`x.Y•s `3y�c"�P �}y.E J'1�s:tkt+ y.ti 1:.-.}9`'�{T,.rY..` .rn Y r.f � ,W z .., err �'� �� } ,(�g+c, ��,st�, ter. � r�., n�r+ SY'4 1 _ {'ykff iSi_e."=�"47'7 i 7'"F' Ir e Yr i-,•.a %' S:r h.$, Svi• [+Y."i :-e.? a2y a,aSy,,h..r>.��3'•,4 ..�: `"- I v' ..,�, ;: ..t,• ,-, . '? 2''k�'. .C£' ;�y'SS7# >r... ..�' ,S `t+ 1. J [ J .yx t <».�' k• xr,..'t.:�r rw�:c fi,,, r�YJ� t'- ti w,ki ',,/ ?•�•.�.2-,% x -.t w i (C .St.r L�,Y4t_;7 x' v:, :.'. a'S.�,. �:�;5' r '7�^`^'�'l ;;i 7C-k3.ti:' `•v�•J,,. ,�_a6� 'r-w i - r/,ri ?•`w •i� �Six:_ 'Jc;�, P� 1 ;'�. .sy� �y, -f7 ,; S' r.i S 17,�,S, 1�' k,.. \S�•,`' a hAll �� •• aa.P3- • 5:. ,4.?'r'..; �,ti`- .&w �.i r Sri.a".,x, �t'9 -' r ,,,r +- i4 K t•;- y x 1d r"�}•.,:x, •i. .�.� i�h ry�`t:. .0-b�;�f ,,.G .r.,�^. ��'v�"�:i2��u,� �{'" dYz `'r:. y�it 't':;zC.. �;r,;..`t� .4-'f,+ �."tytr,�y���}' •-,','r�� .yS",tyi 'sl' T.:�:_', y's'�k ,�'r:. �1��It.`�`���'s.-cl}Cc ,l•�`y}'�`i�,use.. ,t �A,�'.. s b r e rk a4^I rSs :r' ` t �'�' 7r'r"# (�i}S]•.•.. e. r =.-.T''F '.. y,} ,;° .,4:_ yYt c a'•, ':i t frr r a r t'L' t t a r ,til ^'...�. ro- •1`r t. 'ti ;Ji; iZ - d v. , r ! .: 1+- 5a�-� 3_ $-,. r.+ ^Ji, z F> e `fig"" V-3x¢ ;, ,..,�'LY'- Mw•ti+'' ..+.`r;. �. ,,. �C+�`-;s'1i/r , Y..y� ;�fis. a a.. a ^�,'�`f �F a �` �r s. ,✓ +-� ''�l .rr•� �i:_,y 'K1 r 'a 5-,5; '; i� J'G7K.�.. �; #G �w"t" °h ,�' .ns` ,•a k.+ Ar' " .+a e • ; "�,.YY-'-.� 7 .I t�! S+:'i :rro.r�'tLr°Y w wk i4• .'S'' *• a r �i k.v nr t..r � l '`t - fit'• . -� r'e C ,,t 1�' ti i .. y'i frt. ai7�- r .1 h co .�•-� .' r''S- L r ,..`�rS ,-.._ ''a� •'7; .:4`t+�n•,ti,,f a,t'ia:, F ,.`. . •si L'N G�.� r•'}.S•�r'7 ,�q; � - '. ,f3 a.1' �.'hu-. �t` rz "^�, `` CT � }�S►L T'`r"{1 �' �'` ''4 w�•r,',' ,A'r' �a ,+�{ v �' *' y � c r�• �1�.ex>\.> Sz)c y 4i �,��. Sit': .:•K s - .c" r �: -=.f:. S'y}.1 :'.i�,-qtr,. SY'1,E -"i �'s'cy ciJ'- k• ,,. 1L '.,,i.yr,r J hehSt�i S,.? +c. J.yY :. Ot >?r:1trtS`nJ 'Y�. ;,a. s:"4,F.'f= 4s.• x," 4I- FF �. Z i4;{'C '1• .,3'- '4 '+,L: ` :2kf 1}' " •k ', rrwS, -._ ur",7 ,;{'n `• .1-c,�� .�,,, F '4" .iC;i.a .-r'..-j �.l`+.fr"Z`•r� sr 4 t )21't �' Z� 17'` 8r ,,� r•� 2Vz.:i ^4 .h {' .'^�„ 1. 'S• ysyl-II'. .J�s.;} • 'rET? I -�yP ' i�,. zc,'< ! ..w�ry�K7'„°�nr-a$ �L.�. "S'`4�i. :$-�a'>:.� r~.;3� �!'_. _ 7t-•;.e%S'F a•'mss: . 1" \:.} „j. Jar �"••'”"2`-•L.a."'4 .,y,:"q},._r-'9r''s�Ji.'�r `•a�,. .�«a a � yr,•. '4 f't� 44n r:: ,'•;, r { fc { Ei�,4r _ � cJi, Yc� C}'Qt• 'f t",�,L4 .;.' � ,. _ ,Y.•� TJ.•r7. , f i-.y amu '.. K.. Ff r,7,�L.-l�-r,,� �d�r`a�:i``+' ;x .;x° �l.a•,t a.r7+!..,''� rir.,; ,r' tL�.,•r y` Ifs { 4t . J, lir.. tL•VS. +�' �i. .�i1-n Y, uk =:c 'r'7`t:."�`{` �-`�?- "t•„k,;y, � r 1ii6,�, cif •' !.PrG. �1...,`•�.'. f'f "w:yrs- 1,•4.' , 1 y ,, cL'- - t P S. s ',..sir-r frf'In '�;1�y ?� �l.>t`�r c.,�r ,y,,,,1+t7, rR:ci�- �.r'• :�. ;r o.'ItA- .€'.; �' ,�� "d�.,iii '�swe� � k� n r s*;�l �•'� w •s ���,.,r,-,� •�'��,,-' ? h'= d tr tt -xY. i°-i 3•c ••.Qc i y "' i,•\ S{: 1,-{ 5�TiiSiLS�' -li" ��,.t �. f�S •t•. _. .,t4r 4 �t�4 -a rc,�”' �;-:��{,,k .�,� �y -�F.y a l�%-- 'dva-.F p,.y�C,-r 3. .,d y. U c$ - L x ¢e•�.+ <�`�.r-"ti i Y.ti ^.i �r. ti• jsry'1 i!' i t . t ,r ,crn [W..5ri t.: r�" �?:�. r. �- r r -.Fsw'� �,.:in i9Y ..c �Yrh 4 •i- .�� `,1p"'' �h'X'Y:t,�nSC 'j''- ~#3f�a c �"�std2 •Y 5„f r � •`�' m• � y..i..f• x;;l { : 'kc#ro .? r��}'�Z �;rcYp �i!- F, rF �+' ry �S.•4,' .- S'� z'vy,�c' .� Ct+ L.fi't..F r t Z} �•. „(. -,;- ,,t• l .#. Y v.. yg7ri ;rY �'.' '7, 7 :`y" �' ;;ZtS .. Jc-Sri•-N. L,?[. G_�v, ' yL*•„ -. Yti .sC .�{ Lair°, ,ths 3.'^ r"-�.-?''",:.r �'i ' t ?' e.' �fk,.P� -K:l: .4 �'5�..,��z«f ":. 'nit ,'.T4r;.�q r {Ib' tr',rtr 3}.'E._,�rM ;4v w'. •`Sfk� :,�:. ' =. °a7^" �''xv +;u' • ._'FY? >.;- : •:'+Y '..� dr ; r 'l i. - C .�£r Ir";'•o,,r .. c'.,•'c,w.0 ,+,f ._t w F'�'[ x `�i: '4'� "ai '�`A,��.}. f�,l•";"v'h:1`P'SYr'L r-`�:t Y.. ,`i r f�• _a -,. �rx 'c .F•1 �'a..:'%. M.lia`.. ., c r r .r x t ¢•1n-4.;F .�:S,rt Ya '3}� ! .7-t.i,;.ti.3} tr !t ,xF ••t! [y....2C : '� - e +.t 1 °'nfi .,f } �'-� .x\�•y „ ,t'{�,y'}t! tih t. :2 l�Jvf , MON cctlr -r, w*•F. 7k• Si ;.tt `{'` 1r Y..^fc-ts5• f`ir 'r Sit! n a}Y 5 r Y fi lv�ti It ,s . Jc } y •(y p, ti y,�f S q4� ^b.. 'N Y- -V( Got j:? 5� •t .; .r .i. -� •,7('r4�,.- *..k °*'{+ ur {�`5.�3• fir.r9 '.e ir.,. 7• '% -a 'J.: rF� `q. : ,.L..,•. a .�, I ) t t, .t ''7„fi. ,�r,,• ,*. . Try,«t-.f-t-' f' ,r : ,,Y• Jti"t ,2ac`::-§ lr" ;{:Dia•■••+r"i;'Y9a"li �{' r".y�"' 3 i�.�J.k�-:_�-"F.�.t,':,5� .*c-h:,FV vv{k .�}.a vt1� ti:L�� �r,y,.•ti_fi r..i� vj:..5 {f:'Y:r •i"S,. `' i?'?t` ..+p5'. 1�.1'•�",1,{Je.tyz,r•. Will.' O,, :`' J.y �'.•y r S; cam'^ a .7•fti. .a"'"° .i f .i, -'' k �5r�{1 + t^ --Wm ...{r yy� rY �:"�ya�•t->`Fya.nG�i'•r.�..S' N "'��'+N`l�� ,.rf:'"�C ��i.�%s:`;u C��y+�'. �a ���.tP...[�.Si��'c'4• �h,'lF��t��C•,.; �`S•4'y`•_ .S.)7�;. : r•5�.�r+•i (•t�• . � 'd T• a4l ry't .��. 'Yr L •�'" 7 -L .. �. c:,3 -�. Tyy,.ti..!f i.�. •'_y Yri..+'1yM"✓:(`'=.J , p,7v.t4 P.0 7�'� ..5. r c" rP*•, _ 'l.3-4^.�v+�� E 3 z y R,L,'1•,' �¢.�r' .,� E_t ', �JF, t'c.,-r it;u4'� y.e.C � ::t'i-.syr•c•Y.stYrd� i:.r+tl.. .M.r' " '�t '� r---!'i?'I..r,� -..< ;-r,i n 'S-1 .7 i v.`it;,J,- '1j [. r;t - F _ "7�-r ..�..rf,(. �.'Ir■' -Y'•x .�•� '�f; `a'y1i+y3'PrF,^� ';?e?+rvf- 3 :Cfis. .k�?` -:':,�faT"yrJ '`..-�y '7'' '-) YA��.. �..�,-` '� _arz R..Yy a.Y�,i;._+,+'r' r,r,.� i.'k, r dy.,�rffyt;•,St `^e- ''�•:Jf �:#';t5� � -4M,, ��'�'E'Yi'r+,e;,� •".'`�r�.,v '�r4.� �,z'S�'%�' �d'�utr�a�"� �z �:�•iL'>~'.4H�,r-4�� wr-J3��, � ^� .ti Y,-. cL-i• S :•ti.a r1•,ti � -�.r.r J.. �.r- �Lls• r z. •y :rt; r. y �,..fy •� - k*"• � T� l!.-�,,.." A"t� �+..a-,j"y �`+ll.'S�3^#qa -r,•i'• •-r i�'t .'E-.-,P 4'y>`. f_w.t,' "•t"�'.t5t c .o.1r. �?'d5''?�.'¢,...Y,n;�'+ ;j¢a` ,;1:. `a+lESE�.0 'Yr`':5.. -L. t •;1 '--c -'y _:.'•►" -. i �? ;"F,.. ri": •x, :[ Y-- aCh. ne r Hri ..., }!F c. rY?It,.,a.i •a ';,fa' 7diJ', '.+caT�, `+c ?+l,':9- + - i�.y�;a+.., ;SY•J`i., s. ' - �tt,:.s �-L"F..�.,_• ,g,,a a,r�-,.�r`� #e t'•". `^ , vY ,.� ti.}� '4..4LlR'S1S�lC• J'f' }'.S p i J 1 F.M' �1�{;•`:_y-�c,,4• n s�r�� �r�rS�'-i `G'?� .t �{¢,'.".ax• h', 3'd;!• �' '� .' glrtHc ,.F•Y ■F r• y r YELL'-r�J.i,.. `�` �x fr fir. fit. h!'z '�•5v.t. h. iT 'i ''"3:e•'t'r '�'a�6nk.,y + $ .H• :an �: ,Wf• 1. 1 .{�„• "k � ��. �• 'r'�': [ .._'F ,h„� {s '�?' '� '.:F y k'dr. E ,''ti;•r �a.-, -r,• 3 k' }. ,ii" '- ,LF.•� n. }>. j n Y.nv�,.rvt�. l,-t 'J 's,+,7 -.?' 1,vYj M� - � � :� - � 4 i h •-{ 1. � 4"[ '.LL � ^FL{i 9..•• _+x`c,x�� ,'�w..' (r�r- �� v� .krb ,.t,, i;'NR 'irk r.�,4 ,`"j-e "Irt�::•!'F��'qn,��atr9 +.r� _�'���•• t t SI',�TM r'k' a �`.+�!' .R'� W.z. ?ct - 1 ss.l, 'M§ -e• cY r `,1 c :;'Ik tis 't /'<�.' ` sfr: �:° t- t' .a X-z° J �IiY ��rraT r'' 5 '�, . .• rat'v`q r 7ik F} G5 i ,,.. 1. ,i.:1 3{, .8'�....>`;,r. .Lr.:d t �';§ns . .:�}�r�. 4 ",r�' :' q�5 <.,.�.��i'q � b��'r:�zlf,_.,4�,e�'�dTy�h y"" ° - •T-"`F "�7�:_ _ x yt.s-in `f:},• 1 "i :.c ;•�?' ?,�_:,,')s.*'+'•yNiyy{ .�^..; rF,r.'E. ;J"; w� :kJ°t ..,� i�., Y�; '^i��7 `��'". ° ���,�yr.4�s� &�•�` �����.z� r�„�',�t`;�=r'.�' '," '`�'t�r��'.�;��•c*�,� '- ' • �-�-' '�. a'wk.;c �,��'.��� f��t.x ;�� `�f �'��. ?* x z' � r ry 4 ,�c � ,,}}�" . _ " :_c" r`4 5• - ' Y p t �,tti r t�r3 �5{ +GIF x ri kT .'!t'••yS. c' �, � �J'i'�:,;phGL''�•i"c�"#x- r .r .y� ."R»6 'nh:t r3J . ._. �g'?S••k'��+e+ .... to _.. t. �_ r'S,`{' ". _ .:. ,. "si..:' .a..'e r A' F.-r.� r L_. .a, A � ' _v'C"'."L.,a .r.: v .err ,, L: _ c«- ver• -t,t�'.ad �' a. "cif �✓..'v Y _ v� United States GAO General Accounting Office Washington, D.C. 20548 Human Resources Division B-247447 March 23, 1993 The Honorable Charles B. Rangel Chairman, Select Committee on Narcotics Abuse and Control House of Representatives Dear Mr. Chairman: AIDS or the acquired immune deficiency syndrome is an epidemic that is disproportionately affecting the nation's young, poor, and women in minority communities. Injection drug use is considered a major risk behavior that is helping to spread the human immunodeficiency virus (Iiv), the virus that causes AIDS, among these groups. II>,jection drug users are at greatest risk for AIDS when they share Hrv-infected needles and other injecting equipment. One strategy to reduce the spread of iuv among drug users who cannot stop taking drugs or get treatment is needle exchange. Needle exchange programs typically involve the exchange of new, sterile syringes for used ones that may be infected with Hrv. Programs can take a variety of forms: some are legally sanctioned, others are not; some operate on street corners, others operate out of mobile vans;some are funded by a public health agency, others by AIDs advocacy groups; and some have a much wider range of services, such as testing for Hry and tuberculosis (Ts), than others. In July 1991, the National Commission on AIDS, an independent body created to advise the President and Congress,put forth five recommendations to reduce the spread of Hry infection among drug users. These recommendations reflect an array of strategies, including the removal of legal barriers to the purchase and possession of injection equipment.'The Commission reported that legal barriers—such as state drug paraphernalia laws—limit the availability of new and clean injection equipment and,therefore, encourage sharing of injection equipment and the increased possibility of Hry transmission. In presenting their recommendation to remove legal barriers, the Commission cited the value 'Others are:(1)expanding drug abuse treatment and continually worldng to improve the quality and effectiveness of this treatment.(2)federal leadership in developing and maintaining programs to prevent HIV transmission reiated to licit and illicit drug use,(3)expanding and funding research and epidemioiogical studies on the relationship between licit and illicit drug use and HIV transmission. (4)mobilizing public and private sectors to mount a serious and sustained attack on the social problems that promote illicit drug use.National commission on AIDS.The Twin Epidemics of Substance Use and HIV.July 1991. Page 1 GAOIEMD-93-60 AIDS and Needle Exchange Programs B-247447 , of programs such as needle exchange in reducing the risk of Hry infection among those who continue to inject drugs. This letter responds to your concern over whether there is evidence to show that needle exchange programs reduce the spread of HIV. Specifically,you requested that we (1)review the results of studies addressing the effectiveness of needle exchange programs in the United States and abroad, (2) assess the credibility of a forecasting model developed at Yale University that estimates the impact of a needle exchange program on the rate of new HIV infections, and (3) determine whether federal funds can be used in support of studies and demonstrations of needle exchange programs. Background In June 1986, the U.S. Public Health Service (PHS), within the Department of Health and Human Services (HHS), projected that of the estimated 1 to 1.5 million Americans infected with Hrv, 200,000 to 450,000 could develop AIDS by 1991. In 1989,AIDS was the second leading cause of death for men and sixth leading cause for women between the ages of 25 and 44 years. As of September 1992,242,000 people were diagnosed as having AIDS and 160,000 deaths had been attributed to the disease. Approximately 32 percent of adult/adolescent AIDS cases are related to injection drug use.Injecting drugs in and of itself does not pose an AIDS risk, but sharing needles does. Some drug users may share their needles without sterilizing them between use,thereby enabling the transmission of Irv. Furthermore, HIV-infected drug users can spread AIDS to nondrug using populations. Pregnant drug users, for example, can transmit the virus to their unborn children. In September 1992, the Centers for Disease Control and Prevention (CDc)reported that among children (those under 13 years old),40 percent of those with AIDS were born to women who contracted my through injection drug use and 17 percent were born to women who contracted my through sex with an injection drug user. Needle exchange programs emerged as a strategy to reach dependent drug users unable or unwilling to stop using drugs in order to minimize the health risks associated with such practice. These programs aim at encouraging injection drug users to exchange used needles and syringes for new, sterile ones and at discouraging sharing injection equipment with others in order to reduce the spread of HIV. The goal of the programs is to, if not eliminate needle sharing, at least moderate sharing to reduce the transmission of AIDS and other blood-borne diseases. Some programs also Page 2 GAO/HRD-93-60 AIDS and Needle Exchange Program. B-247447 provide other services to participants, including referral to drug treatment and health care services. Needle exchange programs were originally begun in the Netherlands to reduce the spread of hepatitis B among the hard-to-reach injection drug users.Later, programs were developed to reduce the spread Of HIV in Australia, Sweden, the United Kingdom, Canada and other countries. Such programs are not widespread in the United States and they are also controversial. First, many states have statutes that directly restrict access to sterile drug-injection equipment. These include(1) drug paraphernalia statutes that ban the manufacture, sale, distribution, or possession of devices that may be used to introduce illicit substances into the body and (2)statutes that criminalize the sales of needles and syringes without a medical prescription.'Second, program opponents contend that providing needles gives the appearance that public officials condone illegal drug use. In addition, opponents are concerned that providing needles may not only perpetuate but increase drug use. As of December 1992, 32 known needle exchange programs were in operation in 27 different United States cities or counties. Beginning with the Tacoma, Washington,program, all of these programs came into existence since 1988. Only 15 of the 32 programs are legally sanctioned.3 Results in Brief Measuring changes in needle sharing behaviors is an indicator often used to assess the impact of needle exchange programs on HIV transmission. We identified nine needle exchange projects that had published results. Only three of these reported findings that were based on strong evidence. Two of these three reported a reduction in needle sharing while a third reported an increase. One concern surrounding needle exchange programs is whether they lead to increased injection drug use. Seven of the nine projects looked at this issue, and five had strong evidence for us to report on outcomes. All five Gostin,Larry,J.D.,"The Needle-Borne HN Epidemic:Causes and Public Health Responses." Behavioral Sciences and the Law(1991),Vol.9,pp.287-304. 'Despite state drug paraphernalia and/or syringe prescription laws,some needle exchange programs have obtained legal status.For example,while retaining their state drug paraphernalia laws.the Hawaiian and Connecticut state legislatures enacted laws in 1990 authorizing the establishment of these programs for the purpose of reducing the transmission of HIV among infection drug users:in the state of Washington,legal status was approved by the courts for needle exchange programs administered by local health authorities:and,in New York,the state health commissioner recently exempted individuals connected with authorized pilot needle exchange programs in New York City from prosecution for possession of needles without prescriptions. Page 3 GAO/I[RD-93-60 AIDS and Needle Exchange Programs B-247447 , found that drug use did not increase among users; four reported no increase in frequency of injection and one found no increase in the prevalence of use. None of the studies that addressed the question of whether or not the needle exchange programs contributed to injection drug use by those not previously injecting drugs had findings that met our criteria of strong evidence. Our review of the projects also found that seven reported success in reaching out to injection drug users and referring them to drug treatment and other health services. We also found the forecasting model developed at Yale University to be credible. This model estimated a 33 percent reduction in new Hn, infections among New Haven, Connecticut, needle exchange program participants over 1 year. Based on our expert consultant review, we found the model to be technically sound, its assumptions and data values reasonable, and the estimated 33 percent reduction in new HIV infections defensible.This reduction stems from the program's ability to lessen the opportunity for needles to become infected, to be shared, and to infect an uninfected drug user. To gather data in assessing program impact for use in the New Haven model,the researcher developed a new system for tracking and testing for HIV in returned needles. While these findings suggest that needle exchange programs may hold some promise as an AIDS prevention strategy, HHs is currently restricted from using certain'funds to directly support the funding of needle exchange program. Under the Alcohol, Drug Abuse, and Mental Health Administration (ADAA1HA) Reorganization Act of 1992, block grant funds authorized by title XIX of the PHs Act may not be used to carry out any needle exchange program unless the Surgeon General determines that they are effective.in reducing the spread of HIV and the use of illegal drugs. However, HHs does have the authority to conduct demonstration and research projects that could involve the provision of needles. Scope and Our work consisted of an examination of published evaluation studies on needle exchange programs and site visits to programs located in Tacoma, Methodology Washington, and New Haven, Connecticut. To review the forecasting model developed at Yale University, we contracted with outside experts. We also analyzed the legal authority applicable to federal support of research and services related to needle exchange. To identify the studies for review, we conducted a literature search of medical and social science computerized bibliographic files; obtained the Page 4 GAO/HRD-93-60 AIDS and Needle Exchange Programs B-247447 research materials used by the National Commission on AIDS; reviewed the abstracts from and presentations given at several international conferences on AIDS; and relied upon information referrals from outside experts in the fields of drug abuse research and MDs. These efforts identified over 800 citations related to needle exchange programs. After eliminating duplicate citations and documents that were not evaluations of exchange programs, we examined 20 published studies and 21 abstracts and/or presentations on evaluations of needle exchange programs in the United States and five foreign countries.