1993/94 San Diego County Grand Jury, Report No. 9

Early in the term of the 1993/94 San Diego County Grand Jury a concern was raised regarding the spread of the infectious diseases of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) in San Diego County. The Jury created a study issue to review national studies and other literature regarding what County government can do to reduce increases of these two infectious diseases.

In addition, the local, state and national medical associations were contacted regarding their policies in these areas. Interviews with experts in infectious disease medicine were conducted by the Jury, and the members of County Department of Health Services educated the Jury in this subject area. Representatives from the Grand Jury also interviewed the San Diego County Medical Society spokesman responsible for infectious disease programs. In addition, local County health and education protocols were reviewed for the study.

The problem which has developed is best expressed by Lawrence Gostin, J.D., Visiting Professor at Georgetown University Law Center, and Executive Director of the American Society of Law, Medicine and Ethics, who has said that:

"Many people in government, criminal justice and community groups believe that the public health approach cannot peacefully coexist with traditional drug control policies. They think needle and bleach distribution programs deliver a mixed message that results in greater drug use. In their view, the drug control policy of 'zero tolerance' is undermined when the state is asked to repeal, relax, or not enforce laws prohibiting distribution or possession of drug paraphernalia." [1]

Can the traditional drug control approach peacefully coexist with the needle-exchange programs?

The following terms/acronyms will be used throughout this report and are included here for easy reference:

GLOSSARY

AIDS - Acquired Immune Deficiency Syndrome

BLEACH/DISINFECTANT - Standard solutions of almost all common disinfectants, and an ordinary dilution of household bleach (one part bleach to 10 parts water) inactivate HIV.

HBV - Hepatitis B Virus

HIV - Human Immunodeficiency Virus

IDU - Injecting drug user

NEP - Needle-exchange program

SEROCONVERSION - Development of antibodies in blood serum as a result of infection or immunization. In the context of HIV, when a person becomes HIV-positive.

FACTS AND FINDINGS

The Grand Jury has learned some alarming facts. By the year 2000, between 40 and 110 million people worldwide will be HIV-infected. The fastest growing rate of infection is among women, adolescents and young adults. Although cases resulting from heterosexual contact are showing the greatest rate of increase, intravenous drug use remains the highest risk factor. This is significant locally because 43 percent of the AIDS cases in female heterosexuals, and 32 percent of AIDS cases in male heterosexuals have been reported as being due to an injecting drug user (IDU) sexual partner; likewise, 50 percent of AIDS in children under 13 years of age are linked perinatally, e.g., in utero or by breast feeding, to intravenous drug use. [2]

Further, the Grand Jury has learned that AIDS patients are among the most expensive patients in the public hospital system of most California counties. The health costs of each HIV patient from the time of diagnosis until death is estimated at approximately $119,000. [3] Controlling the spread of HIV will contain health care costs. The Grand Jury has also learned that needle-exchange programs are effective in reducing the incidence of transmission of HIV. A good example is a study conducted by Dr. Don DesJarlais of Beth Israel Medical Center in New York where he studied the medical records of 173 addicts in Bangkok. [4] Of 111 addicts who stopped sharing needles from 1987 to 1989, only five percent became infected with HIV, compared with 18 percent of the 62 who continued to share needles.

The Grand Jury turned to the medical profession as a source of sound information regarding controlling these diseases. The Jury found that the California Medical Association's stated policy is:

"CMA supports needle and syringe exchange programs to reduce transmission of HIV infection among injection drug users with the following caveats. Since we are concerned that such a program might incorrectly be perceived to be a complete solution, which it is not,* CMA believes needle and syringe exchange programs are likely to be effective only when part of a comprehensive approach which includes:

"1. Priority on treatment programs for opiate and stimulant users;

"2. Outreach for hard-to-reach addicts to include: o Referral for treatment o Training on safer injection, e.g. bleach o Training on safer sex;

"3. Provision and evaluation of sterile injection equipment;

"4. Voluntary (confidential and anonymous) HIV testing, counseling, and medical follow-up for infected persons and their sexual partners;

"5. Confidential counseling, testing, and appropriate treatment programs in jails and prisons;

"6. Social services to support families of HIV-infected drug users;

"7. Evaluation of all components, and;

"8. Community involvement in decisions as to how the program will be carried out." [5]

* "Several areas of the world have provided sterile injection equipment to drug addicted persons. The conclusions to date from the experience at these sites have been:

"1. They do not increase drug use. "2. They increase referrals to drug treatment programs. "3. They may reduce the transmission of HIV and other blood-borne infections. "4. That HIV risk behaviors decrease from some participants of needle and syringe exchange programs."

