Shoot to win

Needle-exchange supporters launch a new fight to bring a program to Worcester

by Nancy Rappaport

With a new state report that shows the success of needle exchange in lessening the spread of HIV, and a recently elected City Council that may be more sympathetic than the one that voted it down twice before, AIDS Project Worcester and a coalition of residents are quietly building support for a needle-exchange program in Worcester.

But once again, proponents may face what proved to be their biggest obstacle in past political battles: staunch opposition led by William Breault, chairman of the Main South Alliance for Public Safety who has taken his crusade against needle exchange statewide.

Although many proponents acknowledge being gun-shy after failed attempts to introduce a program in the city, this time around they are armed with what could prove to be evidence that needle exchange is effective in combating the spread of HIV in IV drug users.

A new report by the Massachusetts Department of Public Health contends that while the number of AIDS cases decreased nationally in 1997 as a result of combination therapy, the number of cases of HIV in Worcester rose 55 percent in the past five years. In Massachusetts, where injecting drug use has become the leading cause of AIDS transmission, the report also links needle-exchange programs with a decrease in HIV infections. The study points out that nearly half the people diagnosed with AIDS in Massachusetts in 1997 live outside Boston -- a city with a needle-exchange program -- up from 29 percent in 1988. In fact, more than two thirds of new AIDS cases in the communities of Fitchburg, Holyoke, Lawrence, Lowell, Lynn, New Bedford, Springfield, and Worcester contracted the disease by injecting drugs, through heterosexual sex, or both. None of those communities currently operates needle-exchange programs.

FOR THE TIME BEING, officials at AIDS Project Worcester are reluctant to go public with details of their proposal. Staffers at the Green Street agency were expected to meet on March 4 to rally behind the most recent petition filed with City Council.

"We're in the preliminary stages, at the point of getting interested parties together to discuss the feasibility of discussing the matter again," says Charles Carnahan, executive director of AIDS Project Worcester. "It's one of those things where we can't reveal our cards just yet."

---

"I don't think we should be in the business of enabling drug users. I don't see needle exchange helping the community." -- Billy Breault chairman of the Main South Alliance for Public Safety

---

The agency was at the forefront of the last attempt, in 1995, to introduce a local program. Several models were proposed, including a fixed-site program based in a health-clinic setting or a storefront, and a van program, where a mobile unit would visit specific locations.

But the proposals were fought successfully by activists living in Main South, one of the neighborhoods where needle exchange would likely be located.

"We are portrayed as uncaring and callous when, in fact, it's quite the opposite. Our neighborhoods are left dealing with social problems, and that has left us gun-shy about supporting needle exchange," says Barbara Haller of the City Manager's Advisory Committee on Beacon-Brightly.

Haller says that both the van and the storefront scenarios presented problems. "They would act as magnets not only for IV drug users, but for the trafficking that goes along with it," she says. "In fact, in other cities, where they have such programs, the police would agree to not go into the area while a van was there -- an understandable approach, but from a neighborhood prospective, not acceptable. You'd have drug dealers on every corner."

A fixed site has the same problems, Haller says. "Once people obtain needles they leave and find our alleys and our parks and our back yards in which to inject themselves."

The discussion grew heated and in the end, the City Council defeated needle exchange 8 to 3.

"There was a big debate," says Joe McKee, director of client service programs at AIDS Project Worcester. "But we're definitely going to stand up and bring up this issue again. We don't want to go into our strategy at this time, but we're going to have a strategy meeting here in the near future, and a number of interested citizens will be invited -- from business leaders to substance-abuse service providers to those in the medical community. Then we'll move to have this issue revisited by the City Council. There's a lot of support coming from a lot of different quarters."

McKee and others are hoping that some of that support will come from City Council, which includes four new members -- At-Large Councilors Stacey DeBoise, Timothy Murray, and Joseph Petty and District 5 Councilor John Finnegan, who now chairs the health subcommittee.

At-Large Councilors Konstantina Lukes and Timothy Cooney both voted in favor of needle exchange last time, along with District 1 Councilor Stephen Patton. Finnegan has suggested that it's something that warrants consideration. Finnegan did not return repeated telephone calls made by the Phoenix.

"We'd need three out of four new council votes," says Cooney, who recently observed the eighth anniversary of his brother's death due to AIDS. "His death wasn't related to IV drug use, but I think anything that can be done should be done to stop the spread of HIV," Cooney says. "I hope both sides keep an open mind and see what's been done in other communities. There's strong opposition. There's got to be some give and take."

Even longtime opponent Nadeau acknowledges that the issue might be worth another look.

"We've taken the issue up two or three times in my 10 years on the City Council, and I'm against it," Nadeau says. "I haven't changed my mind on the issue, but people have a right to bring it up if they so chose. It's my feeling that the citizens of Worcester don't want it. Most cities have turned down programs throughout the state."

