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Preventing HIV Transmission: The Role of Sterile Needles and Bleach 4 Community Views In the evaluation of needle exchange and bleach distribution programs, one dimension involves scientific evidence on whether the behavior of injection drug users changes and rates of new infection are reduced. However, these issues cannot be viewed in isolation, because injection drug users inhabit communities that are affected by and have already developed responses to the behavior and consequences of drug abuse. Whether HIV prevention programs, such as needle exchanges, are established and what forms they take are shaped by multiple forces in the community. The sheer variety among the operational characteristics of needle exchange programs described in the previous chapter is to some extent a function of local Note: Some of the information used in this chapter is from a paper prepared for the panel by Stephen Thomas and Sandra Crouse Quinn, Community Response to the Implementation of Needle Exchange and Bleach Distribution Programs (1994). Their paper discusses the primary historical, social, and political factors that have shaped community responses to the implementation of needle exchange and bleach distribution programs. It also presents results from cross-sectional surveys of selected African American populations to demonstrate how deficits in AIDS knowledge and attitudinal barriers have shaped the perceptions of African Americans toward needle exchange programs as an HIV prevention strategy advocated by public health authorities. In addition, some of the discussion is based on information from another paper prepared for the panel by David Metzger and Dominick DePhilippis, Treatment Community Views on Needle Exchange and Bleach Distribution Programs (1994). Their paper explores the basis for the dilemma faced by the large and diverse drug treatment community regarding the public debate and political controversy surrounding the brief and turbulent history of needle exchange programs in this country.
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach responses to such programs. The community is not some monolith; rather, it is a dynamic interaction of groups whose views and actions vary with location and time. The panel undertook a wide range of activities to gather pertinent information about the views of various groups on the issues relating to the implementation of needle exchange and bleach distribution programs. We reviewed the literature systematically to gather the range and extent of opinions for two groups in which the expression of viewpoints has been extensive: the African American community and the treatment community. In fact, a special workshop was held, to which representatives of the community groups covered in this chapter were invited. The panel members conducted site visits to Chicago and San Francisco to discuss issues with community outreach workers. We also solicited information from pertinent professional organizations to identify formal positions on needle exchange and bleach distribution programs. Finally, a number of public opinion surveys were identified and reviewed. In this report, we embrace a broad definition of community, which includes ethnic groups, business and religious organizations, government bodies, and professional groups. Understandably, the information presented in this chapter focuses primarily on those who have been most vocal in expressing their concerns about needle and bleach distribution programs. Other views have not been overlooked intentionally. The chapter begins with a brief consideration of the moral and ethical arguments that come into play in these issues. We then discuss public opinion polls, which are informative to broadly gauge community attitudes toward needle exchange and bleach distribution programs over time. The chapter goes on to discuss the perspectives of a number of community groups and their responses to needle exchange and bleach distribution programs: minority communities, which are disproportionately affected by drug abuse, law enforcement officials, who are sworn to enforce laws, pharmacists, who hold supplies of sterile needles, and drug abuse treatment providers, who work with limited funding to impact the difficult processes of addiction. The material presented in this chapter contributes to the panel's overall assessment of the effectiveness of needle exchange and bleach distribution programs, and its findings and conclusions are integrated in the recommendations that appear in Chapter 7. As stated in the Introduction, this approach reflects the development of the panel's deliberations on the issues.
