Harm Reduction: Lessons learned from the AIDS crisis

Giving addicts syringes to shoot up was never a popular idea. It still isn’t.

Despite medical authorities’ confident assertions that such programs dramatically cut down on disease transmission, so-called needle exchange programs—which aim to dispose of potentially contaminated syringes by giving drug users new ones—remain illegal in half the states in the U.S. And although New York legalized the practice in the early 1990s, it continues to struggle with how best to integrate it into the health care system. 

The Empire State is not alone.

In the last few months, the governor of Indiana made headlines by saying he opposes the idea of distributing free needles as anti-drug policy, but has accepted it as a measure to stop the recent outbreak of HIV/AIDS in the southeastern part of the state. As of June 4, the outbreak had reached 166 cases, up from 26 when it was first announced in February. The director of the National Center for HIV/AIDS called it one of the worst documented outbreaks of HIV among IV users in the past two decades. The outbreak has been linked directly to injection drug use.

Authorities’reluctance to embrace needle exchange initiatives goes back to at least the early ’90s, when the first major outbreak of AIDS sent New York into a panic.

At the end of the 1980s, New York City was still reeling from a crack epidemic when the mysterious disease started killing off gay men and injection drug users.

By 1994, 50 percent of injection drug users in New York were already infected with HIV. Some organizations, drawing a link between needle sharing and infection, began distributing clean needles illegally in an attempt to stem the tide of the new virus. By the early 2000s, the American Medical Association, the National Institutes of Health, and the World Health Organization had blessed needle exchange programs, saying that they effectively reduce disease transmission and do not increase injection drug use among participants or society, as many detractors feared they would.

In the winter of 1990, however, the medical community was not yet convinced and neither were lawmakers.

“It felt like I was operating in a hostile environment”said Daniel Raymond, one of the early pioneers of the needle exchange movement in New York, currently with the Harm Reduction Coalition. “There was a heavy emphasis on law enforcement and a very punitive and stigmatizing attitude towards people who use drugs,” he said. Addicts were criminals in the eyes of the law. 

Reflecting on the early days of the exchange, Raymond paused. “I think the statute of limitations are over,”he said. “Yes, I exchanged needles while it was illegal.”

Raymond and others took to the streets with shopping bags filled with sterile syringes, handing them out to drug users in exchange for used ones. They dressed inconspicuously and spread the word in the neighborhood: fresh needles, free of charge, it’s all anonymous, and we’re not the cops. 

Despite the risk of arrest, Raymond said he felt a moral obligation to do something. “While this policy debate was swirling around over whether needle exchange was a good thing or a bad thing, we felt that we had enough information,”Raymond explained. “It’s just common sense. If people don’t have needles, they’re going to share needles. And if they share needles, they’ll get HIV/AIDS.”

By the time New York enacted laws legalizing needle exchange programs in 1992, over 200,000 Americans had been diagnosed with the virus. Authorities realized that the existing drug treatment tactics were failing. 

“The available capacity for substance abuse treatment was nowhere near enough to meet the needs,”Raymond said. “And that’s really how harm reduction found its niche.”

Harm reduction is an approach to drug treatment that proponents describe as a practical set of strategies that attempt to reduce the negative consequences associated with drug use, particularly health consequences. In other words, harm reduction centers are willing to work with drug addicts even if they don’t quit.

It’s on the more liberal end of the health care approaches to addiction treatment, especially when contrasted with the traditional perception of drug users as criminals. The “Rockefeller drug laws”passed by the state Legislature in 1973 mandated long prison sentences for the possession of narcotics.

Peter Moskos, a professor at John Jay College of Criminal Justice and a former police officer, described a general attitude among officers toward drug users at that time: “They’re all a bunch of junkies, and it’s only crazy liberals who want to do things like give out free, clean needles,”he said. “It was very hostile.”

In his time operating harm reduction programs, however, Raymond says “the changes that we’ve seen for the first two decades were very incremental, but they’ve started accelerating recently.”

While Raymond may be more sanguine, Dr. David S. Festinger, the director of law and ethics research at the Treatment Research Institute, believes policy has a tendency to swing between punitive programs and more therapeutic programs. “I see it as more of pendulum; we’re now in a more public health focus,”he said. “A number of efforts have tended to either focus on a pure public safety approach—the extreme of that is ‘lock-’em-up and throw away the key’ on one end—to more of a pure public health approach, which is that substance abuse is an illness, a disease that needs to be treated like any other disease.”

A recent effort has been an attempt to bring health care out of hospitals, which are often ill equipped to deal with the needs of drug users, and into harm reduction centers by “co-locating”medical care facilities with harm reduction centers.

A recent study by the New York Academy of Medicine found that “Partnerships between harm reduction providers and health care providers hold exciting promise …and should be encouraged.”

Raymond says that challenges remain despite the progress that has been made. The health care field is “a giant network”that will be slow to change. And while institutional change is always a hurdle, it’s the cultural understanding that will be the largest obstacle.

“There’s a lot of accumulated stigma towards people who use drugs,”he said. “It’s going to take some time to untangle.… I think the people that we’re concerned about are still vulnerable to criminalization and arrest.”

Moreover, there are still issues with how the public understands addiction recovery, Festinger says.

“People have looked at programs to permanently cure drug dependence,” but nothing could be further from the truth, he explained. The accomplishments of methadone clinics, needle exchanges and other harm reduction programs have indicated that addicts frequently require prolonged periods of care that may include periods of relapse. “The realization that people need that is one of the breakthroughs that have occurred,” he says. Some addicts “need a continued level of care forever.”

This poses a daunting challenge for the new health care regime.

“Somehow,” Festinger said, “the system is going to have to figure out a way to provide some continuing level of care.”