{To avoid any duplication of the study findings, we grouped those published studies, abstracts, and presentations that represented the same study effort into projects.'A total of nine separate projects were identified.6 Only one of the evaluation projects was on a needle exchange program in the United States. For each project we sought to identify study findings on the following outcomes: (1)rate of needle sharing, (2)prevalence of injection drug use, (3)frequency of injection, (4)rate of new Iiv infections, (5) rate of new entrants to injection drug use, (6)incidence rate of other blood-borne infections, (7)rate of other HIv risk behaviors, and (8) risks to the public's health. We also reviewed the methodologies used in developing the findings. For these eight outcomes, we present only those project findings that met our criteria for strong evidence. We considered evidence to be strong if: 1. supporting data were published in a scientific journal or a government research monograph, 2. a statistical significance test was done, when appropriate, and the statistical significance level was 0.05, and 3. the author did not attribute the effect to anything other than the needle exchange program. 'The studies included in our analysis cover needle exchange programs in Sydney,Australia(3 studies and 3 abstracts/presentations);Vancouver,Canada(1 study);Amsterdam,the Netherlands(4 studies and 4 abstracts/presentations);Lund,Sweden(1 study and 4 abstractsipresentanons);the United Kingdom(10 studies and 7 abstracts/presentations);and Tacoma.Washington(I study and:3 abstracts/presentations). These projects include studies conducted on the same needle exchange program and by the same team of researchers.Many of the studies were published at different points in time as new study data were developed. 'See bibliography for studies that makeup the different projects and for ether reievant abstracts/presentations reviewed in preparing this report. Page 5 GAO/HRD-93-60 AIDS and Needle Exchange Programs B-247447 As a result, we found strong evidence for only the first three outcomes (rate of needle sharing,prevalence of injection drug use, and frequency of injection). For the next five outcomes, either the study project did not address the outcome or the findings did not meet our criteria for strong evidence. For three other outcomes, which represent the ability of needle exchange programs to reach out to injection drug users and refer them to drug treatment and other health services, we present only those project findings that reported evidence that these services were offered and also reported the number of injection drug users who received them. For information on the project designs and methodologies see appendix I. Appendix H provides more details on the needle exchange programs by location for the nine projects we examined as well as for the New Haven program. To review the New Haven model, we contracted with expert consultants with backgrounds in operations research-based modeling techniques and Hw transmission among injection drug users. Issues reviewed were: the technical adequacy of the model's mathematical specifications, reasonableness of the underlying assumptions used, quality of the data and sources relied upon, and the conclusiveness of the model's 33 percent estimate. See appendix III for more information on our review of the New Haven model. Our work was conducted from January 1992 to November 1992 in accordance with generally accepted government auditing standards. Some Research Six of the nine projects we reviewed provide strong evidence on one or more of three AIDS-related risk behavior outcomes: (1)rate of needle Suggests Programs sharing, (2)prevalence of injection drug use, and (3)frequency of May Reduce injection.Table l presents the results of our analysis. AIDS-Related Risk Behavior Page 6 GAO/HRD-93-60 AIDS and Needle Exchange Programs B-247447 Table 1: Results of Needle Exchange Program Study Projects HIV transmission Injection drug use Project number, by Rate of needle Frequency of country sharing Prevalence of use injection Australia a No increase b Canada 2 b b b Netherlands 3 a a No increase 4 Lower b No increase Sweden 5 a a a United Kingdom 6 a a a 7 a b Less often 8 Increased b United States (Tacoma,WA) 9 Lower b No increase aStudy project addressed outcome but results did not meet our criteria of strong evidence. bStudy project did not address outcome measure. Two of Nine Study Projects The risk of becoming HIv infected or transmitting the virus to others is Associate Reduced Needle, diminished if needle sharing is reduced.All but one of the projects we Sharing With Programs reviewed examined needle sharing behaviors, but only three of the projects reported findings that meet our criteria of strong evidence. Two of these projects found that needle exchange programs are associated with reduced needle sharing among participants.A project that studied a needle exchange program in Amsterdam,the Netherlands, found that needle exchange participants reported significantly less needle sharing than a sample of injection drug users who were not participants, both at the outset of the project in 1987 and a year later.'A second project, which studied a Tacoma, Washington exchange program,found that exchange participants reported borrowing and lending used needles less often Project 4:The Netherlands.Hartgers,Christina,et al.,"The Impact of the Needle and Syringe-Exchange Programme in Amsterdam on Injecting Risk Behavior."AIDS(1989),Vol.3, pp.671-76. — Page 7 GAO/HRD-93-60 AIDS and Needle Exchange Programs B-247447 during the time they participated in the exchange than they did before participating.$ A third study found that those using an exchange program in Manchester, England, on a regular basis were more likely to lend injection equipment to others than a sample of injection drug users not using the exchange program regularly. The authors noted that some needle exchange program participants reported that they were the focus of pressure to supply injecting equipment to others once it was known that they were getting regular supplies themselves. Program participants also reported giving away unused sterile equipment at times. However,the authors also concluded that those participants who were in long-term drug treatment were less likely to pass on their equipment than those who either were in drug treatment of shorter duration or not in treatment at all.9 Most Projects Suggest That Some policymakers have been concerned that needle exchange programs Programs Do Not Increase will increase injection drug use by increasing the availability of needles. As Injection Drug Use table 1 shows, of the seven projects that examined injection drug use, whether by measuring either the prevalence of drug use or the frequency of injection, five reported findings that meet our criteria of strong evidence.These projects used data based on self-reported behavior or urine specimen tests. Four of the five projects presented strong findings that drug use did not increase and one reported that injection drug users injected less often once they began participating in a program. For example, results of an Amsterdam project showed that injection drug users reported no increase in the frequency with which they injected drugs for a 2-year period during which there was an exchange program in that city.10 The Tacoma project reported a similar finding.11 In a second Amsterdam project, 72 percent of needle exchange participants reported that they injected as often or less than they did 6 BProject 9:Tacoma,Washington.Hagan,Holly,et al.,"The Tacoma Syringe Exchange,"Journal of Addictive Diseases(1991),Vol.10,No.4,pp.81-88. "Project 8:United Kingdom.Klee,Hilary,et al.,"The Sharing of Injecting Equipment Among Drug Users Attending Prescribing Clinics and Those Using Needle-Exchanges,"British Journal of Addiction (1991),Vol.86,pp.217-23. 1OProject3:The Netherlands.Van den Hoe;Johanna A.R.,et al.,"Risk Reduction Among Intravenous Drug Users in Amsterdam Under the Influence of AIDS,"American Journal of Public Health(1999), Vol.79,No.10,pp.1355-57. "Project 9:Tacoma,Washington.Hagan,Holly,et al.,"The Tacoma Syringe Exchange,"Journal of Addictive Diseases(1991). Page 8 GAOIHRD-93-60 AIDS and Needle Exchange Programs B-247447 months previously as compared to 49 percent of injection drug users in the study who did not participate in the exchange program-"This study reported that this difference between exchange participants and nonparticipants remained the same at follow-up which occurred 10 to 20 months later. A United Kingdom project found that participants reported injecting less often in the third month after entry than before they entered the program.13 In addition to these four projects, which used data based on self-reported behavior, a fifth project used what is considered more objective evidence—the results of urine testing. An Australian project reported no difference in the prevalence of injection drug use among methadone clients in a clinic near a needle exchange program and clients in a clinic 251alometers from that exchange program over a 3-month period.l� Projects Show That As table 2 shows, data from several projects support the view that needle exchange programs are reaching injection drug users and referring them Programs Reach Out to drug treatment or other health services. to Addicts and Provide a Link to Drug Treatment and Other Health Services "Troject 4:The Netherlands.Hartgers,Christina.et al.."The Impact of the Needle and Syringe-Exchange Programme in Amsterdam on injecting Risk Behaviour.".AIDS(1959). '"Project 7:United Kingdom.Hart.Graham J..et al.."Evaluation of Needle Exchange in Central London:Behavior Change and anti-fIKv Status Over One ear."AIDS(1959).Vol.3.pp.261-65. 14Project l:Australia.Wolk.Jael.et al.."The Effect of a Needle and Syringe Exchange on a Methadone Maintenance[:nit.'British.iournal o!Addic^on('1990). pp. 14.15-30. Page 9 GAO/MD-93-60 AIDS and Needle Exchange Programa B-247447 a Table 2: Needle Exchange Program Outcomes Measured and Reported Referred IDUs to Project number, by Attracted IDUs° Referred IDUs to other health country not In treatment drug treatment services Australia 1 0 b b Canada 2 ° Yes Yes Netherlands 3 b o b 4 Yes b b Sweden 5 Yes ° Yes United Kingdom 6 Yes ° b 7 Yes Yes Yes a b b b United States (Tacoma,WA) 9 Yes Yes b 'injection drug users. bNot measured or reported. Five of the nine projects reported that many of the injection drug users who were participating in an exchange program were not receiving drug treatment services. Projects in the Netherlands, Sweden, the United Kingdom and Tacoma, Washington reported that between 24 and 74 percent of these exchange participants were not receiving drug treatment_t5 "Project 4:The Netherlands.Hangers,Christina,et al.."The Impact of the Needle and Syringe-Exchange Programme in Amsterdam on Injecting Risk Behaviour,"AIDS(1989). Project 6:Tinted Kingdom.Stimson,Gerry V.,et al.,Injecting Equipment Schemes Final Report, University of London:Goldsmiths'College, 1988. Project 5:Sweden.Qungberg,Bengt,et al.,"HTV Prevention Among Injecting Drug users:Three fears of Experience from a Syringe Exchange Program in Sweden,"Journal of Acquired Immune Deficient:;: Syndromes(1991),Vol.4,pp.890-95. Project 7:united Kingdom.Carvell,Andrea M.and Graham J.Hart."Help-seeking and Referrals in a Needle Exchange:A Comprehensive Service to Injecting Drug Users."British Journal of Addiction (1990).Vol.85,pp.235.40. Project 9:Tacoma,Washington.Hagan,Holly,et al.,"The Tacoma Syringe Exchange,"Journal of Addictive Diseases(1991),Vol. 10,No.4,pp.81.58. Page 10 GAO/HRD-93-60 AIDS and Needle Exchange Program, B-247447 Once injection drug users are enrolled, needle exchange programs can play the role of linking them with drug treatment and other health services. The Tacoma project reported that the exchange referred more than 150 active injection drug users to drug treatment.16 The Swedish project documented that in each of the 3 years following the establishment of an exchange program in a clinic for infectious diseases, the number of HIV tests performed by that clinic increased at least seven-fold. The researchers claim that more than 90 percent of these tests were performed in connection with the needle exchange program.''In two other projects, needle exchange programs played a dual role in linlang injection drug users with both drug treatment and health services. For example, the Vancouver project provides data showing that the exchange program made over 600 referrals to drug treatment, HIV testing and other health services.", 19 Although needle exchange programs are able to refer injection drug users to drug treatment, not all drug users are able to obtain treatment. For example,Tacoma needle exchange program officials told us that publicly-funded treatment slots for specific types of drug treatment are not always available when addicts are referred for treatment. Consequently, many of the drug users referred from the needle exchange program are placed on waiting lists. We also learned of a similar problem facing the New Haven needle exchange program. Local public health officials administering the program there told us that many of New Haven's injection drug users are polydrug users (for example, they inject heroin combined with amphetamines), but the primary public treatment available is methadone maintenance for heroin addicts.They added that they also do not have a sufficient number of public treatment programs designed to treat the needs of women, particularly pregnant women. "i Project 9:Tacoma,Washington.Hagan,Holly,ec al.,"The Tacoma Syringe Exchange,"Journal of Addictive Diseases(1991). 17Project 5:Sweden.Ljungberg,Bengt,et al.."HIV Prevention among Injecting Drug Users:Three Years of Experience from a Syringe Exchange Program in Sweden,"Journal of acquired Immune Deficiency Syndromes(1991). 18-Project 2:Canada Bardsley,John,et al.,"Vancouver's Needle Exchange Program.'Canadian Journal of Public Health(1990),Vol.81,pp.39-15. 19.4 pilot needle exchange program tested in New York City(November 1988 through February 1990)not included in our review also presented data on enrollment of program participants in drug treatment programs.Based on the first 12 months of operation.the program was able to refer 80 percent of 290 program participants.half of whom were confirmed to have entered a treatment program. Page 11 GAO/HRD-93-60 AIDS and Needle Exchange Programs B-247447 Forecasting Model A model developed by a Yale University researcher to estimate the impact of a needle exchange program on HIV transmission among program Estimates Reduction participants in New Haven, Connecticut, suggests that such programs are in HIV Transmission effective.20 The model predicts a 33 percent reduction in new HIV infections over 1 year among program participants. Based on our expert consultant review, we found the model to be credible. Our experts found that the model is technically sound, its assumptions and data values are reasonable, and the estimated 33 percent reduction in new HIV infections defensible.21 (For more details on our review of the model, see appendix The estimated 33 percent reduction stems from the needle exchange program's ability—by gathering used needles in return for unused ones—to decrease the amount of time that needles are in use. Thus, the opportunity for needles to become infected, to be shared, and to infect an uninfected drug user is lessened. In order to measure the program's impact, the researcher developed a data collection system. This system, syringe tracking and testing(m), collects data on needles distributed and returned, including to and from whom they were given or returned as well as when and where they were distributed or returned. The needles are monitored by assigning sequential tracking numbers to each needle and anonymous code names to each program participant. In addition, tests are conducted on a sample of returned needles to detect the presence of HIV from the residual blood remaining in the syringe.These tests use the polymerase chain reaction (PcR)procedure, a technique capable of detecting HIV in extremely small amounts of blood. Lecrislation Limits The Congress, on several occasions, has specifically prohibited or 1--) restricted the use of appropriated funds by HHS to support needle Funding of Needle exchange programs.'