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach MORAL/ETHICAL ARGUMENTS The moral arguments that are a common theme of community groups concerned with needle exchange and bleach distribution programs also appear in federal policy statements. A critique of the New Haven needle exchange evaluation study by the Office of National Drug Control Policy illustrates this point (1992:1): "There is no getting around the fact that distributing needles facilitates drug use and undercuts the credibility of society's message that using drugs is illegal and morally wrong." Ideological and moral concerns are not scientific, empirically based arguments; however, this in no way dilutes their importance. Needle exchange and bleach distribution programs can be established only within the context of communities, and their success or failure is highly dependent on the support and leadership of community members. The strength of the scientific arguments and their weight relative to the ethical case for or against these programs can be and have been debated at length by ethicists and other concerned individuals. Although it is beyond the scope and expertise of the panel to fully examine the complex range of ethical issues that might be judged relevant to analyze the establishment of public health policies, we nonetheless present two fundamentally divergent views that may contribute to an understanding of the polarization encountered when the establishment of needle exchange and bleach distribution programs is considered. Within the context of an ethical debate, whether needle exchange and bleach distribution programs contribute to increased drug use in society constitutes one of many harms and/or benefits that must be weighed relative to others (Pellegrino, 1990; O'Brien, 1989). Weighing the relative benefit and relative harm associated with an action before making a judgment about its ethical soundness has been called the proportionalist approach to ethical analysis (Fuller, 1993). Using this approach, one can argue that people are morally compelled to support a lesser harm (evil) in order to prevent a greater harm. From this perspective, the most convincing argument in favor of needle exchange programs lies in their claim as a significant strategy for reducing harm. Two ethical traditions take the proportionalist approach. In Jewish medical ethics, the principle of pkuach nfesh mandates the protection of human life and holds that, when a life is at stake, all prohibitions contained in the Torah and the Talmud may be waived to save that life (Jakobovits, 1959). The other ethical tradition that supports the proportionalist position is the moral theology of Alphonsi Mariae de Ligorio (1907), which argues that it is ethical to support a less evil activity in order to prevent a more evil one. In the case of needle exchange and bleach distribution programs, according to this tradition, even if some empirically demonstrated harms
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach were associated with program implementation, it would still not necessarily be ruled out on ethical grounds. A fundamentally different approach to ethical analysis is the deontologist approach. In this approach, actions are taken because they are right within themselves, not necessarily because some good will ensue. Accordingly, if one has concluded that injection drug use is immoral, then one may not ethically cooperate in any way with this behavior. Needle exchange programs would be viewed as immoral because they provide the material means for an immoral activity and therefore share in the evil of that activity. Given these examples of two fundamentally divergent views of what is ethically acceptable, it is not surprising that there has been and continues to be substantial public discourse about the distribution of needles, syringes, and bleach. Nonetheless, both the public health and community well-being are at stake until we find common ground on which to clarify objectives and establish appropriate ways to reduce the spread of HIV, which may include the establishment of needle exchange and bleach distribution programs. As noted by O'Brien (1989), there is value in developing common definitions and mutually agreed-on ethical standards of analysis. Until such standards are set forth, it will be difficult to engage in a constructive ethical debate. PUBLIC OPINION POLLS A thorough review of public opinion polls conducted between 1985 and 1991 indicates that half of the general public supports harm reduction efforts that include needle cleaning, legalizing needle sales, needle exchange, and needle distribution (Lurie et al., 1993). Approval has tended to be higher for programs that combine bleach distribution and needle exchange than for programs that focus on needle distribution (Table 4.1). More important, the available evidence indicates that this support has tended to increase over time, as the issues have been publicly debated and more programs have