Since 1993, the Massachusetts Department of Public Health has been allowed to start up as many as 10 state-funded needle-exchange programs, as long as they had local government support. While there is a ban on using federal money for such programs, in Massachusetts $200,000 in state funding is available to supplement HIV prevention outreach programs. According to the Center for AIDS Prevention Studies, the median annual cost for running a program is $169,000, whereas the lifetime cost of treating an HIV-infected person is estimated at $119,000.

"Everyone has a different definition of local approval," says Andy Epstein, director of health services at the state DPH's HIV/AIDS Bureau. "In New Bedford, for example, we had all of the City Council for it, but the mayor vetoed it; in Springfield we had lots of support from the mayor, but not enough from the City Councilors."

Epstein says she is well aware of attempts by AIDS Project Worcester and other groups to establish a program in Worcester.

Likewise, Breault's attempts statewide are well known. Breault so vehemently opposes needle exchange that he took it upon himself to pay a visit to Southbridge when a program was being considered there in 1996. "It went nowhere there," he says of needle exchange, adding he spoke against similar proposals in Fitchburg and Leominster which also failed.

Breault's latest battle is with the state DPH itself.

"The opposition keeps hounding our commissioner to cease and desist," Epstein says, referring to Breault. "He's very vocal. He's called me and ended up slamming the phone down on me. He doesn't understand the nature of the program."

In a recent letter to state DPH Commissioner Dr. Howard Koh, Breault expressed his outrage at what he calls the department's "encouragement of the misuse of the programs" by allowing residents from communities that have voted down needle-exchange programs -- specifically, Lawrence -- to access clean needles from Boston and Cambridge, communities that offer the programs. Northampton and Provincetown also have needle-exchange programs.

"As you well know, the idea behind these pilot programs is to test the concept of needle exchange, but only in communities which specifically adopt a local-option ordinance," the letter says. "We demand that you immediately withhold further funding until these matters are thoroughly investigated and you are assured that these pilot programs serve only the communities which have accepted them."

Breault says he also objects to the fact that state tax dollars are being used to fund the very programs that Worcester and other communities rejected.

"We're going to make it clear to them we'll have something to say about these sites," Breault says. "It's an outrage to say what you can't get here you can get there. To ask communities to take on these types of programs with the damage that's been done, I don't think we should be in the business of enabling drug users. I don't see needle exchange helping the community."

Although needle exchange has plenty of opposition in Worcester, some call Breault a one-man show. "He packs more wallop than his constituency would dictate," one needle-exchange proponent says who declines to be named. "He presents well on TV and has learned to talk to the editorial board at the T&G. He's gotten himself to be a real staple in the community."

Breault shakes off claims against him, saying, "I'm staunchly against needle exchange. If the DPH were as aggressive in doing advocacy and outreach as they are in trying to get needle exchange where people don't want it, I'd be in favor of that."

Breault says he and Jim Voltz, former executive director of AIDS Project Worcester, "went nose to nose for many years" over needle exchange.

"But there are groups all over the city we network with on a quiet basis on drug movements within the city," Breault says. "Drugs and drug distribution is not a just a Main South problem, not just a Billy Breault problem. We have good relationships with groups in the city. The vast majority of folks we know are opposed to needle exchange -- overwhelmingly. You find out when you have a problem with distribution in different areas. Make no mistake," Breault says, "use and addition are intertwined with trafficking. The next step to that is what it means at a neighborhood level. The carrot is the dollar signs, and it's the hell with the neighborhood. We'll fight the fight from our own neighborhood and network out."

Since the early 1980s, public-health officials have recognized the relationship between injecting drugs and HIV. But as for recent reports that link needle exchange with a decrease in the spread of HIV, Breault doesn't put much stock in the "self-reporting" that needle-exchange programs have done, he says. "It's studies versus scientific proof," Breault says. "It's all smoke and mirrors."

ACCORDING TO THE CENTER FOR AIDS Prevention Studies, needle exchange "almost certainly" reduces the spread of HIV by eliminating the item that helps transmit infection from one person to another. In New Haven, Connecticut, a study tested needles returned to the needle-exchange program and developed a mathematical model that estimated a possible 33 percent reduction in the rate of new HIV infections among needle-exchange clients.

In 1995, the Centers for Disease Control gave President Clinton a recommendation to begin needle-exchange programs across the nation. Earlier the same year the National Academy of Sciences reported to Congress that providing clean needles to IV drug users does prevent the spread of HIV and AIDS.

One third of all AIDS cases are linked to intravenous drug use, according to the Center for AIDS Prevention Studies. In women, 64 percent of all AIDS cases are due to injection drugs or sex with partners who inject drugs; and injection drug use is the source of infection for more than half of all children born with HIV.