-=More recently, the ADAitilHA Reorganization Act of Exchange Programs 1992 generally precludes the use of block grant funds (authorized by title but Allows Research JX of the PHs Act)for needle exchange programs. Existing statutory 2DIntervention strategies for social programs often require longitudinal studies to measure their results conclusively.In the interim,researchers sometimes use proxies.such as forecasting models. 2'As a result of the New Haven model,the Connecticut state legislature enacted legislation that. expanded legal authorization to needle exchange programs in other cities.In addition.the legislature modified existing laws to allow for the purchase and possession of up to 10 needles without a prescription effective as of July 1,1992. Appendix IV provides a detailed review of congressional action on needle exchange programs. Page 12 GAO/HRD-93-60 AIDS and Needle Exchange Programs B-247447 authority does, however, in our opinion,permit use of federal funds for studies or demonstrations of needle exchanges, which might involve the provision of needles. Our position on this issue is supported by the 1993 HHs appropriations act. which states: ..no funds appropriated under this Act shall be used to carry out any program of distributing sterile needles for the hypodermic injection of any illegal drug unless the Surgeon General of the United States determines that such programs are effective in preventing the spread of my and do not encourage the use of illegal drugs,except that such funds may be used for such purposes in furtherance of demonstrations or studies authorized in the ADAAtHA Reorganization Act(P.L 102-321)." Demonstration projects are typically used to explore new areas and conduct research where a sound body of knowledge does not east. In such projects, the delivery of services is often coupled with an evaluation methodology to build a strong base of knowledge about the impact of the services provided.At present, HHs has not conducted demonstrations of needle exchange programs.23 As requested, we did not obtain written agency comments on this report. However, we met with officials from PHS on the subject of HHS's authority to fund research and demonstrations on needle exchange programs. In addition, we discussed our findings on the New Haven model with the principal researcher. Where appropriate, we incorporated their comments into the report. Unless you publicly announce its contents earlier, we plan no further distribution of this report until 7 days after its issue date. At that time, we will send copies to other interested congressional committees; the Secretary of Health and Human Services; the Director, Office of Management and Budget; and other interested parties. We will also make copies available to others on request. 'However,there are HHS research activities that do not involve the pro%ision of services.These include:a 1992 research award through the National Institute on Drug abuse(?NIDA),now part of the National Institutes of Health,for refinement of the New Haven model;two other NIDA awards for studies of programs in San Francisco,California and Seattle.Washington;and a study contracted by the CDC to review existing data on needle exchange programs,conduct site visits to programs,and to obtain unpublished program data Page 13 GAO/HRD-93-80 AIDS and Needle Exchange Programs B-247447 Should you have any questions concerning this report, please call me at (202) 512-7119. Other major contributors are listed in appendix V. Sincerely yours, 11;%%� Mark V. Nadel Associate Director, National and Public Health Issues Page 14 GAO/IIRD-93-60 AIDS and Needle Exchange Programs Page 15 GAOMD-93-60 AIDS and Needle Exchange Programs Contents Letter 1 Appendix I 18 Study Project Designs and Methodologies Appendix II ?o Needle Exchange Programs: IDU Population and Program Characteristics Appendix III 22 Review of the New Technical Adequacy of Model's Mathematical Specifications 22 Reasonableness of Model's Underlying Assumptions 23 Haven Model Quality of Model's Data Sources and Values 24 Model's 33 Percent Estimate Defensible 24 Appendix IV 25 Legal Barriers to Federal Funding of Needle Exchange Programs Appendix V 27 Major Contributors to This Report Bibliography 28 Project 1:Australia 28 Project 2: Canada 28 Project 3: the Netherlands 29 Project 4: the Netherlands 29 Page 16 GAO/HRD-93-60 AIDS and Needle Exchange Programs Contents Project 5: Sweden 30 Project 6: United Kingdom 31 Project 7: United Kingdom 32 Project 8: United Kingdom 33 Project 9: Tacoma, Washington 33 Tables Table 1: Results of Needle Exchange Program Study Projects Table 2: Needle Exchange Program Outcomes Measured and 10 Reported Abbreviations ADAMHA Alcohol, Drug Abuse, and Mental Health Administration AIDS acquired immune deficiency syndrome CDC Centers for Disease Control and Prevention HHS Department of Health and Human Services HIV human immunodeficiency virus IDU injection drug use IDI;s injection drug users NIDA National Institute on Drug Abuse PCR polymerase chain reaction PHS U.S. Public Health Service STD sexually transmitted diseases STT syringe tracking and testing TB tuberculosis Page 17 GAO/HRD-93-60 AIDS and Needle Exchange Programs Appendix I Study Project Designs and Methodologies Study methodologies Project and location Study designs Data collection method Sample designs Australia 1 Longitudinal—cohorts with Urine testing for drugs, administrative files of client Universe comparison group demographic data Long itudinal—trend° HIV testing of needles,self-administered duestionnaire "Selected arbitrarily" Canada 2 Longitudinal—trend Administrative files Universe Netherlands 3 Longitudinal—panel° Structured interview and HIV testing for incidence Self-seiected Longitudinal—trend HIV testing for prevalence,administrative files—hepatitis B Self-selected surveillance data 4 Cross-sectionals and Structured interview Self-selected Longitudinal—panel with comparison group Sweden 5 Longitudinal—trend Interview , HIV testing of exchange clients, Convenience self-administered questionnaires, administrative files—HIV surveillance data United Kingdom 6 Longitudinal—trend Structured interview Snowballe Longitudinal—panel with Administrative files, structured interview Not specified comparison group 7 Longitudinal—panel HIV testing of exchange clients(saliva test), Not specified interview, administrative files—client demographic data Cross-sectional Self-administered questionnaire—HIV testing of exchange Self-selected clients(saliva test) 8 Cross-sectional with Semi-structured interview Not specified comparison group United States (Tacoma, WA) 9 Cross-sectional with Structured interview, HIV testing of exchange Systematic, comoarison group clients, administrative files—hepatitis B surveillance data self-selected, snowbal! 'Designed to permit observations over an extended period of time,so that specific subpopulations(cohorts)drawn from general populations can be examined as they change over time. °Observations made at many times of samples drawn from general populations. `Observations made at many points in time of the same sample of people each time. °Based on observations made at one point in time. BMethod of developing an ever-increasing set of sample participants. Page 18 GAO/FMD-93-60 AIDS and Needle Exchange Program~ Appendix I Study Project Desigas`and Methodologies Page 19 GAO/HRD-93-60 AIDS and Needle Exchange Programs Appendix II Needle Exchange Programs: IDU Population and Program Characteristics Program start Estimated IDU Estimated HIV infection Location date population size levels among IDUs Australia 11/66 10,000- 14,000a 5.2% (1989) (Sydney) Canada 03/89 10,400-13.000 Not available (Vancouver) Netherlands Summer 1984 2,800 340/0 (1989) (Amsterdam) Sweden(Lund) 11/86 1,000 1% (1990) United Kingdom° 04/87 60,000- 100,000 Varies United States 11/90 2,300 60% (1991)-- (New 1991)°(New Haven, CT) (Tacoma,WA) 08/88 3,000 1-2% (1990)e Page 20 GAO/HRD-93-60 AIDS and Needle Exchange Programs • Appendix II Needle Exchange Programs:IDU Population and Program Characteristics Exchange protocol Hours and mode of operation Services offered Needles exchanged on a Days and hours vary by site. Moble ous visits Information on HIV risk associated with needle 1-for-1 basis. areas of prostitution and.IDU and fixed sites at sharing and unsafe sexual practices. drug abuse clinics and pharmacy. Counseling and referrals to drug treatment and AIDS assistance. Also provides condoms, swabs, spoons, sterile water and cotton. Needles exchanged on a Hours/days of operation not reported. Mobile Educational materials and advice on HIV risks, 1-for-1 basis. Maximum of van and walking tours of minority safe sex and safe injection techniques. 2 provided per exchange. neighborhoods. Fixed sites at a youth center Referrals to drug treatment and medical and a shopping mall opened to the general services(e.g., HIV testing and counseling, public. sexually transmitted diseases(STDs), and IDU-related illnesses). Also provides condoms. Needle exchanged on a Daily. Mobile buses that also dispense Information on safe drug use and safe sex. 1-for-1 basis. Limit on the methadone, visit 6 IDU areas, and fixed sites at General health education and referrals to number of needles that drug agencies and STD clinics. methadone and drug-free clinics. Also provides can be exchanged. condoms, first aid, and counseling. Not reported. Open during office hours. Fixed site at a Information on HIV and STD risks as well as the hospital outpatient clinic. availability of HIV testing and referral to drug treatment services. Also provides condoms. Needles exchanged on a 15 programs with various hours and days. Counseling and advice on drug problems, HIV 1-for-1 basis. An average Fixed sites at hospitals or health centers and transmission, safe sex, and HIV testing. Also, in of 9 needles issued per drug advice agencies. many cases, a broader range of social and exchange. medical care for clients. Needles exchanged on a 4 cays/week, 6 hrs./day. Mobile van visits 5 Risk-reduction education, drug treatment 1-for-1 basis. Maximum of IDU areas. - referral, counseling and advocacy. Information 5 provided per exchange. on HIV and other health risks(e.g., TB, STDs, hepatitis B)and available medical services. Also orovides condoms and bleach kits. Needles exchanged on a 5 days/week, 5-8 hrs./day. Mobile van visits 2 Risk-reduction education, counseling, HIV 1-1or-1 basis. IDU areas and delivers clean needles to testing, and referral to drug treatment and other requesting IDUs. Fixed site at health medical or social services. Also provides department's pharmacy. condoms, bleach, and alcohol pads for cleaning needles as well as TB and STD screening. aEstimate is for New South Wales,in which Sydney is located. °England and Scotland only. °Estimate for England ranged from 0 to 10 percent(1987);and in Scotland 4.5 percent`or Glasgow(1985)and between 38 and 65 percent for Edinnurgh(1985-86). °CDC estimated at 35.6 percent in 1990. eEstimate is for Pierce County,in which Tacoma is located. Page 21 GAO/FMD-93-60 MDS and Needle Exchange Programs Appendix III Review of the New Haven Model Our review of the study of the New Haven needle exchange program entailed an in-depth assessment of its forecasting model.This model predicts that the needle exchange program results in a 33 percent reduction over a 1 year period in the rate of new HRR infections among injection drug users participating in the program.The prediction is based on the theory that the program may be able to reduce the length of time that needles are in circulation by exchanging used needles in return for unused ones.This reduces the opportunity for needles to become infected, to be shared, and to transmit HIV to an uninfected drug user. To assess the reasonableness of the model's estimate, we (1)analyzed relevant published and unpublished materials describing the model's specifications, assumptions and data sources; (2)visited the New Haven needle exchange program and interviewed the principal researcher who developed the model, Dr. Edward H. Kaplan,Associate Professor of Policy Modeling and Public Management, Operations Research and Medicine, Yale University, to obtain clarifications on the approach used and the rationale for incorporating certain assumptions and data values; and (3) obtained expert review from two outside consultants, Dr. Margaret L. Brandeau, Stanford University, and Dr. N. Scott Cardell, Washington State University.' Our review and expert inquiry explored the technical adequacy of the model's mathematical specifications, reasonableness of the underlying assumptions used, quality of the data and sources relied upon, and the conclusiveness of the model's 33 percent estimate. We also explored with our experts the impact on the model's outcome if various other assumptions or data values had been adopted.The results of our assessment are summarized below. Technical Adequacy of The New Haven model incorporates two simultaneous nonlinear differential equations that express the level Of HAI infection among Model's Mathematical injection drug users and needles in circulation over time.'This modeling Specifications approach is based on the concept of a dynamic epidemic model 'We selected these two experts after considering several potential candidates recommended by others in the fields of drug abuse and epidemiologic modeling.our selection criteria were twofold-(1)The expert possesses advanced knowledge in operations research-based modeling techniques for HIV transmission as well as issues related to HIV transmission among injection drug users and(2)The expert provides assurances of objectivity and no professional conflicts of interest. Me concept of needles in circulation was also introduced in this study.This concept pro%ides abasis for estimating the effect of a needle exchange program on the number of new HIV infections among injection drug users.The effect is estimated by measuring the impact of a reduction in needle circulation time with the program. Page 22 GAO/FLED-93-60 AIDS and Needle Exchange Progrants Appendix III Review of the New Haven Model traditionally used and validated by epidemiologists studying many infectious diseases, including HrV infection. Both our experts found that the mathematical specifications used in both equations appropriately express the dynamic process of Hiv transmission among injection drug users via infected needles.They agreed in their assessment that the model is technically sound and incorporates all key parameters. MEN F- Reasonableness of The model assumes that the needle exchange program impacts only on the length of time needles are available to be shared, and that it does not Model's Underlying produce changes in addict behaviors. That is,the rate at which injection Assumptions drug users share their needles, the frequency of their injection practices, and the frequency of their bleaching practices were assumed as not affected by the exchange program. By adopting an assumption that the program did not have any positive effects on drug users'injection practices,3 our experts found that Dr. Kaplan's model works to produce a conservative estimate of the program's impact. If the model had assumed any positive behavioral changes, the estimated number of infections averted due to the New Haven program would have been greater than the 33 percent estimate. Our experts agreed that Dr. Kaplan's assumptions serve to underestimate the impact of the New Haven program on the rate of new HIV infections. The expert reviewers strongly believe that 33 percent understates the true percentage reduction in new infections attributable to the program. Other assumptions incorporated into the model that also serve to understate the potential impact of tate needle exchange program include: no change in the size of the injection drug using population,'high level of needle sharing behaviors, and Hw-infected injection drug users would continue to inject drugs until development of AIDs. ''For example.positive changes would include some combination of reducing the level of needle sharing,decreasing the frequency of injection.and increasing the rate of bleaching practices. 'The model ignores any reductions in the size of the injection drug using population and consequent reduction in new HIV infections attributable to the placement of participants in drug treatment.During the:first 7-1/9.months of New Haven's needle exchange program.about one out of every seven participants were placed in drug treatment Page 23 GAOMD-9:3-60 AIDS and Needle Exchange Programs Appendix III Review of the New Haven Model The data used in the model were primarily obtained from three sources: Quality of Model's (1) data developed from the program's syringe tracking and testing Data Sources and system,5(2)self-reports from injection drug users participating in the Values program, and (3) data developed from other AIDs research studies. Our experts noted that the data values used from these sources are reasonable and produce a conservative estimate of the program's impact on the rate of new HIv transmissions. For example, Dr. Kaplan chose to use an estimate of the sharing rate he developed based on the sTT system because it was higher than the sharing rate based on self-reports of program participants (31.5 versus 8.4 percent). If the lower estimate was used, the model's outcome would be significantly greater than the estimated 33 percent reduction in new Innv infections. In addition to choosing conservative values for use in the model, Dr. Kaplan conducted a sensitivity analysis using several different values for the parameter reflecting the probability that drug users disinfect their needles using bleach. This analysis showed that, even if the actual probability of disinfecting was much lower than the probability based on self-reported data used in the model(0.84), the estimated decline in new Hw infections attributable to the needle exchange program remains significant. Model's 33 Percent The model's estimate that the New Haven needle exchange program results in a reduction of new HIV infections among participants over 1 year Estimate Defensible is defensible as a minimal estimate of the program's impact. The 33 percent difference is strictly attributable to the reduction in levels of infection in needles due to the shorter length of time that needles are in use(or needle circulation time). 