been implemented. For example, the Gilmore study (Table 4.1, Panel A) showed an increase in approval between 1988 and 1991 for teaching people to use bleach. In the same interval, that study showed an increase in support for legalizing the sale of needles and syringes to drug users (Panel B), and a similar rise in approval for needle exchange (Panel C). The studies in these three panels show substantial, sometimes majority support for measures that make sterile needles more available to injection drug users. With regard to the distribution of free sterile needles to injection drug users in order to retard the spread of AIDS (Panel D), again, between 1985 and 1991 across various locations, substantial support was found, although less than a majority in each opinion study. As another illustration, the results of a 1994 household survey showed a
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach 12 percent increase in the proportion of Maryland residents who support needle exchange programs (Figure 4.1). These results also point to a larger increase (19 percent) in the city of Baltimore than in the state as a whole. Moreover, findings from a recent nationwide telephone survey undertaken in February 1994 showed that, among the 1,001 adults sampled, 55 percent favored implementing needle exchange programs to reduce the spread of diseases such as AIDS, 37 percent favored allowing drug users to buy sterile needles without prescriptions from pharmacies, and 40 percent favored removing criminal penalties for the simple possession of needles and syringes (Hart, 1994). We turn now to discussion of the views of particular groups in communities across the nation. AFRICAN AMERICAN VIEWS Much of the voiced African American opposition to needle exchange and bleach distribution programs must be understood in the context of perceptions that historically there has been government negligence in response to the drug abuse epidemic, distrust of public health authorities, and fear—and, for some, the conviction—that the broader society considers large segments of the African American population expendable (Thomas and Quinn, 1991, 1993). Pervasive throughout the African American community are uncertainties about the motivations of what they perceive as the white establishment. This underlying distrust is grounded in part in a history of medical neglect and significant violations of human subjects. Most specifically, the legacy of the Tuskegee Syphilis Study is a vivid reminder (Thomas and Quinn, 1991). This study, conducted by the U.S. Public Health Service from 1932 to 1972, deliberately and irresponsibly withheld treatment for syphilis from an African American community in Tuskegee, Alabama. The Tuskegee study continues to serve as the basis for much of the widespread distrust of public health and government authorities (Jones, 1981). Recently confirmed reports about other government abuses (e.g., radiation experiments, cocaine distribution) are portrayed as further evidence to support suspicions and fears about the motivation and intent of officials urging the utilization of needle exchange programs. According to Thomas and others (Thomas and Quinn, 1993; Belgrave and Randolph, 1993), many African Americans, including many who are well educated, believe that HIV is manufactured and that drugs are being deliberately supplied to African American communities. The prevalence of AIDS itself, as well as programs purported to reduce its spread, are viewed as part of a larger genocidal conspiracy against African Americans. In a 1990 survey of the views of African American churchgoers in five cities—Atlanta,
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach TABLE 4.1 Results of U. S. Public Opinion Polls on Needle Exchange and Needle Cleaning, 1985-1991 Date of Survey Description of Respondents Polling Institution Question Results A. NEEDLE CLEANING April/May 1988 Washington State; n = 800 Gilmore Research for Washington State HIV/AIDS; General Population Survey (Olympia, WA) (Washington State Department of Health, 1991) Would you support a program to teach people how to clean needles with bleach? 59%—Yes; 41%—No/don't know May 1989 Utah; n = 849 Survey Research Center, University of Utah (Salt Lake City, UT) (University of Utah, 1989) Free needle cleaning kits should be available for IV drug users: agree or disagree? 43%—Agree; 57%—Disagree/don't know April/May 1991 Washington State; n = 801 Gilmore Research for Washington State HIV/AIDS General Population Survey (Olympia, WA) (Washington State Department of Health, 1991) Would you support a program to teach people how to clean needles with bleach? 65%—Yes; 35%—No/don't know
