Photographs by Steve Hahn
War on HIV: Santa Cruz Needle Exchange Program's Patrick Stonehouse says a lot of politicians still fear that support for the program will make them appear 'soft on drugs.'
With thousands of future HIV infections hanging in the balance, John Laird takes a stab at freeing up AIDS prevention funds for needle exchange programs
By Steve Hahn
This month, John Laird launched his latest attempt to cure California Gov. Arnold Schwarzenegger of his trypanophobia--a fear of needles that, in certain rarified cases, can be brought on by political considerations. On Jan. 5, the Santa Cruz assemblyman introduced Assembly Bill 110, which would allow state HIV prevention funds to be used for the purchase of clean syringes.
For Santa Cruz AIDS prevention workers and volunteers, the bill's timing couldn't be more critical. The Santa Cruz Needle Exchange Program (SCNEP), stunted by financial and legal restrictions since its formation, was on the brink of closing its doors when a handful of year-end grants bought it more time. Laird's bill would also bolster similarly struggling programs throughout California, where needle sharing is estimated to result in more than 1,000 new HIV infections each year.
But while the measure is almost certain to pass the state Assembly and Senate, there remains one final obstacle. Schwarzenegger already vetoed a similar bill sponsored by Laird when it got to his desk back in 2005. Last year, Laird again got it passed through both houses to demonstrate the state Legislature's support, but ended up shelving it out of concern that Schwarzenegger wouldn't want to appear "soft on drugs" right before the November elections.
The election year posturing now over, Laird expresses optimism that Schwarzenegger may agree to sign. "Third time may be a charm," he says.
Merle Smith, executive director of the Santa Cruz AIDS Project (SCAP), was worrying about how to pay rent on the needle exchange program's 412 Front St. drop-in center before the North American Syringe Network came through with a $4,000 grant to continue their operations in November. Shortly afterward, the Tides Foundation awarded a $40,000 grant, and the Comer Foundation donated $30,000.
"We have these grants but they will barely maintain us through this year," says Smith of SCNEP's HIV/Hepatitis C outreach, prevention and education programs. "Every year we're trying to go back and find funding. If we had a constant stream of funding from the state or feds, it would reduce the necessity to constantly be out there trying to hustle for every dollar we can find to keep our program running."
Patrick Stonehouse, who helps run the needle exchange, quickly added, "We'd be out there doing the things we love, instead of doing the things we have to do to do the things we love."
It was actually Laird, a former executive director of SCAP, who helped to found the SCNEP back in 1989 as a response to the rapid spread of HIV in the injection drug user community. According to an executive summary of the Santa Cruz County Health Services Agency, 12 percent of HIV transmissions in the county are caused by the sharing of needles and the cookers used to heat injected drugs.
In California as a whole, the problem is even more pronounced. New HIV cases linked to injection drug use each year represent nearly 20 percent of the annual transmission rate.
Meeting a Need
Before SCNEP was founded, there were few options within the county for addicts looking to satisfy their habit without the risk of infection. Engaging in illegal and culturally taboo activities, drug users were often uncomfortable seeking help on their own and, when they did, were frequently told to kick their habit and enter rehab. SCNEP has distinguished itself over the years as an HIV prevention option that focuses exclusively on the principles of harm reduction, leaving the often daunting existential concerns of resolving drug addiction to the addicts themselves.
"The needle exchange does not judge; everyone is welcome," says Chris Pak, a former UCSC student who served as an SCNEP volunteer from 2002 to 2005. "We understand that not everyone is going to abstain from risky behavior, and for those who do engage in it, we provide supplies, literature and services to help reduce harm to themselves and others."
Michelle Coffey of the Tides Foundation says the broad scope of SCNEP's creative programming (which includes at-home service, youth nights, women-only drop-ins, a program training peer educators who develop trust within the injection-drug user community, and established connections with rehabilitation and counseling services throughout the county) was the main reason for awarding the $40,000 grant.
"Santa Cruz has always been a leader in the national field," says Coffey. "They have innovative programs that really address the needs of the specific constituency that they're serving. They go beyond just the basic needs in terms of providing syringes, but also providing the necessary wraparound services."
SCAP officials say they want to establish deeper and more widespread connections with other agencies serving populations at-risk for HIV and Hepatitis C. They're also looking for a permanent office in Watsonville that will allow for more extensive programming and one-on-one counseling. In a staff meeting with Smith and Education and Prevention coordinator Susan Pratte, Stonehouse rapidly fires off creative ideas for expanding their services, including collaborating with women victim organizations, providing material incentives for drug users to receive testing, and re-establishing drop-in sites in Ben Lomond and Felton.
"We can move ahead ideawise," Smith reminds the room. "But we just don't have the funding to do what we really want to do."
Supply-side economics: Current law makes it illegal for state HIV prevention funds to be spent on clean needle and syringe exchange programs.
While the historical relationship between needle exchange programs and the California state government would seem to indicate a sharp divide between two approaches to dealing with injection drug users, there is a growing consensus among state officials that needle exchange programs are a crucial tool in California's HIV prevention framework.