'STT data provide estimates on the level of needle sharing and the level of HIV infection in needles. The estimate for needle sharing(31.5 percent)is obtained by tracking those needles returned bi someone other than the person to whom the needle was given to.An estimate for the prevalence of HIV infection(60 percent)is obtained based on testing a sample of returned needles using the polymerase chain reaction testing procedure to detect the presence of the virus. Page 24 GAOIHRD-93-60 AIDS and Needle Exchange Programs Appendix IV Legal Barriers to Federal Funding of Needle Exchange Programs Since 1988, Congress has passed at least six laws (in addition to the Alcohol, Drug Abuse, and Mental Health Administration (ADA.'4 HA) Reorganization Act of 1992) that contain provisions prohibiting or restricting use of federal funding for needle exchange programs and activities. These provisions are contained in: • the Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act of 1988; • the Health Omnibus Programs Extension of 1988; • the Ryan White Comprehensive AIDS Resources Emergency Act of 1990; and • the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Acts of 1990, 1991, and 1993 (the Appropriations Act of 1992 did not contain such a provision). The Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act of 1988 required states, as a condition for receiving ADAMHA block grant funds under title XIX of the PHs Act, to agree that funds would not be used "to carry out any programs of distributing sterile needles for the hypodermic injection of any illegal drug or distributing bleach for the purpose of cleansing needles for such hypodermic irdection...." This provision was repealed by the ADAMHA Reorganization Act(1992). The Health Omnibus Programs Extension of 1988 authorizes funds and programs aimed at combatting the AIDS epidemic and preventing its transmission. Among other things, the act authorizes grants and contracts through the Director of the National Institute of Allergy and Infectious Diseases to assist public and nonprofit private entities in conducting research and training in advanced diagnostic, prevention, and treatment methods for AIDS.These grants may be used to operate demonstration projects in long-term monitoring and outpatient treatment of HRI-infected individuals. The act also authorizes funds for AIDS education. Additionally, the Director of the National Institutes of Health is to establish projects to promote cooperation among public health agencies and with private entities in research concerned with the diagnosis, prevention, and treatment of AIDS. The act provides further: "None of the funds provided under this Act or an amendment made by this Act shall be used to provide individuais with hypodermic needles or syringes so that such individuals Page 25 CAOMRD-93-60 AIDS and Needle Exchange Programs Appendix rt' ' Legal Barriers to Federal Funding of Needle Exchange Programs may use illegal drugs,unless the Surgeon General of the Public Health Service determines that a demonstration needle exchange program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for acquired immune deficiency syndrome." The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (42 U.S.C. § 300ff et seq.)authorizes grants to localities disproportionately affected by the HIV epidemic.The act prohibits use of "funds made available under this Act,or an amendment made by this Act...to provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs." The Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Acts of 1990 and 1991 contained identical prohibitions regarding needle exchange programs (section 520 of P.L. 101-166 and section 512 of P.L. 101-517). The provision stated: "None of the funds appropriated under this Act shall be used to carry out any program of distributing sterile needles for the hypodermic injection of any illegal drug unless the President of the United States certifies that such programs are effective in stopping the spread of my and do not encourage the use of illegal drugs." In contrast,the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriation Act of 1993, states in section 514 of the."General Provisions": "Notwithstanding any other provision of this Act,no funds appropriated under this Act shall be used to carry out any program of distributing sterile needles for the hypodermic injection of any illegal drug unless the Surgeon General of the United States determines that such programs are effective in preventing the spread of iiiv and do not encourage the use of illegal drugs,except that such funds may be used for such purposes in furtherance of demonstrations or studies authorized in the ADAMxA Reorganization Act(P.L. 102-321)." Page 26 GAO/HRD-93-60 AIDS and Needle Exchange Programs Appendix V . Major Contributors to This Report Human Resources Janet L. Shikles, Director, Health Financing and Policy Issues (202) 512-7119 Division, Rose Marie Martinez, Assistant Director Washington, D.C. Nancy J. Donovan, Assignment Manager Clarita Nlrena. Supervising Social Science Analyst Steven R. Machlin, Social Science Analyst Luarui M. Moy, Social Science Analyst Joel I. Grossman, Social Science Analyst Office of General Dayna K. Shah, Assistant General Counsel Sylvia L. Shanks, Senior Attorney-Adviser Counsel, Washington, D.C. New York Regional Patrice J. Hogan, Evaluator-in-Charge George F. Degen, Site Senior Office Julia C. Kou, Student Intern Page 27 GAO/IIRD-93-60 MDS and Needle Exchange Protzrams Bibliography • Project 1: Australia Published Studies Wodak,Alex D., et al. "Antibodies to the Human Immunodeficiency Virus in Needles and Syringes Used by Intravenous Drug Abusers."The Medical Journal of Australia(1987),Vol. 147,pp. 275-76. Wolk,Jael S., et al. "The Effect of a Needle and Syringe Exchange on a Methadone Maintenance Unit." British Journal of Addiction (1990), Vol. 85, pp. 1445-50. Wolk,Jael S., et al. "Syringe my Seroprevalence and Behavioral and Demographic Characteristics of Intravenous Drug Users in Sydney, Australia, 1987."AIDS(1988), Vol. 2, pp. 373-77. Abstracts and Wodak, Alex D., et al. "Hry Antibodies in Needles and Syringes Used by Presentations Intravenous Drug Users."Presented at the Third International Conference on ArDs, Washington, D.C.: 1987; (MP.186). t Wolk,Jael S.,Alex Wodak, and James J. Guinan. "The Effect of a Needle and Syringe Exchange on a Methadone Maintenance Unit."Presented at the Fifth International Conference on AIDS, Montreal, Canada: 1989 (W.D.P.63). Wolk,Jael S., et al. "HIV Seroprevalence in Syringes of Intravenous Drug Use;using Syringe Exchanges in Sydney,Australia, 1987."Presented at the Fourth International Conference on AIDS, Stockholm, Sweden: 1988; (8504). Project 2: Canada Published Studies Bardsley,John,John Turvey, and John Blatherwick. "Vancouver's Needle Exchange Program." Canadian Journal of Public Health (1990), Vol. 81, pp. 39-45. 'This and subsequent parenthetic entries at the each of each citation are code numbers for publications from each conference. Page 28 GAO/HRD-93-60 AIDS and Needle Exchange Programs Bibliography Project 3: the Netherlands Published Studies van Haastrecht, Harry J.A., et al. "The Course of the Hry Epidemic Among Intravenous Drug Users in Amsterdam, the Netherlands."American Journal of Public Health(1991), Vol. 81, No. 1, pp. 59-62. Van den Hoek,Johanna A.R., Harry J.A.van Haastrecht, and Roel A. Coutinho. "Risk Reduction Among Intravenous Drug Users in Amsterdam Under the Influence of AIDS."American Journal of Public Health (1989), Vol. 79, No. 10, pp. 1355-57. Abstracts and Van den Hoek,Johanna A.R, Harry J.A. van Haastrecht, and Roel A. Presentations Coutinho. "Evidence for Risk Reduction Among IVDU in Amsterdam." Presented at the Fifth International Conference on AIDS, Montreal, Canada: 1989; (W.A.P. 107). Project 4: the Netherlands Published Studies and Burling, Ernst C., Giel H.A.van Brussel, and Gerrit W. van Santen. Government Monographs "Amsterdam's Drug Policy and Its Implications for Controlling Needle Sharing." In Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives, U.S. Department of Health and Human Services, National Institute on Drug Abuse, Research Monograph Series 80, pp. 59-74, Washington, D.C.: 1988. Hartgers, Christina, et al. "The Impact of the Needle and Syringe-Exchange Programme in Amsterdam on Injecting Risk Behaviour." VDs (1989), Vol. 3, pp. 571-76. Abstracts and Buning, Ernst C., et al. "The Evaluation of the Needle/Syringe Exchange in Presentations Amsterdam." Presented at the Fourth International Conference on.IDS. Stockholm, Sweden, 1988; (8513). Page 29 GAOMRD-93-60 AIDS and Needle Exchange Programs Bibliography Buning, Ernst C. "Prevention Policy on AIDS Among Drug Addicts in Amsterdam" Presented at the Third International Conference on AIDS, Washington, D.C.: 1987; (MP.183). Hartgers, Christina, Ernst C. Buning, Roel A. Coutinho. "Evaluation of the Needle Exchange Program in Amsterdam." Presented at the Fifth International Conference on Ams, Montreal, Canada: 1989; (T.A.0.21). Project 5: Sweden Published Studies LJungberg, Bengt, et al. "mv Prevention Among Injecting Drug Users: Three Years of Experience from a Syringe Exchange Program in Sweden." Journal of Acquired Immune Deficiency Syndromes (1991),Vol. 4, pp. 890-95. Abstracts and I,jungberg, Bengt, and Bertil Christenson. "Still No xIv Epidemic Among Presentations Local Drug Users at Four Year Follow-up of the First Swedish Syringe Exchange Program."Presented at the Seventh International Conference on AIDS, Florence, Italy: 1991; (W.C.3290). Wungberg, Bengt,.et al. "Distribution of Sterile Equipment to IV Drug Abusers as Part of an HN Prevention Program." Presented at the Fourth International Conference on AIDS, Stockholm, Sweden: 1988; (8514). Tunving, Kerstin, et al. "An mv-Prevention Syringe Exchange Program in Lund, Sweden.Two Years of Observation of the Attenders." Presented at the Fifth International Conference on AIDS, Montreal, Canada: 1989; (W.D.P. 65). Tuning, Kerstin, et al. "An Illy-Prevention Syringe Exchange Program in Lund, Sweden. Observation of the Attitudes of. 1.Attending VDUs. 2. Counsellors in a Nearby Drug Treatment Center. 3. Society." Presented at the Fifth International Conference on AIDS, Montreal, Canada: 1989; (Th.D.P.36). Page 30 GAO/HRD-93-60 AIDS and Needle Exchange Programs a , � Bibliography Project 6: United Kingdom Published Studies and Donoghoe, Martin C., et al. "Changes in my Risk Behaviour in Clients of Government Monographs Syringe-Exchange Schemes in England and Scotland." AIDS, (1989), Vol. 3, pp. 267-72. Stimson, Gerry V., et al. Injecting Equipment Exchange Schemes Final Report, University of London: Goldsmiths' College, 1988. Stimson, Gerry V., et al. "Preventing the Spread of HIV in Injecting Drug Users—the Experience of Syringe-Exchange Schemes in England and Scotland." Problems of Drug Dependence, 1988: Proceeding of the 50th Annual Scientific Meeting,The Committee on Problems of Drug Dependence, Inc. U. S. Department of Health and Human Services, National Institute on Drug Abuse,.Research Monograph Series 90, pp. 302-10. Washington, D.C.: 1988. Stimson, Gerry V., et al. "Syringe Exchange Schemes for Drug Users in England and Scotland." British Medical Journal (1988), Vol. 296, pp. 1717-19. Stimson, Gerry V., et al. "iuv Transmission Risk Behaviour of Clients Attending Syringe-Exchange Schemes in England and Scotland." British Journal of Addiction (1988), Vol.'83, pp. 1449-55. Abstracts and Dolan, Kate, Gerry V. Stimson, and Martin C. Donoghoe. "Differences in H Presentations Rates and Risk Behavior of Drug Injectors Attending, and Not Attending, Syringe-Exchanges in England." Presented at the Sixth International Conference on AIDS, San Francisco, California: 1990; (F.C.108). Donoghoe, Martin C., Kate Dolan, and Gerry V. Stimson. "Changes in Injectors' my Risk Behaviour and Syringe Supply in UK 1987-90." Presented at the Seventh International Conference on AIDS, Florence, Italy: 1991; (Th.C.45). Donoghoe;Martin C., Kate Dolan, and Gerry V. Stimson. "An Evaluation of the Further Development of Syringe-Exchanges in England." Presented aE Page 31 GAO/HRD-93-60 AIDS and Needle Exchange Programs Bibliography ,. the Sixth International Conference on AIDS, San Francisco, California: 1990; (3060). Stimson, Gerry V., et al. "xtv and the Injecting Drug User: Syringe Exchange Schemes in England and Scotland." Presented at the Fourth International Conference on AIDS, Stockholm, Sweden: 1988; (8511). 1 Stimson, Gerry V., Martin C. Donoghoe, and Kate Dolan. "Changes in HIV Risk Behavior in Drug Injectors Attending Syringe-Exchange Projects in England and Scotland." Presented at the Fifth International Conference on AIDS, Montreal, Canada 1989; (W.A.P.108). Project 7: United Kingdom Published Studies Carvell,Andrea M. and Graham J. Hart. "Help-seeking and Referrals in a Needle Exchange: A Comprehensive Service to Injecting Drug Users." British Journal of Addiction(1990),Vol. 85, pp. 235-40. Hart, Graham, et al. "Evaluation of Needle Exchange in Central London: Behavior Change and Anti-HIV Status Over One Year."AIDS (1989), Vol. 3. pp. 261-65. Hart, Graham J., Nicola Woodward, and Andrea M. Carvell. "Needle-Exchange in Central London: Operating Philosophy and Communication Strategies."AIDS CARE (1989), Vol. 1, No. 2, pp. 125-34. Hart, Graham,J., et al. "Prevalence of HIv, Hepatitis B and Associated Risk Behaviours in Clients of a Needle-Exchange in Central London." AIDS (1991),Vol. 5,pp. 543-47. Abstracts and Hart, Graham J., et al. "Needle Exchange in Central London." Presented at. Presentations the Fourth International Conference on AIDS, Stockholm, Sweden: 1988; (8512). Hart, Graham J., et al. "Needle Exchange in Central London: One Year Follow-lip." Presented at the Fifth International Conference on AIDS, Montreal, Canada: 1989; (T.A.0.9). Page 32 GAOIHRD-93-60 AIDS and Needle Exchange Programs Bibliography Project 8: United Kingdom Published Studies Klee, Hilary, et al. "The Sharing of Injecting Equipment among Drug Users Attending Prescribing Clinics and Those Using Needle-exchanges." British Journal of Addiction (1991), Vol. 86, pp. 217-23. .Project 9: Tacoma, Washington Published Studies Hagan,Holly, et al. "The Tacoma Syringe Exchange."Journal of Addictive Diseases(1991), Vol. 10, No.4, pp. 81-88. Abstracts and Des Jarlais, Don C., et al. "Safer Injection Among Participants in the First Presentations North American Syringe Exchange Program" Presented at the Fifth International Conference on NIDs, Montreal, Canada, 1989; (T.A.0.20). Hagan,Holly, et al. "Lower Hiv Seroprevalence, Declining HBV incidence and Safer Injection in Relation to the Tacoma Syringe Exchange." Presented at the Seventh International Conference on AIDS, Florence, Italy: 1991; (W.C.3291). . "Drug Use Trends Among Participants in the Tacoma Syringe Exchange." Presented at the Fifth International Conference on Ams, Montreal, Canada: 1989; (Th.D.0.13). (t 08939) Page 33 GAO/HRD-93-60 AIDS and Needle Exchange Programa 1 CJO O + G C O C � O O •` — OO.. Q+ E & C c �_ w , ' 2 tox o o� y �UA U c. ... � a:c .� �U D Q.,. Q Q •�` .0 O wC O C .� 'C "y Off+ C..� co H.1.r +r � t} �" Lwoo f7 UPC w 0 0 yN. O �r o Cc 0 N . cc A {rr tL fi •» O VQSa C. O G .] �" y' cc C y 4i "'� U N Cr w C,' 0 U aj �� t�i� O E ca O �� O cis C� Qa �'i L" �` N +t4+ .� w:I' Z #. Q � cd N �r lr ;� {a ".E` t/� O .wN �_ >% OCIS P., w y, v N .t ri it �»' ij y , "O �+ .,N. C O -M .+ •Z3 i.► tip N �•` '^' C . O 1. cr.. «C C O O O O L] O O C 4� C 'C .� "" •� O 03 O sem. C+ �''"C O iN. ►* N p N aso3.ti � x3�va oo"a •� r. o `' •°' —Z PC cc o bo bo C QMr ,1� .fir d b C N pr1 �i {a 0 C'.1 •� tr N a .L� •�.•.1 b+ .,�•' CIO � Q�� •1>+ ° '~ ` 0 Qooa) Q :.► y y C Q C c0 Q W.....� U Ifs Q CQ �, W y Q O b0 `✓ H b0 Ori O I.. O cts cd .r > H > C >+^ O �' cb ++ ++ GV O '�--• co .0 .r .., • ... C i".� 1[� ^ -• C O O CO c3 Q y x d C ,� O Q cu Q �, 3 ��„ 'C �., C 7 .y. 7 Q) O + O Q^1 CO Q •rn W, Q C4 y y 0 .9 t'+ CS r. O y Q y C� Q 4 "'Q L4 U b0 Q U C O vs C Q ,r Q4) ."r Q .0 Q'w'fl yy QU Q 4Q Q G� C a0 `'" 00CAv QS .rC cU bo-0o Q .� Q ++ y �G +' y .E a O Q E y O C .O r SCO O c O C Ur QC �Crr Cn bo • ..UObag p C y +OQ+-++QCar y , WQ0. UUCpL .— .'' •yQ. OM 6L�O OQ yy 0 to U O rCQ Q CQQ.+'"-C'p�• yz3+ CQ CSS 1» •r r. c)yA0en � � �Q ++ �' C •Ced „OyC ,ryC-n U (1) 1 m- � VCCD Q a yO � � � yp � C Q y C , U o .9 CM U+ FcC y bo C'C C • M ' : U Q Q Q G Q y '� O U C'L7 tts Q �v.e �'C> bo.0 I Q 3 �. C4 U N C b0' O y y Q Q w" W C C U...� Q Q o -12) ci0 .p y a O �� E C a � cr. C � •'. 4) 00p Q ^O �" Gt+OQ C C ^.+ .E � 3 C PC u2 Q y y a O eyyd ^, y 'O t0 vct 7 O Q a 3 i7. C) C a C cn o Q� us VJ L .