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach Date of Survey Description of Respondents Polling Institution Question Results B. REMOVAL OF LEGAL BARRIERS TO NEEDLE PURCHASE April/May 1988 Washington State; n = 800 Gilmore Research for Washington State HIV/AIDS General Population Survey (Olympia, WA) (Washington State Department of Health, 1991) Would you support making needles and syringes legal to sell to drug users? 38%—Yes; 62%—No/don't know April/May 1991 Washington State; n = 801 Gilmore Research for Washington State HIV/AIDS General Population Survey (Olympia, WA) (Washington State Department of Health, 1991) Would you support making needles and syringes legal to sell to drug users? 45%—Yes; 55%—No/don't know
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach Date of Survey Description of Respondents Polling Institution Question Results C. NEEDLE EXCHANGE April/May 1988 Washington State; n = 800 Gilmore Research for Washington State HIV/AIDS General Population Survey (Olympia, WA) (Washington State Department of Health, 1991) Would you support a needle exchange program where a drug user could obtain a free sterile needle in exchange for a used one? 55%—Yes; 45%—No/don't know January 1989 Pierce and South King Counties, WA; n = 411 Tacoma Morning News Tribune Poll conducted by Tacoma Marketing Research (Tacoma, WA) (Eskenazi, 1989) Do you agree with the Board of Health decision to fund a hypodermic needle exchange program designed to reduce the spread of AIDS? 67%—Agree; 18%—Disagree; 14%—Unsure/don't know 1989/1990 New York City, NY; Members of Harlem families; n = 326 Ann Brunswick Columbia University (New York City, NY) (Brunswick, 1991) Some people have suggested that handing out clean needles, free, would be a good way to reduce AIDS among intravenous drug users.; Other people say that providing free needles would encourage drug use. How do you personally feel about allowing drug users to exchange their used needles for clean ones? 38%—Agree strongly; 16%—Agree somewhat; 35%—Disagree strongly; 5%—Disagree somewhat; 6%—Not sure
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach Date of Survey Description of Respondents Polling Institution Questions Results 1989/1990 New York City, NY; Injection drug users in Harlem families; n = 38 Ann Brunswick Columbia University (New York City, NY) (Brunswick, 1991) Some people have suggested that handing out clean needles, free, would be a good way to reduce AIDS among intravenous drug users.; Other people say that providing free needles would encourage drug use. How do you personally feel about allowing drug users to exchange their used needles for clean ones? 53%—Agree strongly; 19%—Agree somewhat; 18%—Disagree strongly; 6%—Disagree somewhat; 4%—Not sure April/May 1991 Washington State; n = 801 Gilmore Research for Washington State HIV/AIDS General Population Survey (Olympia, WA) (Washington State Department of Health, 1991) Would you support a needle exchange program where a drug user could obtain a free sterile needle in exchange for a used one? 68%—Yes; 32% —No/don't know
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach Date of Survey Description of Respondents Polling Institution Question Results D. NEEDLE DISTRIBUTION November 1985 Maryland residents who indicated they had heard about AIDS in the news recently; n = 1,074 Hollander, Cohen, McBride associates for the Maryland Department of Health (Baltimore, MD) (Hollander et al., 1985) One of the ways AIDS is spread is by drug abusers who share needles. Some health authorities have suggested that clean needles be provided free to those who ask for them [to] control spreading the disease that way. Do you agree with this approach? 37%—Agree; 55%—Disagree; 0%—Depends; 8%—Don't know; 0%—Not applicable March 1987 Connecticut; n = 500 The Roper Center for Public Opinion Research (Storrs, CT) (1987) Do you favor or oppose distributing free sterile needles to drug users to slow the spread of AIDS through contaminated needles? 33%—Favor; 60%—Oppose; 7%—Don't know October 1988 U.S.; n = 1,606 CBS News/New York Times Poll (New York City, NY) Would you favor or oppose giving injection drug users sterilized needles for free if it would slow down the spread of AIDS? 40%—Favor; 53%—Oppose; 7%—Don't know
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach Date of Survey Description of Respondents Polling Institution Questions Results February 1989 New York City, NY; n = 1,015 Newsday (New York City, NY) (1989) Do you approve or disapprove of the city's programs to provide clean needles to drug users in order to prevent the spread of AIDS? 50%—Approve; 40%—Disapprove; 10%—Don't know May 1989 Utah; n = 849 Survey Research Center, University of Utah (Salt Lake City, UT) (University of Utah, 1989) Free needles and syringes should be made available to intravenous drug addicts: agree or disagree? 38%—Agree; 62%—Disagree/don't know May 1989 Connecticut; n = 768 Northeast Research (Orono, ME) (1989) I'm going to read a few of the things people have suggested that might help stop the spread of AIDS in CT. For each one please tell me if you think that method should be used. You can answer yes or no, or that you have no opinion about it. Give out free needles to drug dealers. 40%—Yes; 47%—No; 13%—Don't know May 1989 United States; n = 1,054 Media General/Associated Press (Richmond, VA) (1989) The AIDS virus can be transmitted when people who use drugs share needles. If giving intravenous drug abusers free needles would slow down the spread of AIDS, would you favor or oppose giving addicts sterilized needles for free? 50%—Favor; 43%—Oppose; 7%—Don't know