According to AIDS Project Worcester, 67 percent of city residents living with HIV/AIDS report intravenous drug use as the mode of infection.

"The number goes up to 70 to 73 percent once a trust is built between the clients and our staff," Carnahan says. Fifty-six percent of the agency's 231 new clients this past year are women, Carnahan says, who have either HIV infection related to IV drug use themselves or by their partner.

"That's extremely troubling for all of us because we know that if there is access to clean needles we can cut the rate of infection," McKee says. "This is not a drug issue, it's a public-health issue."

LOCAL PROPONENTS MAINTAIN that recognizing needle exchange as a public-health and safety issue is a starting point from which a successful campaign could be waged. And providing examples of other successful needle-exchange programs may go a long way in proving their point, supporters maintain.

"One thing that made the program easy to implement in Boston was that political and law enforcement officials recognized it as a health care issue, not a law enforcement issue," says Boston Police Sgt. Detective James Devlin, a liaison to the Boston needle-exchange program. "By distributing clean needles, that doesn't mean we condone drug use. We have a very active drug unit, and we're doing all we can to reduce illegal trafficking and use. But as for needles, we see the larger health care issue."

The Addicts Health Opportunity and Exchange Program (AHOPE) began in Boston on March 7, 1994. According to an extensive study completed by the state DPH at the end of the first year, AHOPE enrolled 1315 clients, exchanging 37,575 needles, and linking 16 percent of clients to drug treatment. The average age and injecting history of clients were consistent with national averages, with the average age of clients at 38 with an average drug-use history of 17 years.

"You're not going to entice people to start using drugs because you're offering new needles," Devlin says. "What you're doing is offering the opportunity for people who can't or don't want to stop using drugs to not spread HIV. The real benefit is that you're able to do outreach to people you would not normally have access to. You get a chance to make a pitch to them to stop using drugs or to at least get treatment."

Devlin says that while 16 percent of Boston's clients were referred to treatment, opponents might see this as an 84 percent failure rate. "You just have to understand that not everyone is ready for treatment at the same time," Devlin says.

Many of the major concerns -- from the possibility of increased crime and drug use, to the attraction of addicts from other communities into Boston, and the potential of needle stick injuries to public workers -- did not happen.

According to the state DPH, the program appears to have contributed "significantly" to the reduction of HIV risk among injecting drug users with little negative impact to the community.

Eighty-seven percent of AHOPE's clients reported living in Boston or Cambridge. "I'm of the opinion that people aren't going to drive to access clean needles," Devlin says. "They're going to buy them from the underground black market first. They're not going to go across town." The problem, Devlin says, is that drug dealers often repackage used needles to make them appear new.

As for discarded needles lying around, Devlin says, that since the old needles now have value, they're less likely to be found on the street, especially since the program operates on a one-for-one exchange.

"I can't find any validity to any arguments against needle exchange, except that people just don't want one," Devlin says. "When they make their arguments they play on fears of the stereotypical drug user. They don't talk about the innocent victims of HIV -- the children and the spouses."

Haller acknowledges that Worcester has a "very serious" drug addition problem. But for her to consider such a program in the future, she says, "the proponents of needle exchange would have to put neighborhood concerns on the table on par with needle exchange itself.

"Neighborhood impact is my concern, as opposed to HIV statistics," Haller says. "Some say the drug users are in our neighborhood already so why not save lives? We already have that problem with the PIP [the Public Inebriate Program, the controversial agency that operates an emergency homeless shelter on Main Street] and this would only add to our problem."

The safety of the neighborhoods is a valid concern, says Leo Negron Cruz, coordinator for the Multicultural AIDS Project at Great Brook Valley Health Center.

"I think, in Worcester, you have to look at the best way of doing needle exchange in Worcester. Main South is concerned about one more social service agency, so you need to look at the best way of doing it," he says. "Let's sit with them and look at the fears and the reality at what has happened in other areas. You have to put a program where the drug activity is happening, but it has to be done Worcester-style, and that style has to be determined. We've never said how. First we have to decide that we need it and how to reach the population we need to reach."

The first step, according to McKee, would be for needle exchange to be accepted on its own merits. "Then we can look at how we can do this," he says. "To deny the sanity of doing it based on problems with where it would be located is wrong.

"Last time, there were attempts to make it a moral issue," McKee says. "Last time, there were groups that weren't even Worcester residents or residents of the Commonwealth of Massachusetts that got involved and had their own political agendas. The politics needs to be taken out of it. The language needs to be more civil.

"This time, if those who support needle exchange can address the fears and concerns of the people not in support of this, things may be different," McKee says. "This time, if we can talk about apples and apples instead of apples and oranges -- instead of opponents using as an argument the declining rate of AIDS cases while the rate of people diagnosed with HIV infection has not declined -- things might be different. When you bring this type of information to the public, and put the faces of people in our community on it, people might listen."