� ti Lr y a Q Q Q .= .r U y O O Ctt r ryCCQUQ�eO+")y'rwU1CQr"'..OrCc.E. �QQ"+y�+ "CyQ HqQ ►�y+ QC yy+ WQC f1ya y p QO%�'� { C ?►+++� � 'QQ r. > Q O 'C .a "C = .•+.UC+.+ •fC W P.Q O m .L Ci.+ r.O CO . •rU �Q. :•^:UrpO,"yf,yy�..G;y•.�y-rQ'�QUt.d' +�'UOO O OC U "C O G CyQ O � • L6. — Q y + Xw 'y) O Q ', CO 'u y 'C O U C �EO �s �+ ^ 00 O Qy C -C O acCo �Qc„ Qa Q pa OECC � Q p0 Ca O U � > y0P y 1.;o bo a) QwE QprLHC Cn Q CA C y Q tom; or Q Q U p y Cp •Q ' C4 n r7 U O ^� tr ^� i.1 CQ CO) Q ^. p C .r C r•.. y y E, U eC ^ ►. •r Cn in �+ Cn y ..., Q ►•� CSf '� E O Q a^ bo > PC bo COQ .O U .r U ++ U +' �' Q 'y ++ 3 Q .� a �, bO.0 •� '� •r •� �i O A 1. A Q Q V �� r. y 4i S: > r ++ v ^ Q v w > C r.. 1. ►, y H �-+ y e� �--� w .0 Q Q O Q O w "'' y O w ltd y cts E. ..� � 46). O v a C� ti, CC "C a-o � � y aQ .EE-� � ayU 3 Uyxp�pa U O .� o E H .E ci �• •••4GVmlvlo Dti0000 - 04MM410CD0001O91 a ' nC9 � CO � � MMCM') � � c0') McM� CO� � O "C y y i' i' W Q >,4W y -o Q ti. b0 Q y "Ccz v C C '"' '" �_ �`" Q C C � V yr �. � � ,1; 0 �sA cu O � E � w ,: •ays �'ci • 0-4 o`= E � w-Cy ^, " Ey "Q U3 aoo � E 'cci .y w V ++ U 3 O cd a"C C O O O ..y. ~ y; Q 'L7 C 'r Q y Pi'" bpc"� �:+ U "C Q) '�+ ,� Q Q) �'y CSS Q y +^+ y V W ••••� C C a �• •j" Q C ^ Q r_�"CaooQmQ �. > Q Cd � Q �5E `� ,� w°, � °.°.c Cn W Q y r CA V ica >r y Q O �"" U y �" Q •ipi C9 O +' IQr �� ~ y Q y A S:�_ Q•b pu C: y C y Q E Q E m C v w 'O � U �l) C 0 > 0Q cd0 '� �. 4i O 0 .0 V a+� : Q .Q•� `LQ�tiw O' C� ^' E C� II yO0QQ"�•eQy.0+^•.,"3rG' +'.irCaa TpCpJ CQ wy+a+'�y Q ••�Q .r.L, •y o UnS �Q Qy� "wO U? CE ." > O 1. „C .ryC l ."d > t10 it 4.0U Cn �a C p A0VcyO yCy C C • pen CS 4.0 ..aOC RM � x OC yy a+ Q CO yr A. P= 4.0 Q y s Sr rr 0 0 iVfn• n bo Q s � o 0 0 Q 0 Q y'� "4 o Q U >~ s �o a� Q ° 'E y ++ y o y U Q �+ .r'� C "" =° S) .Cvi LO� .0 "Ct.�E3 •o�O� .a^,' �`yQ y ��Qa��53 •a`QE'�U 4�p3" •�r+i a� (� U ^cvc a� boO � Gy 6.0 cu O ° a' � o0 ac0a4) � 0 ., a a '. a Qoca � �Q �Q . C"0 �wO C 3 ;2 UQ O'C CQ w C Z7 C - w ed Occ cC ci Q v'Z a C =� L. 0p C pQC Q «S Cd o Q y � w O Ccn yL=+ o U _ ea � U ^ r.p ,� Pic , o ($� U'r Q V O^' O V ry� a . �+ .Q U C y .� Cd •C C y 'L� 'a �- p.QC o 0 0 � � •>�C 'y aai O "a •�F a� H � F" > � � c4MvincOtiao00 --� c� Ma O U ++ �+ � U G C CO e# 7 w d d �+ 'O C ++ v � a ,, y u. ,.+ ° GOA✓ �",�G;+ o N y ° 3 O NN N:� °o � G O �t^�• O 4 ti0" O � 7� � Q,��•�(.� rou. •Q: �� N Da ?�� � � �,•, G, i � O G•Cy0+4�. ,,�� C► r to �,, G �CL O .G p �•,� ° W � � Gca .G O '" G 0 G N O �� A � o� aO+ G ° p •y c_oO �_�•U •� � � Ste, ?' caS o K3 O " 's > •OU�pj•c� � G� c.� cs 6G� p ¢1 aE,. p3 0 Go v "� 83? •Gy. O O 0 .G O y CA� Gt.:, O +.l O toG �• `n � .00 ° CS G S' r % G ""' N G, OS N p �, '.�3.+r � ° • .G �.. > v ees Z G+ O O G O „' p d) •.,�, v a?p,3 .� , to...O W v j O G N ,,,► O 0 G ?,y C.C 'y� v Q. p a,0 o p v �•G i, O ,'�'' >,+�+ O 'ca �•+ r •• O O Gt ws 01 G.+ y•+' '',} G i O G v ~' �✓ ,,0,,, C, O � � C � N ✓ .✓•v O OJ "G"C1 O R .+ �.+ O, v r�W r—✓ ,Oa u.K� �, y ••.. O O cs oo�' •G cs G v .O O O .G �'++ G' O c4 :3 .s O O ' O y •T s'a s °`o 3 0�---"` cJ� a� Fa t, ,o a o►.?'"G•3 c C. o .�'"S v, C O ++ 4) X. ba O •• Gd LSO '>"� Gcd ti' O 43 O C .0 ..1 N ': ci G t 4 �.•eS G G �/'. ?, U •U ~ O V Ca C'3 -a 3 o ua cs `ci 'boo) w cl) ' C3 c G3 CA co es"G O y�G �•G G� a�3i N o & G , � Nty,o N Oi% O GyG �!,✓d% C-lot � w r O G red r d .% ✓4)SQ.y.' '? .r U 7 G O O G O c4 Q 0 G y O v, �v t�� N ,.. r, CS ae y'�i ✓, y, G► : p �' '4 'y � d" r �" O "O r•" r O �•, .'J s,. O aOGO° , ^ �ad✓y�': 0 Ids SOy ? ? p C, osO O0 G ... J GG N ! rvyO O� u0" o yd c.r .. o o� G CY G ?• G•c4 N N ✓ O O .� e4 O r cd y O ,• r .G N N V IA ° .. 0 r a _O yrj V d N O V. y � n � r Na) Q+w O �Ci y O ?,S u. yn '' d0•`1' N c4 ? + y'° Z`+ ✓ r y. es, y O y O t4 O y CS O 41 y G ? .. O Ir. �'� o�"G N G . r L Tw 3 y y S, o�p•�ter° ;� o' 7P, a� v G t5 y ° O'y AA- ds .G �.+ N ,G O r ? ''' .+ 4) '" y "3 y'+' r. G �.`G ✓ G yrs 0 y y y G� � rO+ctOs.►+ .by`4 � O+G N r U ✓, Gp � y GQ UO F G O o� yr G G 0 � O .rC) r' O6? .;a. to 0 o O . c o ,� N ct� �, N t°'�: G' 0. to ces .y G cd o� v O r .+N " .N ° O •y '✓ P+.✓ . • v c4 .�� cd v t4 • o O N ?' N �" ' ✓ r v O U . p °:,V �• d y i 0 7^0,�✓ p+ .� 7 td ca G� y� ted` y '�+ V Gi R cs Q' d �.y c6 7 o °� S'a �° ° '�� t, ,;c ° •vo> >° o.°o o'o'°Z, OSG 4 �a c CLAS Sp.OA a� +. 'ca•d � 7, y+ bo >i 3 G N y+ G dl � �. �.'Z`�"Ci ' c4 t0 y � y, p � ea G y, G �, � N ° G o yai o v yGo � as G G G .. G d •^ G r w y. ,.� >� O C� N y N �, .� v ° v t13 p+'y us i. .Gr 03 G O ° ° •tGS ,a► � y'� N 0 O p� 'C3 C u�'�'`',�w`�•�.+� P+•td NCO � G y+""c� � G ¢► �� �.y, y� cb V tp O� �' x N p� r vo� r y .� r c'� ..� ° U+ y U ° m C1 cs 'C, to G N G.�+ 4 c G �. y. ..• Q y N Q+ T 3 N c� G .y y. ,h �, .r °��G c >.c o• 3 ° as 55 ° , " •U. 9�, oo ,y y mr - ts�'O •a� 3 cs>Cr`3 °o a ° �G Q► ° r p► a .. ei 1 0 , Q'' G OA -;P* y N OU � r. OG° 0 �,, ay U �C�� r :N'G� ✓'d ,°G GO �` d Vii, + U �". >� y ✓ d+° c0,�+ Q .:. O C C C 4: O G .E C it U vs Q) •� ti ,0 O > rn Q .� 00.0. w C &n ' 0 C w O y O w e0 0 Q •� C: y G 3 U C. r'n M:� �'C •� y y U O i0+ y ,.0, r FA _ ca o y 6._ U M C C 7 Q) Q) 0 cis W i.. Q) �.' •C ca rn 0 y O 'b co •., "" �' O O w cn 0 � 0 4+ cd 6. > • C 6 ._ 0w U Q) � w �+ ;� 0 �•• U y > CO 0 p "" 7 Q) O QQC9� LC. �'-C O O% y _� Cy U m 0 0 a� •�,' ,fir, t.Q.. cl G O C'. 01 O a"L1 •� y U"". V VZf cn •� ire .� O 4+�Q^Y• ' 1+ L: �" ^".� Q. ca ri w C 'C O �•n r7 r. ++ >> 0 '0 Fr >� y H i. Q) }„ N ct �.w O '^' 3 N CC 0 O �' C, +•'.L .� bO.N O > pp+: Q) d00 cn ++ 0 �.,�. p 0 Q) y C Q- w c'0 c� w 0 3 0 .� �. C F C p `' .0 e0 y.0 O S+ C o y ++ U w .� . vs `y„ y.� U ^Q i C 0 3 O +' c0 O i' !r G 0 co .n' .0 �.+ y M� r. I O c�s C O rOn 0 y y �'' c0 e0 '� O L, C CL fl'' Q)y y '' ..>. o y O w. G. O a ++ C p,. 3 C e0 c� CL 1' �• C C to O LL y V e0 C �Q) 0 y ca ed ++ vs e0 C C Q) vCi y Q) G G a E O •> 10 C y y > CO Q' vi y 1y. U y ..0.�++ C� y b0 p •L" U y 0 ty •U. ,�0, O �'cp c0 M- O O Q) e0 cn p w. i... C .+J 0 c4 0 :.. y rn a n„i y Q) Q) 0 �. 'O e0 rn C F, e0 > w C w rn ,_ ►. rn O ,�, •-+ C > > O Q) O > "L7 cc F. 0 C'� 0. C. }" O x'�C+ iC Q) C Q) y �. e0.Z w .cti >.0 O O >.i+ Q) 0 � M 15 y cn cd O I>. S. .y. yy y > y y e0 C �� C H +' eo O k O �++ ^' C ... •.. O > e0 p y ci i0, O �.. Q) •-• 3 U 0'O �, •_ > O O 0,� 0 u C C Q) u. 0'O w 0 C ,_ y > 0 Q) 0. C ca CUp^C t, w O y p . sy H p .. U •--�y C 0 0 Q) Q) Q) Q) 0 ia U v� rn 0 4'"� `r C •,�,�"" y >� C. O y U c0 0 y Lz0 00 i30 Q) 0 O V C G 0 C r.. L: .0 .0- 11) +' 0.0 .�.10 O L a w � ... y �'' �+ Q) w. r' G 0 e0 G.0•o •C •O C V a y q y R.O O ed O O 4.+ y O o y .0 C 0 c.c E" ok- � � � � •^� aw �,.-. �_ a� o � U_ r. .>. >: U o � 4 ZUUUU 0 cD t` a0 ' U C O -' C.L^ ^' .^i j C j C» LSO UC y U C 7 a'.: ^, 0 `7 c'»' cc .. > .� 0 .�� `.w G y �. e0 C y �. LOy �, .� ' r. 0 C O 0 • �. 0 .�......�.`. "a y 3 3 a u G w U U C c4 U 'O Qr C) U bo�i:O rte.+ •� GVmvinccr- 00O cgmv10COt- 00.0O � �y v 0t� ppO� O � Nc'� '� mf c1�. w = 0 � •r P-4 • 4 •-4 �4 -4 � •-r P-4GV C4 GV CV N �.V GV GV c'� C'� C'� m m m C"� m M cn O p p C 0 0 Q) C Z, C 0�O C c3 C_ O �c 0 0 O C O o ys L` C C y O U C • O .0 ++ a O .... ++ •.. ++ C� $ • 0 CL'•O >"O wo o = Q 0 0 ..(%� ^2 � - y'C U H C Q) vs o O y c.3. cd CC y C C 0 ^' .y O t30= 0 'G C Q) t. Z O,�,C ; ,a o C _ Q) w y . 0 �+ 'O �.� p I. h O �, P: 0 ,-a 0 I �ir •C .� �.,C vp.O ,� G. U c C i, V ... .., �+ v� G:r V C y �' H ..>. L" y > •O 3 �" C �., O .:. �• •>`'� CL 0 'y w +, r C 0.L' y++ 0 t+ • y Q) H C O vs rr Lr p G. H y cn O O 0. s+ C e0 CT O N v C `� e0 ^p 0 C"d y) y 0.0 v x G= pp QO v ^C m y y 04 Q) cy b+ 4) 7 a+ �' 7 �p C 0 y f" � .0 � w y 4C •C`. yC•� � '� tv 9 y p cj O ,0 U O Q) `�' e0 s' U.y C0. 0 �, y y �+ O 0 t0 .9 � O c0 C q ''n � �`•^ 0 0 ~ ++ Q) ..0 G y 'A�+ E ++ C 0 y 0 •'� .V ~ •'H' U2 y —'C yca .�. O U ca H 0 y 0 . C. ap c4 V .> 0, Q) O 0 0 C C Q1 rn a C � Q) rn O ccs h +, O o ,y ty0 y �'' "O C cn o Q) H y t C M E � cn �" ,C Q G' cj' C O C y Ccs a 0 cn V 3 � C e0 p y.z e0 CL �. 0 ++ w r0+ v' +-Cd 0 Q) `0 e0 w C CLO V 04 0 .- 4.j ~ y 0 cis y S }. U y �'' CO i'. ^r CO O 0 0 0 0 0 .p y O _y_O Q) G.� avi 'O w 4r y 0 w w v0 Q) C0 y y ^ E"O �� V V y G A. C '.' y� •C ... T o ++ Q) 0.�'O y O � 0 O C 0 O 0 V •S il*: w. 0 Q) V Q) e0 'L3 0 0 O •." CL OG V V �. V O C 4-, C Q) Od .0 y y ++ O cc 0 y O ."C,'*' r0n >. �." ^`J +^O+ cl >`tO C 0 w CL `� 00C+ �, v� C C •V 0 es C1.r. 0 f• law �" O >. rn G C. Q) w ,C .O 4f•, 'Y OO.Ot�.•...�.r.'r+.+. .0� C _CIO.,. •',b„ Od '�O y y C G0 C C CpUC '>Ow V O C O OU > y t0 A > Cc.,0 Jo 0 Qmd 4.0pC .->dr.O cE U yO O rn U3 O Od O O . C4.0 Q)O UC >o .e% N C ,r Oz b >".•r�Q.."++^pOQ,) �..rOOVC.r >, � Fsa� e � .s .r R004., � aiE"'-• vooE'" �; mo ,a �'L„ y °? 4� r.. 4• r.. �• r�. C L �• N .'� cf y .Lr .•.tOr V �+ t ^'fl O O CO O O CO O C'C 0 Q) ++ Q) ..•� e0 r+ ^ Q) ”. y �•► C U 0 C^..O Q) -C.0 y Od 0 w S +' �' ""�y V U CV .� V i. . c9 > O �' to o� -- � o0O� o -- � $; ^' � � o0_pu,x as Ecv '` C •c ° "s a x" � N Ueo 012, w =—. .nom 3caUAeaUa, c... �a ... .0o ... tz. -va� .... o �- a:; a) •o q .. egCID VM = t- w m0 - 0cV Mot- ao04 "' c� c� s 'r� cotiogo� o -• c� m " ►r� coraoa� o /� r .� �. A Al /� A A A7 A7 /V /�7 M M M M M Iw I I.A w% M !M >,.6J y w GJ C C ° L cC C cOn U y- r O O y U 4.0 'F. 'C O� O H •� �' Q) �_ Q) y p •� a Q) •� p tr. C O r'� `� d U y y C Q) I.. E O G Q) ++ ' •�" U C ••d y G �' U d +' O ca 't H Q) '+• AO O y C O Q) �+ r•� ,.,, U C . C C to r. >% vs eC �. ... A O O J.. •> H t+.± d U () ^G ti Q) y y O y O 4 ++ O CO Q)'� •w U C•� +.. tS0 y C O 4. y O �,. y U ., '7 .G 4) y O O 6. > O C� 'a y !.. Q) C •� Q) •� O .fir •� •V �p� C uj 0 ++ O C u a Q) ++ y Q) 1.. U •"'• • .yr r i. d Q Q� C� N� .r •� Q CO X > •r tr. Q) H �+ CO Q y .r O m y U C y y U C �C+ N.U y RS Q y y C aw •r. w. y •� n. = C� y y r .r C it C U iQn S N1 Q y .r ❑ d > ° •> � . ea O"O C ^. bo Q) > d U S.t� d Q) O h C G �» CU U r' N1 Q� "" U r. d U C� •.. U V,y V1 iA h Q Q O Q 1r (/� I.rcd Q _ O •U G �.. ++ H 4-6 U CO... O CC>,y H y y Q) tC O'C y 1.. O V �" p O Q).0 ^.L' U _ y +r y fy b ..V. ,��' i/5 r >, Ln +r 4. ...n Q� r 'y y.C.++ V LZy lI � O 0. O y >S. 1. ° G O cC n0'O O 4. ° y y ;�4) ca '� y y Cl E-+ .0 h O Or. H y C H o •r r, CQ 6. .0GFC.O,aUCyCCyyn4. y OUG++_°+' aO C." G O °4�);o LpC= tC O Q) H ►»tG !� C- SH O C � � O 0rl0. b0 e0 c O U O .0 G S tep r o O : r •r p ++ U! .. fr. H p , b.A � t9 O p 2 4) t%o Q , Qy y . V "Oy jco Cy> rrrC4. eC + UcOyO Ow "C � C > V co C O > 0O O 0. 0 Qd •h $ O bo $.E p vC O y� UCLcpS . O O: 0- QPC y bo >.^.� y C to . O ". 1'". U0 +�+ ,1�'. p +p+ ° +�+ +�+ •U Q� Iyif CC (n r ,..j y Q C y ++ C e a •r y ►r y —14 In O m v3 C7 p C cd L' +' •teS l� >. ca U C4 C U �+ O C .0 C L+ ^� U .'� z 1. 4, r.+ �' i.. y .r t0 W 1. v2"C V H 3 . U h •-•• O 0 �j 1... y .L I'DN CO O) Q>'� H H Q)^7., C y y C H.C. Q) •.--1 b0... Cr > > to t.. r..cd V ca Q! C v v v C �i Q)y Urr co Za Q N.r�" �' Q) .�,. Q� ^ v 1.. Ir = v .0 �..I v Q) G �..' ..0.0 rr g - L= .y C] G G O •r U O ++ ++ Gtr. w G G"O H r� 'V Cd CC H r, y y p..,^. .� �r GV CO3 V k S CO L- 00 0 0 '••I C1 CP3 V M CO t— CC 0 0 0 rc � C -I C7 tM m 0 t- � � r~ .••1 �I ..� .,•� ..r �. ..� ..y ...� c,V c.V �l �V N � �V Gil GV USCM AIDS/HIV PROGRAM ���g CONpF� AIDS y INFORMATION y��,yyou�w EXCHANGE March 1992 t . 5 Volume 9, Number 1 Ne%=w1.4J�e .EXCh nGq in New Hcysn Communities that have for years been ravaged by illicit drug use and its accompanying violence and crime are now being, faced with escalating cases of HIV infection asscciated with intravenous drug use. One such community is New Haven, Connecticut Despite an aggressive street outreach campaign started in 1987 targeting injection drug users(IDUs),Mayor John Daniels,the health department,the Mayor's Task Force on AIDS and others in the community realized that they were losing the fight against AIDS. With an estimated HIV infection rate between 52-69 percent among IDUs,many saw needle exchange as an essential component of the city's HIV prevention efforts. This issue of AIDS Information Exchange(AIM provides a ase profile of the New Haven Health Department's needle exchange program,including examination of local forces which initiated needle exchange,program design,community and law enforcement roles,and evaluation of activities. For additional information about New Haven's needle exchange program,contact Elaine O'Keefe,New Haven Health Department,(203)787-8709. Often seen cruising around New Haven's drug- one of the program's four outreach workers. By infested neighborhoods is a mural-covered van, I providing much more than clean needles to drug painted with green and blue people stretching their users, the New Haven program has won the trust of arms toward the sun. When parked on a street corner, the drug using population and the support of many it is an outpost for outreach workers providing policymakers, local organizations and much of the clean needles to waiting community. drug addicts. Since the first day on the "When you sit in For over one year, the van streets in November 1990, has been making the rounds this chair, when g the you see the devas- of five New Haven neigh- change program has en- talion of HIV, you Interview with borhoods with outreach rolled nearly 900 partici- do what you can to New Haven workers dispensing clean pants(80 percent male,39 stop it.... Now we Mayor John Daniels needles,bleach,water,alco- percentAfrican American, can prove that this page 5 hol wipes, and condoms 24 percent Latino/a), out program is reduc- • along with HIV risk reduc- of an estimated drug us- ing the spread of Program tioninformation,advice and ing population of 2,000-On HIV...." Planning assistance concerning drug an average day, the out- page 6 treatment,and simply dem- reach team will exchange -Mayor Daniels- Working onstrating to drug users that between 200-250 needles. with someone cares about them. 'We have people in the program who have been the Police "They share with usall kinds coming in from the very first day,"said a team mem- page 11 of information [concerning ber. In all, over the past year the program has ex- their health and drug use changed more than 15,000 needles,assisted over 100 Evaluation practices] and are just des- participants into detox and/or drug treatment and page 13 perate to have someone that given away "tens of thousands of condoms." can talk 'to them," relates f _ —coittin«ed,page 2— The United Stares Conference of Mayors • 1620 Eye Street, NW. 0 Washington, DC 20006 • 1202; 293-7320 The Needle Exchange Debate The relatively small number of communities that have implemented needle exchange attests to the controversy surrounding such programs and the difficultly communities experience when grappling with the interrelated epidemics of HIV and drugs. Following are common arguments made during debates in various communities over needle exchange. Supporters contend: isting programs have not been overly disrup- tive to community life. • Needle exchange serves as a bridge to treat- ment and other services. • Findings from existing programs suggest that needle exchange reduces the amount of needle • Needle exchange decreases the number of sharing among IDUs. discarded needles on the street because used needles must be exchanged for new ones. Opponents contend: • Needle exchange is HIV Prevention. Pro- . Increasing access to needles will facilitate and/ grams are designed to prevent HIV infection or promote drug use. not treat drug addiction. • Making needles more readily available may • Needle exchange programs are relatively increase the number of discarded needles. inexpensive to operate. The annual operat- ing cost of some of the existing programs is • Needle exchange programs divert funds from less than the projected cost of treating a drug treatment programs person with AIDS for one year • Needle exchange programs will disrupt com- • Needle exchange usually serves IDUs where munity life by attracting drug users to certain theycongregate or at anaccessible site(where areas. other services might also be available). Ex- • Needle sharing may still take place despite the availability of needles. Needle Exchange(continued from page 1) Needle exchange constitutes the majority of the health department's HIV outreach effort within New Haven. Outreach workers also interact with the general pub- AIDS Information Exchange is an official publication of lic. People frequently approach outreach workers for the USCM AIDS/HN Program,published by The United information and counseling.According to team mem- States Conference of Mayors, with support from the U.S.. Department of Health and Human Services under grant bers,people come up to the van asking for condoms #U621CCU300609-08.Raymond Flynn,Mayor of Boston,.' when it stops at street corners. President;l.Thomas Cochran,Executive Director;Richard . D.lohnson,AssistantExecutive Director;Alan E.Gambrel!, 'Weour ut hone number right on the front of the p p g Director of Health ProgramslEditor;Bob Young,Produc-_`� van," stated Elaine O'Keefe, Director of the AIDS tion Editor.ThiscaseproftlewaswrittenbyPaulaM.Jones" ' Division of the New Haven Health Department, "so SeniorStaffAssociate,withtheassistanceofElaineO Keefe, thatif people have a problem they can call us."Through- Director of the AIDS Division of the New Haven Health out the long process of developing the needle ex- Department and the New Haven Health Department Needle Exchange Program Outreach Staff.Any opinions expressed_ change program, and once it was in place, health herein do not necessarily reflect the policies of the U.S. department staff state that there has been an ongoing Department of Health and Human Services. effort to maintain and