With this information, the Grand Jury contacted the San Diego County Medical Society to determine local policy. According to the chairman of their Acquired Immune Deficiency Syndrome (AIDS) Committee, the current policy of the San Diego Medical Society regarding needle exchanges, as approved at its September 1989 Council meeting, is as follows:

"1. The AIDS Committee endorses programs that encourage the sanitization of needles and syringes.

"2. The AIDS Committee endorses any studies/pilot programs appropriately designed on needle/syringe exchange that determine the risks, benefits or potential harms of such programs.

"3. The AIDS Committee would like to further explore the debate as to whether we should try to change the law and allow physicians to prescribe needles and syringes to drug addicts." [6]

The Grand Jury learned that both HBV and HIV are blood-borne and sexually transmitted diseases, and the primary vectors of HBV/HIV transmission among injecting drug users are needle sharing and sexual transmission. Further, estimates of the number of IDUs in San Diego County range from 7,153 to 23,381. [7] As of February 28, 1994, the data of the San Diego County Department of Health Services/AIDS & Community Epidemiology, reveals that 795 (15%) of the diagnosed and reported resident cases of AIDS in San Diego County were attributable to IDUs. [8] This figure does not include persons who now live in San Diego but were diagnosed elsewhere.

To answer the question if San Diego County should enter into comprehensive discussions with local community groups concerning needle-exchange programs, the Jury turned to a study conducted for the national Centers for Disease Control and Prevention by the School of Public Health at the University of California, Berkeley and the Institute for Health Policy Studies at the University of California at San Francisco in October 1993 and learned that they had recommended the following for local governments and communities:

"o Local governments should enter into discussions with local community groups to develop a comprehensive approach to preventing HIV in injecting drug users, their sex partners, and their offspring. This approach should include needle exchange programs and the expansion of drug treatment services." [9]

In addition, the Grand Jury learned that one community has, indeed, addressed this problem in a responsible manner. In New Haven, Connecticut the behavior of intravenous drug users has changed dramatically. The report of their needle-exchange program reveals the following:

"For the period from 11/13/90 to 6/30/93 the New Haven NEP enrolled a total of 1496 clients, 1173 men and 323 women. The 30-34 and 35-39 age groups were the most represented in the client population. African-Americans comprised 30%, Whites comprised 60% and Latinos comprised 10%.

"A unique evaluation method was developed by Professor Edward Kaplan from the Yale University School of Management and School of Medicine who served as the Principal Investigator on the project. He developed a syringe tracking and testing system to evaluate the impact of the NEP. In order to measure the program's impact, he developed a data collection system. This system, syringe tracking and testing, 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 procedure, a technique capable of detecting HIV in extremely small amounts of blood.

"The New Haven model projects that there was a 33% reduction over a one-year period in the transmission of HIV among injection drug users utilizing the NEP. The percentage reduction is based on the theory that the NEP was able to reduce the length of time that needles were in circulation by exchanging used needles for clean ones. This reduced the potential for needles to become infected, to be shared, and to transmit HIV to uninfected drug users. [Emphasis added.]

"During the year 7/1/92 - 6/30/93, New Haven reported that a total of 699 clients enrolled, 503 men and 146 women and 50 unknown. A total of 30,887 syringes were distributed and 30,517 were returned . The return rate for syringes that were given out via NEP was 68%; the overall return rate for all syringes, NEP and non-NEP was 98%. The number of participants who were referred by NEP staff and successfully entered drug treatment programs was 261, or 37%." [Emphasis added.] [10]

As of August 1993 there were 37 needle-exchange programs in 27 other American cities: Berkeley, Boston, Boulder, Bridgeport, Buffalo, Chicago, Fairbanks, Hartford, Honolulu, Indianapolis, Los Angeles, New York City, Novato, Oakland, Olympia, Philadelphia, Portland, San Diego, San Francisco, San Jose, San Mateo, Santa Cruz, Seattle, Spokane, Tacoma, Willimantic and Yakima. Twenty are legal, 10 are not legally authorized (including the City of San Diego), five are operating underground, one is exempt from prescription laws because it is a research site, and two whose status are unknown. [11] Additionally, the states of Maryland and Rhode Island also recently approved needle-exchange programs.