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach importantly, HIV transmission. These data also clearly show that in-treatment injection drug users will continue to inject on occasion. Moreover, other studies have found drug treatment experience (i.e., past history of exposure to treatment) to be related to higher levels of HIV risk behaviors for certain injection drug users (Siegal et al., 1995; Ross et al., 1993; Chitwood and Morningstar, 1985). Federal Regulations Few treatment programs in the United States have instituted training on how to effectively decontaminate needles or provide information on how to legally obtain sterile needles. Federal regulations governing some forms of drug abuse treatment also are obstacles to drug treatment providers and their patients to make use of needle exchange and bleach distribution programs. For example, federal regulations concerning take-home medication for patients receiving methadone therapy [21 CFR, part 291.505 (d) (6) (iv) (B) (1)] require clinicians to consider the ''absence of recent abuse of drugs (narcotic and nonnarcotic), including alcohol" in determining whether to grant the privilege of reduced clinic attendance and the provision of doses of methadone (take-home medication) for the days when the patient does not attend the clinic. Consequently, for patients who have relapsed and who may consider using needle exchange and bleach distribution programs to more safely inject drugs, this federal regulation is a disincentive to admit to recent needle exchange and bleach distribution program participation. Such an admission would result in denial or revocation of reduced clinic attendance (or take-home medication) privileges. In a similar manner, a counselor cannot advise a patient who is receiving or is eligible for take-home medication privileges to continue to abstain from any drug use, while also suggesting participation in needle exchange and bleach distribution programs if drug use does occur. Knowledge of needle exchange and bleach distribution program participation or any other activity that may be indicative of drug use would require—because of federal regulations—drug treatment clinicians to consider denying or revoking the take-home medication status of a patient. Condoning Drug Use As we document more fully in Chapter 7, reviews of the empirical data show no evidence to support the charge that needle availability promotes drug use among current or potential users (Schwartz, 1993; Karpen, 1990; Watters et al., 1994; U.S. General Accounting Office, 1993; Lurie and Chen, 1993). Moreover, in considering the current knowledge base on the etiology
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach of drug use, it is not surprising that a single risk factor—availability of sterile needles—does not play a crucial role in increasing drug use or initiating noninjectors to injection drug use. This critical point was noted by the University of California researchers (Lurie and Chen, 1993) when they stated that "initiation into drug use is influenced by many social, psychological, and biological factors—and not by the simple availability of syringes" (p. 23). Because treatment is neither quickly nor universally effective at eliminating drug use, some injection drug use may occur even if a major expansion of drug treatment programs were implemented (Joseph, 1989). Also, even if treatment were made readily available, not all injection drug users would be interested in participating. Recognizing this, the approach adopted by needle exchange and bleach distribution programs is a pragmatic one. These programs acknowledge that not all addicts demonstrate readiness for treatment, that many who enter treatment will not be completely abstinent, and that, once abstinent, relapse is endemic to chemical dependence. SUMMARY As with other sensitive issues, communities cannot be categorized as simply either supporting or opposing needle exchange programs. The range of views is far more complex. Members of minority communities ravaged by the effects of drug abuse and HIV infection have articulated both opposition and support for these programs. Law enforcement personnel have been divided on the concept of these programs. Health professionals have debated extensively the pros and cons of needle exchange and bleach distribution. Public opinion polls reflect division and a trend toward more favorable disposition to accept such programs as the issues are debated. Table 4.3 summarizes the concerns of the individual community groups solicited by the panel. They range from fears of worsening drug abuse and crime to concern about promoting immoral activities. The reactions of these stakeholders are not mutually exclusive. All share the concern that handing out sterile injection equipment or bleach bottles to injection drug users does not address the underlying problems associated with drug abuse and in fact may create more negative outcomes. In sum, the main argument against needle exchange and bleach distribution programs is based on perceptions that they do more harm than good. CONCLUSIONS That community responses to needle exchange and bleach distribution programs have varied considerably, not only across but also within subgroups