increase the support of the general public while providing what it considers to be ®The U.S.Conference of Mayors.March 1992. user-friendly services to IDUs. AiC'S Page 2 The United States Conference of lbtcyors iniormcrion E<c,^arge March 1992 r Needle Exchange: Based on Prior Outreach Efforts The statistics speak for themselves in terms of the Over the course of the next year, the Task Force impact of HIV among New Haven IDUs. As of identified a need for educational outreach programs January 31, 1992, there have been 486 cases of AIDS targeting IDUs and approached the city with this reported in New Haven, with approximately 70 per- finding. As a result, the health department received cent attributed either directly or indirectly to IV drug funds to develop an HIV prevention outreach pro- use. The HIV infection rate among IDUs in New gram targeting out-of-treatment IDUs and theirsexual Haven may be higher than 60 percent. partners. In Fall 1987, three outreach workers were hired by the health department to carry out the Recognizing this trendearlyon,the health department program(see"The Outreach Team", page 2). made it a priority to target IDUs with aggressive HIV prevention outreach. New Haven was one of the first With the support of community organizations, cities to dedicate public funds to HIV prevention garnered through numerous briefings held by the efforts targeting IDUs. (See AIX, February 1989, IV newly-hired outreach workers,the team members hit Drug Use and AIDS Prevention: A Case Study.) the streets,concentrating on four inner city neighbor- hoods. Outreach workers immediately began to dis- Those efforts started in 1987, long.before needle ex- tribute safety kits containing bleach, water (to rinse change began. In Spring 1986, then Mayor Biagio syringe following bleach rinse),condoms and instruc- DiLieto, local AIDS volunteers, and the city health tions for the use of both. department formed the Mayor's Task Force on AIDS. The Outreach Team The New Haven Health Department's first team of indigenousoutreach workers took to thestreets in November 1987,armed with pamphlets, condoms,bleach. In the course of outreach efforts it became apparent to the team that—despite the incredible barriers to reaching this population and regardless of stereotypes—IDUs had deep concern for their well-being and would take steps to protect their.health. As a result of the rapport the outreach team built with the target population over time,IDUs began to come to the outreach teams with other needs concerning drug treatment,HIV counseling and testing,housing,and access to social services. When the health department hired the original team of outreach workers,all three had either personal or professional experience with drug addiction and native ties to the community. The health department also sought to achieve cultural and ethnic diversity among the team. The initial team members received two weeks of training provided by former and current IDUs,staff from drug treatment agencies,persons with HIV infection,HN counselors,and state HIV educators. Discussed during the day-long sessions were strategies for effective outreach, availability of resources and referral networks,as well as general information about HIV.The latter was included since none of the outreach workers had prior substantive experience with HIV-related issues. On an ongoing basis,staff participates in health department in-service trainings and state health department trainings for HN educators. The team was eventually expanded to four outreach workers.Two of the original outreach workers,Dominick Maldonado and Sonia Lugo, are still with the program. Those that have left the team since 1987 have usually gone into related work,such as drug treatment counseling. New team members do not undergo the two week training provided to the original outreach team because it would be difficult to provide on an individual basis. Instead,they receive the same level of training from other sources(state health department,seminars,conferences). New staff members also are provided information on using local referral networks for drug treatment:it is essential that team members are able to assist IDUs in negotiating the long, complicated process of obtaining treatment. In training, special emphasis is placed on confidentiality due to the sensitive nature of information staff requests from program participants(Le.,their history of drug use,sexual history,issues concerning HIV status). As part of their orientation to the program,new staff are also required to make a presentation on HIV that is critiqued by fellow staff members(team members are often called upon to speak to the public in addition to carrying out their work on the streets). There is no shortage of applicants when an opening occas,despite the very specific qualifications and experience required for the position. The health department received over forty applications for the most recent vacancy last March. Chris Brewer and George Edwards round out the outreach team. The two men and two women have extensive experience in drug related issues and strong ties to the communities where they work;some are recovering addicts. The multi-cultural,multi-ethnic,bilingual make- up of the team is important because of the large African American/Latino populations in the targeted neighborhoods. the United Stares Conference of/'v±oyors, AIDS Informarion Exchange Mcrcrt 1992 Poge 3 Why Needle Exchange? Feedback From IDUs Why did New Haven begin needle exchange? Under illegally in New Haven by activists. "It was mostly hit the original outreach program, workers conducted a and run and we couldn't really provide information, Knowledge, Attitude, and Belief (KAB) survey in because what we were doing was illegal,"remembers order to obtain baseline information to use in develop- Chris Brewer,who is currently a member of the health ing educational materials and to determine, among department's needle exchange team and was a volun- other things,why IDUs share needles. The findings of teer with the underground exchange program. the survey indicated: The Mayor's Task Force on AIDS continued to study • IDUs would modify their high risk behavior in the feasibility of needle exchange and build commu- order to protect their health; nity support during this time. The Task Force Bevel- • IDUs were reluctant to carry their own syringes oped and put forward a proposal based on a four point and needles for fear of prosecution; strategy that included: • The high street price of syringes contributed to • advocacy for more drug.treatment; sharing. • increased education targeting IDUs; This information contradicted claims.that sharing of • decriminalization of the sale and possession of needles was a social custom among IDUs and indi- syringes;and cated that IDUs might be receptive to adopting safer behaviors.if clean needles were available.. • needle exchange. In fact — while the city's outreach workers were The Task Force held a forum for mayoral candidates providing IDUs with information on safer sex and in the summer of 1989 at which all candidates pledged needle using practices and providing bleach, water to support needle exchange if elected. and condoms—clean needles were being distributed Convincing the Legislature New Haven's Director of Health,William P. Quinn, Shortly after his visit, the "At the end of my M.P.H.,was among those bringing the issue of needle needle exchange bill was testimony...) exchange before the Connecticut State Legislature passed in both the House stated that I would Public Health Committee in Winter 1989. The Task and the Senate and signed be back next year Force's proposal called for the decriminalization of into law by the Governor with a legislative state law on the sale and possession of needles and (Public Act 90-214). The proposal for a . syringes without a prescription. final version of the Bill needle exchange allowed for only one program. The "At the end of my testimony before the committee I demonstration project and chairman of the stated that I would be back next year with a legislative provided $25,000 in state committee told me proposal for a needle exchange program in New funding. The state health not to bother Haven. The chairman of the committee told me not to department designated coming back...." bother coming back and I said respectfully that I had New Haven as the site for a personal and professional commitment to coming the project. -Health Director Quinn- back,"stated Quinn. Back in New Haven,community support continued to The following year in the 1990 session, a bill was grow as program organizers got closer to their goal of introduced in the General Assembly calling for the legal needle exchange. In preparation for the needle decriminalization of sale and possession of syringes exchange program, a subcommittee of the Board of without a prescription and the establishment of three Alders held a public hearing to educate the commu- pilot programs. In May 1990, newly elected Mayor nity on the program and to gain support and input. John Daniels(a former state legislator and prior oppo- The Chief of Police, Nicholas Pastore, expressed his nent of needle exchange)went to the State Capitol to support and offered to assist in the design of the lobby for needle exchange (see interview, page 5). program. Page 4 The United Stores Conference of Mayors AIDS Informcnon Cxc;Longe March 1992 New Haven Mayor John Daniels Following is a Conference of Mayors inter-,"e-v with Ntry Haven ;Mayor John Daniels,held in late 1991,on the city's HIV prevention needle exchange program. What advice do you have for other electe.i crticials who !f State law did not prohibit the sale and possession of areconsidering HIV prevention prosrants`or It ay-ti; needles and 5uringes,do you think needle exchange users,includingadvice on developing needle exchange prod>rarn still would be necessanf? programs? Yes, because we offer more than needles. Addicts Our program would have might get needles from been impossible without the pharmacies but nothing full acceptance and support else.If all ourprogram did early on of the health t was give needles to ad- department, the police 1 w i, dicts we would have never department and a lot of s gained public support.We organization and education s offer counseling, educa- done by the Mayor's Task tion,and support to these Force on AIDS. It took hard people.We get people into work-Igotalot ofheat from treatment while prevent- other elected officials, the ing the spread of HIV. By Board of Alders, church '; arresting addicts and put- groups utgroups and community ting them in jail you don't members...butthisprogram {: solve the problem or pre- . ... ..- saves lives. �S II ' vent the spread of AIDS. We could fill up the jails I didn't always support , and still have a problem. needleexrhange.Inthe state The problem is that there legislature I opposed the - is not adequate drug treat- concept: But when you sit ment available. We can in this chair,when you see _ help some gain treatment the devastation of HIV,you but not all who want and do what you can to stop it. I ` need it. Providing sterile was willing to give needle - � needles protects them un- exchangea try.Now we can til treatment is available. prove that this program is reducing the spread of HIV �_ „`-�,, What is the outlook for thanks to the involvement the needle exchange and evaluation by Yale. ,. - _ - -� program? Aside from increased It has to continue because funding,what policy changes can be made at the federal it works,we have proof. If level tohelpcitiescombat AIDS,especiallitamana drzzs we save one life,I consider the program worthwhile. use? What is needed is more programs in other cities like Bridgeport and Hartford. Our program will draw Without a doubt,the federal restrictions on the fund- addicts from other communities and they will drain ing of needle exchange must be lifted to allow for the New Haven's resources. It happened with the home- development of programs in other communities. Now less. New Haven provides shelter to anyone who that we have proof that needle exchange is effective in needs it and the number of homeless in New Haven reducing the spread of HIV, the federal government has increased. The state has recognized the success of must recognize needle exchange as a legitimate tool in the program and increased funding for New Haven's combating AIDS.Unfortunately,Idon'tseeithappen- program fora nother year but other communities must ing with this Administration. also commit to protecting addicts and develop pro- gams of their own. The United Stares Coniafer_a Pcoe Program Planning Begins The health department formed a protocol committee with members representing drug treatment providers, community-based organizations, AIDS organizations, the underground needle exchange, public health, city government, the police department and Yale University. (Yale University had offered to carry out program evaluation free of charge.) After two months of work,the protocol committee had designed the intervention and disbanded. The needle exchange protocol was approved by the Connecticut Department of Health Services in September. On November 13, 1990,outreach workers began the distribution of clean needles. An advisory committee to oversee the operation of the program and provide ongoing support was established. Members included representatives of the underground needle exchange,former IDUs,public health officials(local and state), the principal investigator from Yale, drug treatment providers, and representatives of organizations serving people of color. Start Up Specific stops were selected by the health department in conjunction with the protocol committee and the The outreach team geared up for the first day of the van simply began to show up. Because the outreach exchange by alerting IDUs that they would soon be team already was known and the community was distributing clean needles. "It was very easy because familiar with their efforts and the nature of the pro- we had alreadyprepared people,"stated Maldonado. gram,there was no organized opposition to the initial "The first day we were out there people were already presence of the van. waiting." The site selection process wasdone quietly;organizers Volunteers who were carrying out the underground felt this was the best tactic since the community knew exchange were concerned about maintaining avail- needle exchange would take place and involving the ability of needles to those who were dependent on the public in the actual selection of sites could create program. They did not want to entirely cease opera unending debate and bog down the process. A spe- tion until they were sure that the legal exchange was cific concern of program organizers in determining functioning effectively. Volunteers with one of the sites was that the van not operate too dose to schools. two underground programs agreed to gradually phase The van makes out their effortsduring the firstcouple of monthsof the five stops a day. Except for the stop in legal program and refer individuals to the new pro- a vacant lot behind the YMCA homeless shelter, the gram. van stops on streets with a mix of houses,apartment buildings,and businesses. In 10 months of operation, No additional training was required for the needle the health department received only one complaint exchange program since team members had been from a property owner concerning the location of the involved in the development of the protocol and were van.The site was moved a few blocks down the street. familiar with all aspects of the new program. Because -continued,page T- all four outreach workers were shifted to the new program from the existing outreach program,needle exchange became the single focus of the health Going Mobile department's efforts to reach IDUs. There was never any doubt in the minds of needle exchange program planners that a van would be neces- sary in order to effectively reach the community. "We Selecting Outreach Sites didn't want to use a table because we felt the community and the IDUs would object to the exchanges taking place The outreach team was active in five neighborhoods of in public,"stated O'Keefe. "A van offered privacy and high drug activity prior to the initiation of the ex- safety for all involved." change program. They were already familiar with "Itreally matters going out to where people are.It makes many clients, having provided them bleach and itconvenient. It's not like these people have cars or even condoms over the past years,and also had provided bus fare. If it was a fixed site some people would use it HIV prevention information to community members but not as regularly as they use it now;' said team residing in these areas. member Brewer. Page 6 The United States Con;erence of Alayors AIDS 1r,;or,Tction Exc�crge 1992 A Typical Day The outreach team reports to the office around 9 a.m. outreach team since they follow days when needles to prepare for the day. One member must pick up the are not available. van at the fire station,where it is parked overnight for security reasons. The rest of the team writes identifi- The van does not go out on Wednesdays in order cation numbers on the syringes (for tracking pur- to give the team a break during the week from poses)and restocks other supplies for the van. This is the pressures of outreach. They typically use this time also the time when staff conduct follow-up on partici- to assist participants in obtaining drug treatment,hold pants