Prior to 1999, needle exchanges were officially considered illegal organizations, and, depending on local politics, law enforcement agencies across California had the power to arrest outreach workers and confiscate their clean syringes.
The exchanges were allowed their first taste of legitimacy when then-Gov. Gray Davis signed a compromise bill legalizing needle exchanges for counties whose governments declared a public health emergency. Since these emergencies officially lasted only two or three weeks, county governments would have to constantly fill out the emergency declaration paperwork to make the exchanges legal. That requirement was reduced to a yearly meeting of county leaders to discuss the issue in 2005, although using state funds to purchase clean syringes is still illegal.
In fact, the state government may be warming to the idea--however gradually--of providing access to clean syringes. In what may be a precedent-setting move, Schwarzenegger signed a 2005 Assembly bill that allows local jurisdictions to approve pharmacy sales of up to 10 syringes to customers over the age of 18 without requiring a prescription. The program has yet to be implemented in Santa Cruz County due to the Board of Supervisors' interpretation that the law requires approval from city councils prior to implementation. But at the statewide level, the availability of clean syringes has been accepted as a necessary facet of HIV prevention.
Leslie Goodfriend of the Santa Cruz Health Services Agency echoes the sentiments of SCAP officials in stressing the importance of the pharmacy program as "yet another way of accessing clean syringes."
Even so, Alessandra Ross, who serves as injection drug use policy and program coordinator for the California Department of Health Services (CDHS), sees an important distinction between pharmacy sales and needle exchange programs.
"Needle exchanges engage people who, for the most part, are very difficult to engage with, in the sense that they're very alienated from a lot of social services and a lot of society," says Ross. "Pharmacy sales give people more options on how they can stay healthy, but it's not a supportive program in the sense [that needle exchanges are]. Most research indicates that injection drug users really need both of these services in order to make positive changes in their lives."
Ross, Laird and others at the state level argue for full legal standing by pointing to numerous statewide and national studies proving that money funneled into needle exchange programs will not go to waste.
"Needle exchange programs have demonstrated intervention that is very effective in reducing HIV infection among injection drug users," Ross says.
View From the Hill
Craig Reinarman, a professor of sociology at UCSC who conducted a localized study of SCNEP in 1996, believes that, in spite of how innovative the program has been, its ability to reach at-risk communities has been hampered by funding restrictions.
"I would be very surprised if anyone who worked at the needle exchange said they were getting everyone," says Reinarman. "I think they could probably do with a great deal more resources."
Reinarman handed out confidential surveys to clients at the drop-in center asking them to rate the frequency with which they shared needles. He found that as clients began to access the site more regularly, they shared needles less.
"You have an aggregate reduction of risk in transmission," he concluded.
Yet what truly struck Reinarman about SCNEP was the level of collaboration with county and other nongovernmental organizations, as well as the ability of volunteers to provide addicts with a safe and comfortable space at the drop-in center to learn about drug counseling and rehabilitation options without being coerced into taking any action against their will.
"This is a strange thing for people in the conventional world to understand, but if you've been down that far for that long, just to take the step of making sure you don't get an additional disease on top of what you already have [is significant]," Reinarman says. "It took an agency that was providing something they valued without also trying to rope them into some kind of control."
Reinarman's study also found that the needle exchange was an extremely thorough organization considering its funding limits, providing clean alcohol wipes for people to disinfect their arms, condoms, free meals, free clothing and clean cookers.
He also found that the client population for the drop-in center was generally poorly educated and deep in financial troubles, and had little hope for the future, although he was quick to point to exceptions.
"I've actually seen this with my own eyes: someone in a business suit driving a fancy car pull up and park and go in and turn in 10 or 20 used needles," he recalls. "But, the great majority of people are ones who have been marginalized by all of the crap that society can dish out."
Former student volunteer Pak was also surprised when he recognized his peers from the UCSC community frequenting the drop-in center.
"When I first started working there, I thought injection drug use was for "junkies. Then I learned that everyone and anyone could be a user," he says.
Since Reinarman's study, the program has expanded its programming, especially in the area of waste reduction. A loan of biohazard devices to downtown businesses has ensured that any needles found around their premises will be properly disposed of. And according to Stonehouse, many in the Laurel Street neighborhood know that a quick call to the needle exchange will make sure a dirty needle around their property will be picked up promptly.
Pak remembers having SCNEP's drop-in center as a reliable place to bring dirty needles he found lying around his Laurel Street neighborhood.
"I took proper precaution to dispose of them at the drop-in, but they could have potentially harmed someone," he says. "It's not fair for some kid on the beach or a garbage man to get stuck by a dirty needle."
The exchange program trains and coordinates clean up efforts with city workers while operating its own cleanup crews that periodically scour the levee and other sites frequented by drug users for needles left on the ground.
"That's also picking up syringes that might have nothing to do with our program," reminds Pratte. "It may be diabetics, people with prescriptions, or people from over the hill. We want to make sure we're at least picking up the amount we're putting out if not more."
Thank you for not sharing: State officials say contaminated syringes account for 20 percent of reported AIDS cases.
Drug User as Enemy or Victim?