Further, the Grand Jury has found that states of emergency exist in San Francisco, Alameda and Marin Counties. Mayoral state-of-emergency declarations, pursuant to Government Code 8630, et seq., have permitted the cities of San Francisco, Oakland and Berkeley, and the Boards of Supervisors of San Francisco, Alameda and Marin Counties to automatically grant approval to needle-exchange programs on their weekly "consent" calendars. The Board of Supervisors of Alameda County stated a 42 percent incidence of female AIDS cases linked to IV drug use. [12] In San Diego County, the same incidence is 43 percent, and in a recent one-year time comparison, female AIDS cases increased 79 percent:

County of San Diego, Department of Health Services AIDS Case Reporting Trends, December 1, 1993

CASES REPORTED CASES REPORTED % INCREASE, POPULATION 10/91 TO 9/92 10/92 TO 9/93 LAST 12 MONTHS

All Cases 649 1316 103% Females 33 92 179% Injection Drug Users 104 256 146% Children 7 16 129% People of Color 205 454 121%

Assembly Bill 2610 and Senate Bill 1048 are both pending in Sacramento. Each bill permits the State Department of Health Services to authorize clean needle and syringe pilot exchange programs in individual California counties, cities, or cities and counties upon the prescribed request of that county, city, or city and county and local health officer. They also provide that if the local health officer determines the program has a detrimental effect on drug use and the increased spread of HIV, the program is to be terminated. AB 2610 and SB 1048 contain sunset provisions of January 1, 1998 and January 1, 1997 respectively.

CONCLUSIONS

1. The medical approach to disease control is superior to the political approach.

2. A needle-exchange program would save the lives of San Diego County residents as well as save substantial San Diego County tax dollars.

3. A countywide conference on needle-exchange programs could benefit the participants by providing education and understanding of the problem.

4. Lack of action to control the hepatitis B and human immunodeficiency virus transmissions is contrary to public interest.

5. The law enforcement and public health approaches can peacefully coexist with the common goal of reducing the San Diego County injecting drug use population.

6. A state of emergency in San Diego County should exist in the same scope and manner as it does in San Francisco, Alameda and Marin Counties.

7. National and international studies have demonstrated that there is no evidence that needle-exchange programs increase drug use by current addicts, or new drug use. [13] [14] [15] [16] [17] [18] [19] [20]

8. These studies show that needle exchange programs can substantially reduce the incidence of HBV and HIV seroconversion rates among intravenous drug users.[21] [22]

9. Needle-exchange programs have been demonstrated to be effective by the School of Public Health, University of California, Berkeley and the Institute for Health Policy Studies, University of California, San Francisco, and others, in reducing the number of discarded needles and syringes found in public areas. [23] [24] [25] [26]

10. Demonstrated success in increasing treatment opportunities for intravenous drug users has resulted in a reduction of the drug population. [27] [28]

RECOMMENDATIONS

The 1993/94 San Diego County Grand Jury recommends that the:

BOARD OF SUPERVISORS:

#94/60: Direct the San Diego County Director of Health Services, in cooperation with the San Diego County Medical Society, to convene and conduct a countywide conference with representatives of local governments, communities and organizations to discuss the possibility of conducting a study of a legal, controlled needle-exchange program throughout San Diego County, under the direction of the Department of Health Services, including the provision for rehabilitation programs for injecting drug users.

#94/61: Support Assembly Bill 2610 and Senate Bill 1048 (AIDS: Clean Needle and Syringe Exchange).

Footnotes:

1. Gostin, Lawrence, J.D., "Law and Policy," Dimensions of HIV Prevention, Needle Exchange, p. 36, a publication from The Kaiser Forums, sponsored by the Henry J. Kaiser Family Foundation.

2. Michele M. Ginsberg, M.D., Chief of AIDS & Community Epidemiology, San Diego Department of Health Services, letter dated April 6, 1994.

3. Hellinger, F., "The Lifetime Cost of Treating a Person with HIV," Journal of the American Medical Association, 270:474-478 (1993).