seeking treatment or actually take participants staff debriefing sessions and network with staff to treatment facilities. from community based organizations. By 11:00 a.m.,the team is on the road to the first ex- The van is used for change site. Over the next outreach year-round; it sixhours the team will make offers the workers some five stops. The actual time protection from the the vanis ateach site varies elements. During the from 30 minutes to one winter the spatial limita- hour. The original sched- tions of the van can be ule provided for only 10 especially confining for minutes transit time be- team members. (During tween each stop. This has the warmer months the recently been revised to back door can be partially P staff a lunch break open.) "We go out in all during the course of out- weather.There wasa huge reach and give them a break snow storm and we were from the hectic and stressful atmosphere inside the out there because addicts are out there...no weather van. stops them,"a team member reported. Between 5:00 p.m. and 5:30 p.m., one staff member The outreach team does observe holidays. When a returns the remaining unused syringes and program holidav occurs on a day the van is scheduled to go out, files to the office,another member,.returns the van to outreach workers inform participants during the week the fire station,and a third drops off the used syringes i before that they will be missing a day. Participants can at the Yale laboratory. Needle exchange is carried out then make plans to ensure that they have safe injection four days a week -- the van does not go out on equipment and are not counting on receiving clean Wednesdays or on weekends. This schedule makes needles that day. As with Mondays and Thursdays, Mondays and Thursdays the busiest days for the the day after a holiday is extremely busy. Selecting Sites(continued from page 6) down. We don't have to say anything," reports staff. The population served at each site varies. One site is Security has never been a problem at any of the needle near housing projects and the participants are mostly exchange sites. The van is equipped with a phone and unemployed. The YMCA site serves primarily home- an alarm in case of emergencies and there are always less people. Another site is a major drug dealing area two staff members in the van. Rarely do the partici- where people may come from other areas,sometimes pants hang around the van after they exchange unless on the way home from work,in order to buy drugs. they have questions for the outreach workers or wish "We have one particular site,"a team member related, to access additional services. The participants are "where we give out lots of condoms and educational fairly good at policing one another, according to materials to adolescents. We might only exchange outreach workers,because they don't want to jeopar- one,two, three or four needles but we didn't cut this dize the program. "If a client comes in and he or she j site because we are reaching a large number of is being rough, the other clients will tell them to calm adolescents." g 7 C ,he United Stoles Con,�erence or',%0cyors e S XCcrce Pae Client Enrollment Staff Roles: Multitasking Participants select their own codenames when they Team members perform three roles as part of the enroll to maintain their anonymity. They may use intervention. All are trained to perform each of the. their initials (although this is discouraged because functions, which are alternated on a regular basis. letters can sound similar and be confused by the outreach workers),take a name from cartoon charac- 0 One team member works outside of the van, ters on a shirt or cap they might be wearing,or—as carrying out general outreach activities,alerting "Serious" did - take a name from one of the AIDS people that the van is at the site and recruitingnew education posters in the van. participants. Upon enrollment,participants are given an I.D.card. • Another team member is available to assist par- In the event that they,are stopped by police, partici- ticipants who wish to enter drug treatment or pants can prove their enrollment in the program and obtain other services such as HIV testing and case. exemption from state statutes concerning the,posses- management. sion of needles and syringes. A ,baseline survey designed to collect.demographic information and par- 0 Two team members conduct the actual exchange.. ticipant historyof druguse and sexual practices is also One collects the used syringes: participants are verbally administered. The survey takes about five handed a small metal canister in which they place minutes. The outreach workers incorporate "AIDS their used syringes and hand back to the worker, 101"and prevention information when they adminis- Who marks, the canister with the participant's ter the survey. code name. The other team member distributes the appropriate number of clean-syringes and Once enrolled in the program,participants receive up records the numbers of syringes provided. to five numbered syringes per.visit. Syringes are exchanged on a one-f6r-one basis. Although partici- Participants are then encouraged to pick up safe injec- pants are encouraged to bring back program syringes, tion supplies. The team.used to.assemble kits with any syringe is accepted. The program uses syringes bleach,: water, cotton, alcohol manufactured in Europe that are commonly not avail- wipes and condoms but not all able in the U.S.,which makes program syringes more participants used all the sup- ".Say you run easily identifiable. into four plies.Now,supplies are keptin easily accessible boxes where people and Since the program began,nearly 900 participants have the participants enter the van; they all want enrolled, although not all are regular users. This brown bags are available so they treatment that constitutes a�large percentage of the estimated 2,000 can collect what they need. doy...it just IDUsinNew Haven.Team members stated thatsome isn't.possible of the participants may exchange for themselves and It is truly a skeleton staff. If a to get them their partner—so only one of the two are actually team member is not at work, in. enrolled. This especially may be the case for some one component of the program women who do not feel comfortable going to the van is compromised.Since two staff or are afraid of the possible consequences of the -members must always be present in the van, in the discovery of their drug use — specifically, losing absence of a team member either outreach or drug custody of their children. Other participants drop out treatment activities are not carried out. i because they enter treatment, stop using drugs on their own,are incarcerated,are able to obtain needles Staff limitations also affect the number of people that elsewhere,or cannot visit the exchange during oper- the team can assist in accessing drug treatment. "Say ating hours. you run into four people and they all want treatment that day...it just isn't possible to.get them in,"relates The health department feels there is a need to expand Brewer. the program, adding.'evening and weekend hours if possible.- The number of exchanges tend to pick up The state has increased funding for the program to toward the end of the day when people get off work. . allow for an additional outreach worker who will be utilized to help participants seek treatment. Page 8 The Unied Stores Conference oi Mayors AIDS Iniorrr.ation Exchange March 1992 Services to Clients: Breaking the Link Full Spectrum Between HIV and Drugs During the lobbying process to bring about the pro- The first question participants are asked when they gram, supporters frequently spoke of altering the enroll in the program is if they wish to enter treatment. perceptions concerning addiction, treating drug use To date,the program has been successful in assisting as a health problem in- over 100 participants to enter detox/treatment. Be- stead of a criminal issue, cause one team member is designated to assist addicts "For some people and developing acompre- seeking treatment,the process can begin immediately the van is their hensive strategy for deal- unless the staff person is already assisting someone home. They come ing with drug addiction. else. in to a very laid- The health department at- back, family-like tempted to incorporate "Usually we talk to them a bit about what kind of atmosphere these concepts when de- treatment they want because there are different treat- where we try to signing the outreach pro- ment options. Then we find out what kind of assis- find out what gram.Veteran team mem- tance (public support) they their problems ber Sonia Lugo stated,"In might have available to them. "Using the are and take care the streets you can go up So depending on what theper- exchange of them." and give an addict a pam- son has and what they need, makes phlet,give them a bleach we'll take them,pick them up people think kit and that's as far as it and provide follow-up," a about their goes. With the van,they can come in and talk,tell us team member explained. addiction problems they have and we are able to refer them to and look at different services so the van has many functions. Team members place great their lives Stopping the spread of AIDS is just one." importance on the advocacy and want to and support they can provide gain control "We have people coming in letting us know that they to addicts. "Addicts have a again." are HIV positive,that they have AIDS. We have been history of people not caring there for them since the beginning,we have an estab- for them and looking at them like they are the scum of lished relationship where they feel comfortable in the earth. So by one of us being there physically with coming to us and sharing that information," echoed them whenever they go for treatment, it provides outreach worker Maldonado. "For some people the support for them," expressed a team member. van is their home. They come in to a very laid-back, family-like atmosphere where we try to find out what Team members also play a role in facilitating what can their problems are and take care of them." be a long process due to waiting lists and other barriers. "Transportation is a real key because a lot of In addition to serving as a link to drug treatment, times it stops people from getting into treatment.They outreach workers seek to assist participants in access- just don't have a means of getting there," related ing other social services like food, medical care,and outreach worker Brewer. The team member respon- support groups. Outreach workers also counsel par- sible for assisting participants in seeking treatment ticipants seeking HIV testing and make appointments has access to a city car in order to provide for HIV testing. transportation. Although program participants demonstrate an inter- According to outreach workers, needle exchange al- est in protecting their health,too few seek HIV testing. lows participants to develop the confidence and This can be due in part to the lack of transportation to strength to seek treatment. As one team member HIV testing sites or the general unwillingness of pro- expressed, "using the exchange makes people think gram participants to seek services. Even when team about their addiction and look at their lives and want members make appointments for participants, they to gain control again." do not always show up at the test site. The health department is currently seeking funds for a mobile testing unit to operate in the vicinity of the van. The United Stares Conrerence of Mayors • AIDS Iniormarion Exchange • March' 1992 Page 9 The Drug Treatment Parad®x "You can't tell an addict'keep waiting,keep waiting' While team members can be there when the addict because they can end up waiting all their life," ex- approaches the van for treatment, their ability to pressed a team member.But the sad reality,according provide follow-up support is limited by their other to the outreach team, is that too often they have responsibilities. "We want to make sure that when nothing else they can say to an addict. When asked they leave detox we are there to pick them up and get what would make his job easier, one team member them into treatment because this is a very sensitive responded,"When we find out there is a cure for AIDS and dangerous time," reports a team member. and when we are able to provide drug treatment on Follow-up is not always possible due to staff demand for addicts." limitations and treatment facility confidentiality requirements. At times it .is up to the addict to The outreach. team expends a great deal of effort re-establish contact with the outreach worker once helping addicts negotiate the drug treatment maze but they have entered treatment or when they are in need the limitations of the system are a constant source of of additional advocacy or support. frustration. "Our program is definitely pushing the treatment system," comments Director of Health The New Haven Health Department received addi- William Quinn,"and that's good." For the outreach tional funds from the state for the coming year and workers struggling to keep up with demand, the plans to hire a fifth outreach worker so that two team system is not responsive enough. members will be available to assist program partici- pants seeking treatment. If resources were available, While availability is a significant barrier to treatment, the health department would like to hire additional there are other aspects of the system that make the job staff to provide follow-up to addicts throughout the of the outreach workers difficult. "We're working entire treatment process. with a population where the majority of the people have gone through treatment not only one but maybe two, "Our program is three or four times and one definitely push- begins to wonder what hap- ing the treat- pened to these people that ment system, they are still using drugs," Program gram Costs ...and that's explained Maldonado. He good." went on to say, "When you try to get them into treatment Both state and local funds support the New you hear, 'they've already Haven needle exchange program. The$25,000 been here'andthey've already been labelledwhen this provided by the state for the first year of the may be the time that they are ready to change. So we program was utilized to renovate the van,train have to constantly advocate and plead for them to be staff, purchase supplies (needles, canisters, given a chance." bleach, condoms) and operate the van (gas, vehicle maintenance, telephone). The needle exchange program does not have any special agreements with drug treatment facilities to The city of New Haven provides funding for give their participants priority treatment. "It is not the salaries of the outreach team (average reasonable to expect that the IDUs we serve would get $25,000 per year) and program management. priority treatment just because they are exchanging needles," commented O'Keefe. However, she noted The cost of the program evaluation compo- that participants do benefit from the support and nent,donated by Yale University,is estimated advocacy of the outreach workers whose services are at$250,000 for the firstyear,which includes the not available to IDUs outside of the program. During purchase of lab equipment,salaries of research- the past year the health department met with the staff ers and technicians and lab supplies. No fed- of all local treatment facilities to ensure that linkages eral funds are utilized for the needle exchange exist and to facilitate the referral process. program. I Page 10 The United Srares Conference of Mayors AIDS Irformarron :cra,^ge ;:'arc~ 1992 Coordinating With Law Enforcement The cooperation of local police is vital to the success of I The Bill passed by the state legislature only repealed needle exchange programs. New Haven's program the restriction on needle possession for participants in has benefited from the sup- the New Haven program. port of Police Chief Non-participants caught Nicholas Pastore. Chief DEPARTMENT OF HEALTH with syringes can still be Pastore expressed his sup- �~ �OF MW HAVRi arrested by the police. O"SrATR SrRm port of the program in the Nal HAVW.CCI•[flC =1*51i Program participants lobbying process. When Z verify their enrollment in the Bill was passed by the the program by showing State Legislature, he vol- their 1.D.card.The health unteered to serve on the department has also de- advisory committee for the Dear veloped a letter for the program. "We are very this letter will rerify enrollment is the.tis� police to verify enroll- Iseen eme1tS Dep•staeays lees a e escaup Profrr mr). fortunate to have a chief of enrolled in cbA Prperme under the code sees as -cd O6 count in the event a par- police rW identificacion card. police with an enlightenedTh• ,anreue. edle suche . pis eetb used e, public "-714 iccV7 ticipant is arrested with- mclom iedl. .p A.rordins to this lar. teos. o Psrticipsce in the Prnsres are view concerning drug ad- --Pc Iras crus nsl paltr foe poseesstbs bmedlss/anwses issued er our out their I.D.card. diction and a deep convic- Pre�me' Tea purpose of the".die awbabp prois to slur tee Apr*"of AIDS tion to help rather than by r.6stue trsnsstasion of tee m vtroa throuss ca di. shsrrss. The Prn.r..'