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach TABLE 4.3 Community Concerns Communities Perceptions and Concerns Common concerns • Drug use is illegal and immoral and should not be condoned.; • Providing clean needles to drug users is misguided and dangerous.; • Programs send a mixed message and may worsen society's drug problem. Ethnic/racial African American • Drug abuse epidemic has been consistently neglected and drug treatment programs are either not established or not funded adequately.; • Drug abuse problems and crime in urban communities will be worsened by the implementation of programs.; • Community leaders are not part of decision making in the establishment of programs within their own communities.; • Drugs are deliberately supplied to the black community and these programs promote their continued use.; • HIV is a man-made virus and AIDS may be a form of genocide.; • Public health authorities cannot be trusted because of past negative experiences, e.g., Tuskegee Syphilis Study, and large segments of the black population are regarded as expendable by the white establishment. Hispanic • Complex cultural web in extraordinarily diverse community will require involvement of community leaders for effective implementation of programs.; • Sexual practices and mores, particularly gender issues, must be addressed adequately.; • Issues of family and safety are critical to the establishment of programs. Law enforcement • Drug use is illegal.; • Needlesticks to police officers may increase due to an increase in the number of needles in circulation.; • Programs should not detract attention from addressing underlying causes of addiction.; • Programs must be tailored to needs of specific communities.; • Drug abuse problems and crime in urban communities will be worsened by the implementation of programs.; • Personnel will need to be better educated about such programs and trained to handle situations that may arise before the programs can be successful.; • Question usefulness of prescription and paraphernalia laws.
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach Communities Perceptions and Concerns Health professionals Pharmacists • Quality of health care services provided to noninjection drug user customers may suffer.; • Subsequent negative effects on revenue.; • Liability for occupational exposure of workers and adherence to rules and regulations set forth by DEA, EPA, FDA, and OSHA.; • Disposal of used needles/syringes.; • Lack or ambiguity of prescription laws.; • Personal discretion.; • Involvement in the development of site-specific programs is needed.; • Education and training are needed. Treatment service providers • These programs promote a behavior destructive to the individual, family, and community.; • Funding will be diverted from treatment.; • Public and professional misperceptions about lack of efficacy of treatment.; • Disincentive to participate in programs because of federal regulations dealing with drug treatment and degrees of drug use.; • Largely strict abstinence orientation poses apparent contradiction to programs allowing the continuation of drug use. and over time, is the major conclusion of this chapter. Many of their concerns stem from the view that needle exchange and bleach distribution programs are limited to one type of activity: the exchange or distribution of drug paraphernalia to injection drug users. It is therefore possible that programs taking a comprehensive approach could respond to some of this community opposition. Such an approach would include an overall strategy to improve the delivery of health services, including drug treatment services and social services, that address other important needs. It would also include an open public approach that clarifies the concept and explains the multifaceted and multilevel components of needle exchange and bleach distribution programs. Focusing on the impact of needle exchange and bleach distribution programs on levels of drug abuse has been central to the discussions of these programs. This underlying focus has generated a multitude of hypotheses about their possible harmful effects. It is critically important to articulate these issues, reformulated as hypotheses, in the process of considering the program effects and operationalizing them in such a way as to steer carefully