Despite Reinarman's study and last year's recommendation by CDHS's Office of AIDS to lift the legal barriers against needle exchange programs, there is still resistance at the state and local level.
Locally, Stonehouse and his outreach teams have a difficult time finding any private businesses or churches in Watsonville that will donate their parking lot as a consistent drop-off point even for one afternoon a week. This forces them to operate out of the trunks of their cars while parked in public view on the street, often leading to calls to the police by suspicious community members. This comes after funding cuts eliminated their drop-in center for South County.
So why has a proven program hailed by Coffey as a "stronghold" in the state's HIV prevention efforts been denied the potential for government resources? The answers are diverse, but most needle exchange advocates believe that fear and social stigmas associated with the injection drug user community play a large part in political resistance.
"Drug users are very marginalized people and [there's a tendency] to say, 'It's their choice, they don't deserve this access to health care,'" Coffey says. "It's systemic discrimination and stigma, but if people really learned [about needle exchange], they would realize that this is one of the most effective ways of promoting health care and it does the least amount of harm in their own communities."
The social stigma is created in part by especially desperate drug addicts who turn to theft and prostitution and through these publicized and disruptive acts become a stereotype for the entire community, according to Pak.
"When you have a disease such as addiction, you're only thinking of how you're gonna get your next fix," he says. "That can lead to many risky and violent acts."
Smith sees discrimination aimed at SCNEP's clients as the result of public misinformation. The idea that needle exchanges encourage and glorify drug use has been a popular rallying call against them, albeit one that has been repeatedly disproven. When Gov. Gray Davis was considering whether or not to sign the 1999 bill legalizing needle exchanges, he added the requirement of an emergency declaration citing the potential harm that full legalization could have on the minds of California's children.
"Some people see this as just a drug support program," Smith says. "It is not that; it is a harm reduction program, and I can't say that enough."
In addition to social stigmas, Stonehouse believes a political culture framed by the war on drugs reduces the willingness of politicians and businesses to be associated with "drug paraphernalia," even if it does have a legal mandate.
"I think a lot of it does have to do with the war on drugs and people not wanting to be the governor or senator who allowed this to happen and then their constituency looks at them and sees they're soft on drugs," he says. "I think on the local level there's a lot of fear of that same kind of political image in the community; they don't want to have the parking lot with all the junkies hanging out there."
That conflation of drug user and criminal has led to occasional police harassment and intimidation of clients at SCNEP off-site outreach points, according to SCAP officials.
Pak remembers when a Santa Cruz police officer approached him as he was staffing an outdoor site alone.
"I told him that I was part of the needle exchange and that I was running a site," Pak recalls. "He asked for identification which I did not have. Then he took my paperwork, which documents all exchanges made. Once he realized I had no incriminating information, he told me to pack up the site and leave because it was 'unhygienic.' That's bullshit. Unhygienic is the complete opposite of the needle exchange's mission."
Stonehouse also notes other instances in which police officers will slowly cruise by outdoor outreach sites and sometimes park nearby, which causes clients to cut conversations with outreach volunteers short or even flee before accessing any services.
"We try to establish this relationship and level of trust with our participants so that we can have fairly in-depth conversations with them about risks and services that are available," he says. "If cops are driving by, they're not going to have that conversation because they're going to just need to get their 'point' and leave."
Repeated calls to the Santa Cruz Police Department were not returned by presstime.
As far as resistance to "codifying" needle exchanges into state law, Schwarzenegger vetoed Laird's bill freeing state money for syringe purchases on the grounds that money spent on syringes would "limit funding for other prevention and education activities."
SCAP officials believe the veto reasoning ignores the collaboration between needle exchanges and other HIV prevention programs and the unique ability their volunteers have to gain the trust of injection drug users.
"Needle exchange is one component of HIV education and prevention that's targeting injection drug users, their family, their sexual partners, their friends, people who they live with," Stonehouse says. "It's a tool we use to get into the trust of the injection drug user population, who are, I think justifiably, somewhat paranoid of institutions. We use that as an opportunity to get in, and then we talk to them about all the other things that come into play. So, it wouldn't offset any of that stuff, because it's all seen as being part of the grand mission that we're doing."
While SCNEP staff eagerly await news on the progress of A.B. 110, which will be heard in the Assembly Health Committee this March, they are simply grateful they have the resources to operate, thanks to the private foundation grants and the continued donations they have received from the local community.
Pratte believes it is important to pass Laird's bill quickly to build upon SCNEP's existing relationship with the drug user community and expand services permanently to underserved cities within the county.
"No one else in this county has access to that population and that's our No. 2 risk group for HIV," she says. "Public health people are going to want to interface with that group, and a lot of other agencies will collaborate and piggy-back with us so they can do work with that population." But that won't happen, she notes, if the program isn't there to bring them together.
Coffey hopes her organization's grant can pull the SCNEP through a tough funding time but believes change must ultimately be made at the legislative level to ensure that a crucial pillar in the HIV Prevention architecture is maintained indefinitely.
"[Lack of funding] for SCNEP would have strong implications for different counties within California and nationally," she predicts. "They would be scrambling; it would be absolutely devastating."
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