• The police force was —me is critical to our efforts to respond effectively co this crisis. Your punish." stated O'Keefe. ca.p.retsan rtU be greatly appreciated. briefed at the start of the If yon bead forth.. inloesstion plsw ra11 as directly at 787-8701. program and the out- "I recognized early on that Sincerely. reach team discussed there was a strongcommit- their work and the public ment by caring people to tea's•p'x••f• health basis for the pro- AIDS Dlvtaibn Dtrsctor this program—people of t, gram. While relations diverse backgrounds, ser- with the police force are vice providers, former generally good,on occa- addicts,grass root organi- sion individual officers zations, people who were will confiscate or break committed to stopping the syringes belonging to spread of AIDS — and I program participants. back caring people" com- "Your 8eslrA to our Cosstr.111.1 w.•�tA" When this happens, the mented Chief Pastore. participant is provided new syringes. "We had our problems along the way," Chief Pastore recognized thatthe program was impor- stated Chief Pastore,"but I was notified and they were tant in stemming the spread of HIV but he also saw dealt with." other benefits that could result from his support of needle ex- O'Keefe characterizes problems with police as rare �I saw the change. "I saw the program as and attributes them to turnover in the police depart- program as a a way of breaking down some ment and a need for more briefings for police depart- way of break- of the'us vs.them'barriers be- ment personnel concerning the nature of the program. ing down tween police and drug users," some of the he explained. "The program "It is often difficult to change attitudes and minds 'us vs. them' opened communications be- concerning drugs when you come from a law enforce- barriers be- tween drug users and police. It ment perspective," commented Pastore, 'but the so tween police lets them know that the system called wars on societies' problems like the war on and drug cares about themchanging their drugs have been just that, they have been mean spir- users;' lifestyle.There'sa nice sublimi- ited and beat on the already oppressed. This program nal message—that police offic- is a step away from the mean spirited policing that has ers do care." led to these mean spirited streets." The United Stares Conference of Mayors 9 AIDS Information Exchange March 1992 Page I I ns t Community Involvement The process of building community support for the living in homeless shelters. All of the teens signed the needle exchange program did not stop when the state back of the van when it was finished.To recognize the legislature passed the Bill allowing the program. The involvement of these and other volunteers,the health health department has worked to involve members of department held a recognition ceremony and pre- the community. sented certificates to about 50 community members Community members have been used to compliment involved in the program duringNa tional AIDS Aware- and augment the efforts of ness Month(October). The mayor issued proclama- The actual painting the outreach teamand con- tions to some volunteers. of the van was tribute to the effectiveness done by a group of of the program. In each of The use of volunteers must be carefully balanced teenagers living in the five neighborhoods between the obvious demands for additional assis- homeless shelters. there are at least two or tance and the specialized nature of the program. All of the teens three businesses that dis- People have asked to interact with program partici- signed the back of tribute materials for the pants. Volunteers cannot participate in the actual the van when it team. Beauty parlors, li- exchange for liability reasons;team members add that was finished. quor stores, laundro'mats- it would not be appropriate to utilize volunteers in and other establishments these circumstances. "We get volunteers who have distribute schedules for the needleexchange,condoms, good hearts, who want to do this work, but it takes bleach and water,and information. "Some of them we more than a good heart to work with the population approached and others approached us,"commented we are working with. We know these people,we live Maldonado. "From a business point of view its good here in thecity and we have established a rapport with for them because they are giving something away and them,"explained Maldonado. its good for us because we're getting our materials out." The bleach kits thatare distributed at these sites To maintain and increase the support of the general and in the van are put together by residents at Cross- community, the health department has continued to roads,a drug treatment center in New Haven. conduct briefings on the program—over 100 during the program's first year of operation. Briefings are Other community members donate their skills in ad- provided to community based organizations (espe- dition to time.The brightly colored mural on the sides ciallvdrug treatment facilities) community groups of the van was designed by a local artist. The actual and other departments within the local government. painting of the van was done by a group of teenagers Continued Community Input During the process of implementing the program,the health department formed an Advisory Committee to ensure ongoing input from the community. The committee is comprised of representatives from the African American and Latino communities,former IDUs,drug treatment providers,political leaders,public health officials,AIDS professionals and activists,former volunteers with the underground exchange,the chief of police,and the program evaluator.The health department asked people who were receptive to the program and who represented organizations that would benefit or whose clients would benefit from the program. Edith Rawls,resident director at the YMCA(one of the van's stops)is a member of the advisory committee. Rawls is very supportive of the program. Before needle exchange was available,the YMCA had a serious problem with discarded needles throughout the facility,endangering staff and residents alike. When the exchange started, the problem of discarded needles was virtually eliminated. Rawls also acknowledges the importance of the other services provided by the outreach team and the availability of immediate help for residents. "I'd hate to think of the program not being here,"stated Rawls. Another member of the advisory committee,Peter Fisher, was previously involved in the underground exchange program. Because of his established ties to the target population,he could approach program participants and solicit their responses to the program,and provide their input to the outreach team and program manager. Page 12 The United States Conference of Mayors AIDS Information Exchange March 1992 Evaluation: Gauging Success Measuring a program's effectiveness is typically a process of collecting and analyzing client data. For the outreach workers who are in the van four days a week success is also measured on a more personal level. Outreach worker Sonia Lugo is rewarded by"seeing people able to change due to something I was able to do for them." Outreach staffer Dominick Maldonado relates, "Community support has increased because we have proven ourselves. The van hasn't created any problems in the neighborhoods we operate in. People are seeing that addicts are going into treatment. It's working." Outcome Measures community at large. "If Ed Kaplan hadn't literally gotten Yale to donate a laboratory to test the needles What the outreach workers witness in their daily we would have had the same data that everyone else work is being substantiated by rigorous program has," commented Director of Health Quinn. The evaluation designed and carried out by Yale evaluation carried out during the first year of the University's Edward H.Kaplan,Ph.D.He is associate program by Yale costs an estimated $250,000, which professor of policy modeling and public management includes the personnel costs(the principle investiga- and operations research at the School of Organization for and two full time lab staff),use of the laboratory, and Management. Dr. Kaplan's evaluation strategy and purchase of equipment and materials with which collects baseline data on the sexual and drug using to conduct tests of syringes. The needle exchange habitsof program participants(follow-up surveys are program is the firstmajor collaborative effortbetween also conducted)and tracks which participants receive the AIDS Division and Yale. "This type of university/ city cooperation is unprecedented," stated Kaplan, and return each individual needle and then tests the needles for HIV. The findings from the testing of "and withanissuelikeAlDSitwouldbeniceifitcould take place in other areas." needles are then applied to a statistical model from which Kaplan can calculate the course of infection. After 71/2 months of the pro- This type of During the developmentof the gram,Dr.Kaplan released re- university/city ...careful atten- overall needle exchange pro- sults based on the tracking and cooperation is tion was given to gram, careful attention was testing of syringes and an esti- unprecedented, planning an given to planning an evalua- mate of the number of cases ...and with an evaluation com- tion component that was that would have occurred in issue like AIDS it ponent that was "unobtrusive and did not in- New Haven in the absence of would be nice if unobtrusive and terfere with the delivery of ser- needle exchange. The find- it could take ings indicated that the needle place in other did not interfere vices, according to Kaplan. exchangeprogramreduced the areas." with the delivery The outreach team was in- annual per capita incidence of of services." volved in the development of the evaluation componentand HIV in New Haven by 33 percent. The results do not conducted "dry runs" of the take into account any behavioral changes that may baseline survey and the syringe tracking process to have occurred as a result of the counseling provided make sure that it would not affect their interaction by outreach workers or received from other sources. with the IDUs. The findings of the Yale evaluation were instrumental Dr. Kaplan stresses the importance of evaluating in convincing the state legislature to increase funding needle exchange programs and data collection:good for the program and have attracted national attention data help to refute criticism of the program concern- concerning the efficacy of needle exchange programs ing effectiveness in reducing the spread of HIV and in reducing the spread of HIV. documents program impact on both clients and the T United States Conference of Mayors AIDS Information Exchange /��'•orch 1992 Face '3 Process Measures "Tracking of syringes makes our program evaluation novel but it also takes a lot of time and effort," commented Kaplan. Less rigorous evaluation measures can also demonstrate program effectiveness and address some of the common criticisms concerning needle exchange programs. To develop programs that are"credible in the eyes of the public" Dr.Kaplan recommends the following evaluation measures be applied: • Record number of syringes distributed and returned. • Measure return.rate of program syringes(whatpercentof the needles returned were obtained from the program). • Track client participation overtime(how many clients,patterns of use,attrition rate). • Collect demographic and behavioral information on participants(race,age,sex,sex and drug use history). Data collected through these four measures can gauge if needle exchange increases the number of needles discarded in the community,whether drug users actually participate in the program on a regular basis,and the type of users (long time addicts vs. new users)who participate in the program. Evaluating the Evaluation Outreach workers frequently have a very different I participants. To date, over 100 follow-up surveys view of program evaluation than academics.Incorpo- have been completed. "We are operating very dose to rating evaluation measures into an actual intervention capacity and part of that translates into not being able without affecting the quality of the exchange between to administer as many follow-up surveys," reported outreach worker and addict has been difficult for Kaplan. AIDSeducators. "When we thought about evaluation the first thing we said is that we aren't going to do Team members report that "We dust say something an hour long," remembers Chris Brewer. program participants have no [to progran "Ours is short because we took part in putting it objections to the evaluation.Ini- participants] together. You want something short and fast so tially,some of the syringes were 'this is your people can come in and out,otherwise people will not returned with the identification program and respond. Our baseline survey takes only five min- numbers rubbed or washed off. in order utes." Brewer.related that Staff was not sure whether this tot continue it participants don't mind the was intentional because partici- we have to -When we baseline survey because it is pants did not want needles be able to thought about a one time thing and that the tracked back to them or if the prove that it evaluation the outreach workers incorpo- numbers came off when partici- works••• first thing we rate basic AIDS information pants were cleaning needles. To said is that we into the survey so it is also an prevent removal,a piece of clear aren't going to educational experience for tape is placed over numbers. do something the participant. an hour long " When program participants have asked about the Administering the follow-up numbering of syringes or the surveys administered by surveys has been a little more the team,they are told that the information is collected difficult for the staff because they are busy with other to determine whether the program is effective. "We responsibilities when out in the van.. On occasion just say 'this is your program and in order for it to student volunteers from Yale accompany the staff in continue we have to be able to prove that it works,"' the van and administer follow-up surveys to program explained Kaplan. Page 14 The United Srcres Con;erence of Mavors • AIDS information Exchcnge • iv'.=,h 1902 Why It Works The knowledge of the street outreach team was espe- very protective of us. A lot of rimes a politician or cially valuable in developing the program, but pro- reporter will call up and say Why are you doing this' gramplanners should not overlook recommendations and Elaine will handle those issues so we don't have of the target population. "You want to work with the to think about them," related a team member. addicts," stated one team member, "listen to what they have to say and what they want out of the Program management also structured the outreach program. You are dealing with very bright,sensitive positions as relatively high level, based upon the people,so if you work with them you're going to have special qualifications required of the team members an excellent program." and the demands of the position. When the original outreach program was developed three years ago,the Another element of the program that the outreach decision was made to pay team cites as critical to the success of the program is staff an annual salary of "You want to flexibility. Because the program was new,'it was $21,000 with all the benefits work with the especially important for management to listen and be received by other health de- receptive to change. No major changes to program partment staff. "Some of the to addicts. en design were necessary but several minor ones, like other organizations in town whatt they h revising the outreach schedule,assisted the outreach thought we were crazy to have to say and team in their work. pay outreach workers that what they want much but we wanted people out of the Outreach staff attributed their ability to continue with highly specialized skills program." working in the stressful environment to the support of and an extraordinary com- program management. Several members have far mitment to AIDS work,so higher salaries were war- surpassed the commonly accepted two-year employ- ranted,"O'Keefe recalls. Current team members earn ment span of outreach workers. "Elaine(O'Keefel.is an average of$25,000 a year. Programmatic Trade Offs Because the needle exchange program was built upon against AIDS. New Haven embarked upon a new and the existing outreach program,many of the activities controversial program that has documented success the team used to carry out have ceased. "All of our in limiting needle sharing among IDUs and the spread time is for needle exchange now," reports one of the of HIV. Limited resources,however, make it neces- veteran outreach workers."Everything we used to do sary for the health department to make tough deci- is limited...street theater,working with inmates,go- sions concerning the targeting of HIV prevention ing door to door.There is a vacuum out there. We can efforts,including and foregoing or scaling back efforts only help the people who come into the van. We're to reach other at-risk populations. missing the greater outreach component." Because so much of the health department's effort and resources are concentrated on "All of our time is for needle exchange,the NES' needle exchange burden on commu- E now.... Everything we nity based organiza- used to do is tions tocarryoutHIV limited—street theater, prevention activities The . NGE working with inmates, has become greater. Sa Q/nt/s to going door to door. Z Save Lives, v� There is a vacuum out Innovation can only d`� We `'are there." o.so far in the battle ' g 1 tieaIth Dept•-k% i The United Srates Conference of Mayors • AIDS Information Exchange Marc,i 1992 Page 15