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach between the conflicting objectives of the campaigns against the two epidemics of drug abuse and HIV. For example, when proponents of needle distribution argue that repeal of paraphernalia laws is more important than instituting discrete needle exchange programs because pharmacies are more plentiful, have more convenient hours, and cost less to operate, community concerns need to be acknowledged. Citizen groups and police are concerned about an increase in discarded needles and accidental needlesticks. Pharmacists are concerned about the impact on their other customers if they expand business to serve injection drug users. Public opinion polls are less supportive of needle distribution than they are of needle exchange. This combination of community views suggests that needle exchange, with the systematic collection of contaminated needles, is more palatable than outright needle distribution programs. Another observation that arises from this chapter is that community support has built gradually for needle exchange and bleach distribution programs. Repeat surveys over time in a single geographic location are consistent in showing an increase in the proportion of respondents who react favorably toward needle exchange and bleach distribution programs. The most recent surveys in Baltimore and the state of Maryland show that a majority favors needle exchange. Similarly, quotes from politicians, drug abuse treatment providers, and African American clergy reflect a change in attitude over time. The change reflects the growing discussion of needle exchange and bleach distribution programs as part of a campaign aimed at stemming the epidemic of parenteral transmission of HIV infection—rather than as an incongruous initiative amidst a broader campaign aimed at drug abuse. As community concerns are recognized and addressed, the concept of needle exchange and bleach distribution programs is refined. Initial constraints placed by communities on needle exchange programs in New York City and Washington, D.C. (as described in Chapter 3) resulted in programs that were universally recognized as ineffective. With continued dialogue and progressive iterations of balancing community concerns, the concept of needle exchange and bleach distribution programs continues to evolve. When needle exchange and bleach distribution services are viewed as one of many components of a comprehensive strategy against HIV, a reduction in resistance and broader coalitions for these programs can be expected to follow. At the same time, efforts to develop comprehensive programs must recognize that change or expansion of needle exchange and bleach distribution programs must be combined with significant attention to long-term societal impacts (e.g., on community-level drug use). Failure to include community members in the decision-making process about the implementation
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Preventing HIV Transmission: The Role of Sterile Needles and Bleach of these programs can fan the flames of fear and distrust within the community (Thomas and Quinn, 1993). NOTE 1. Dr. Primm has reversed his original position of opposing needle exchange programs and has stated publicly that he now supports them (Primm, 1995). REFERENCES The Arizona Republic 1993 Poll on AIDS Concerns, January 21. Ball, J.C., and A. Ross 1991 The Effectiveness of Methadone Maintenance Treatment. New York, NY: Springer-Verlag. Ball, J.C., W.R. Lange, C.P. Myers, and S.R. Friedman 1988 Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 29:214-226. Bannon Research 1990 Massachusetts Telephone Survey, Politics Poll "Media #6" (unpublished material), February 19. Bates, K. 1990 AIDS: Is it genocide? Essence 21:77-116. Belgrave, F.Z., and S.M. Randolph, eds. 1993 Psychosocial aspects of AIDS prevention among African Americans. Special issue of The Journal of Black Psychology 19(2) May. Billingsley, A., and C. Caldwell 1991 The church, the family, and the school in the African American community. Journal of Negro Education 60:427-440. Brettle, R. 1990 HIV and harm reduction for injection drug users. AIDS 5:125-136. Brown, R. 1991 Political action. In Life in Black America, J. Jackson, ed. Newbury Park, CA: Sage Publications. Brunswick, A. 1991 Longitudinal Harlem Health Study, NIDA Research Grant R01-DA05142 (unpublished material), April. Calsyn, D.A., A.J. Saxon, G. Freeman, and S. Whittaker 1991 Needle-use practices among intravenous drug users in an area where needle purchase is legal. AIDS 5:187-193. Center for Substance Abuse Research 1994 Needle Exchange Programs Supported by a Majority of Marylanders. CESAR FAX 3(28): July 25 (Weekly FAX from the Center for Substance Abuse Research, University of Maryland, College Park). Chitwood, D.D., and P.C. Morningstar 1985 Factors which differentiate cocaine users in treatment from nontreatment users. The International Journal of the Addictions 20:449-459.
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