A Publication from The Kaiser Forums; Sponsored by The Henry J. Kaiser Family Foundation
Edited by: Jeff Stryker, Center for AIDS Prevention Studies University of California-San Francisco; Mark Smith, M.D., M.B.A. -

Despite such recommendations, needle exchange programs have been instituted in fits and starts, with much Sturm und Drang. Although there has been a recent proliferation of programs, both legal and "underground," their growth has been halting, impeded by opposition in minority and church communities, governmen-tal skepticism, bureaucratic intransigence, and the NIMBY ("not in my backyard") phenomenon. This book addresses some particular questions concerning the implementation, funding, evaluation, and legal context of needle exchange programs. These are the issues in the foreground--the trees, if you will. But what about the forest? Why has the needle exchange controversy garnered so much attention and controversy, often at the expense of broader issues in drug policy?

According to Grund and colleagues, the syringe and needle have become "fetishized": "Perhaps because of the involvement of biomedical researchers unfamiliar with the worlds of drug users, almost exclusive attention has been focused on the physical objects responsible for transmitting the virus--needles and syringes--often obscuring the fabric of social relationships in which these objects are used."3 There are striking parallels between the focus on needles and syringes in the drug field and the impact the HIV epidemic has had on sex research. John Gagnon has noted that for researchers and funding sources, "what is interesting about sex is what the disease makes interesting."4 Carol Vance has written, "The reliance on survey instruments and easily quantified data in biomedically based research increases the tendency to count acts rather than to explore meaning."5

There are other possible explanations for the focus on needles and syringes. Clearly, needle-and-syringe use and sharing are directly linked to HIV transmission. Needle sharing is a dramatic aspect of drug use upon which it is easy to focus. Finally, implementing needle exchange may be less daunting or expensive than confronting broader issues of crime, HIV prevention, and drug abuse.

Though needle exchange is only one aspect of the HIV and drug problem, it is a window that offers a perspective of broader public health questions. How does society view injection drug use and drug users? What is the proper balance between criminal justice and public health approaches to problems involving drug use and the spread of AIDS? Drug use of some type has always been a part of American life, and tolerance of drug use and drug users has waxed and waned.6 Drug use is an addictive behavior that occurs mostly in private settings. It can be very difficult to change. Drug users tend to be on the margins of society, little valued, and much feared. The first decade of the AIDS epidemic was a time of "neo-Prohibitionist" drug policy, exemplified by the "just say no" slogan that found expression in aggressive criminal justice approaches to drug use and drug users.

At the vanguard of the needle exchange controversy have been zealous activists, including many former drug users and individuals whose lives have been touched by losses to AIDS. Acting in a tradition of public- health civil disobedience and treading the path trod by predecessors concerned with reproductive freedom and access to contraceptives, needle exchange proponents have been willing to risk arrest to help clients gain access to sterile drug-injection equipment.
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