4. Don C. DesJarlais, et al., "AIDS Risk Reduction and Reduced HIV Seroconversion Among Injection Drug Users in Bangkok," American Journal of Public Health, Vol., 84, No. 3, p. 453 March 1994).

5. As approved by CMA Council action November 10-11, 1989.

6. San Diego County Medical Society, AIDS Committee minutes of June 19, 1990.

7. Green, J.O., "Estimates of Drug Users in San Diego County, 1990- 1992, Final Report," prepared for the County of San Diego Department of Health Services, Alcohol & Drug Services (June 1993).

8. The Coalition Connection,April 1994, p. 3.

9. School of Public Health, University of California, Berkeley and Institute for Health Policy Studies, University of California, San Francisco (prepared for the Centers for Disease Control and Prevention), The Public Health Impact of Needle Exchange Programs in the United States and Abroad, p. 23 (Oct. 1993).

10. State of Connecticut, Department of Public Health and Addiction Services, Report to the General Assembly on Needle-Exchange Programs, p. 3 (undated).

11. N. 9, supra., pp. 161-164.

12. Oakland Board of Supervisors' "Resolution in Support of Needle Exchange and Local Emergency Declaration"

13. Johanna A.R. van den Hoek, Harry H.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, 79:1355-57 (1989) and as cited in N. 16, infra, p. 50.

14. Paone, Denise, et al., "Risk Reduction Behaviors Among Participants of Syringe Exchange Programs in New York City, USA, APHA 121st Annual Meeting, San Francisco, CA, October 24-28, 1993.

15. Graham J. Hart, et al., "Evaluation of Needle Exchange in Central London: Behaviour Change and Anti-HIV Status Over One Year," AIDS, 3(5):261-65, 264 (May 1989), and as cited in N. 15, infra, p. 54.

16. DesJarlais and Friedman, "AIDS and Legal Access to Sterile Drug Injection Equipment, Annal, AAPSS, 521, p. 64 (May 1992).

17. N. 9, supra., p. 15.

18. Ernst C. Buning, "The Role of the Needle Exchange Project in Preventing HIV Infection Among Drug Users in Amsterdam" (paper delivered at the "What Works Conference: An International Perspective on Drug Abuse Treatment and Prevention Research," (New York, October 1989), as cited in N. 16, supra., pp. 50-51.

19. N. 16, supra., p. 54.

20. Elaine O'Keefe, Edward Kaplan and Kaveh Knoshnood, Preliminary Report: City of New Haven Needle Exchange Program, p. 40 (New Haven, CT: New Haven Health Department, 1991), and as cited in N. 16, supra., p. 61.

21. Russell Newcombe, "The Liverpool Syringe Exchange Scheme for Drug Injectors: Initial Evidence of Effectiveness in HIV Infection" (paper delivered at the First International Conference on the Global Impact of AIDS, London (March 1988), as cited in N. 16, supra., p. 54.

22. Harry J.A. van Haastrecht, et al., "The Course of the HIV Epidemic Among Intravenous Drug Users in Amsterdam, the Netherlands," American Journal of Public Health, 81(1):59-62, 60 (Jan. 1991), and as cited in N. 16, supra., p. 51.

23. C. Buning, G.H.A. van Brussel, and G.W. van Santen, "Amsterdam's Drug Policy and Its Implications for Controlling Needle Sharing," Needle Sharing Among Intravenous Drug Abusers: National and International Drug Perspectives, National Institute on Drug Abuse, Research Monograph Series No. 80, ed., R.J. Battjes and R.W. Pickens (Rockville, MD: National Institute on Drug Abuse, 1988), pp. 59-74, 73, and as cited in N. 16, supra., p 51.

24. Van Ameijden, van den Hoek and Coutinho, "Risk Factors for HIV Seroconversion," as cited in N. 16, supra., p. 59.

25. Affidavit filed by the Sanitation Department of Tacoma, WA in a civil suit brought by the state attorney general, as cited in N. 16, supra., p. 59.

26. N. 9, supra., p. 16.

27. "The Pilot Needle Exchange Study in New York City: A Bridge to Treatment: A Report on the First Ten Months of Operation, p. 12 (New York: New York City Department of Health, p. 12 December 1989), and as cited in N. 16, supra., p. 58.

28. N. 9, supra., p. 10.

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