A. Introduction
C. Findings and Recommendations
D. Discussion
We strive to remain sensitive to community healthcare needs, to initiate model programs, to form project-related partnerships with other organizations and to increase community awareness of critical healthcare issues.
Through these endeavors, we will contribute to a healthier future for the communities we serve.
Moshe Engelberg, Ph.D., M.P.H., Principal, Research Works
Phyllis Jackson, Case Manager, Crash, Inc.
Susanna Knott, Ph.D., M.F.C.C., Resource for Change
Linda S. Lloyd, Dr. P.H., Senior Consultant, Alliance Healthcare Foundation
Judy Moutsatson, Program Officer, Alliance Healthcare Foundation
James Orlos, Program Director, Project PARA, Episcopal Community Services
Daniel J. O'Shea, Consultant, Alliance Healthcare Foundation
Ruth Lyn Riedel, Ph.D., Chief Executive Officer, Alliance Healthcare Foundation
Howard Rogers, B.S.W, Program Specialist, Stepping Stone
Rick Siordian, Project Manager, San Diego Council of Community Clinics
Michael Stepler, San Diego Clean Needle Exchange
Andrea Taylor, Health Education Coordinator, Project TRUTH, San Diego Urban League
Jeffery Tom, Staff-San Diego City Council Member Christine Kehoe
We would like to thank the outreach workers who made it possible to carry out the one-on-one interviews with injecting drug users (IDUs). The information obtained from these interviews has enabled us to include the perspectives of IDUs on injection drug use as well as quantitative data in the needs assessment. Many thanks go to: Chester Abbott, Alfredo Alvarado, Brad Ballard, Wendy Sue Biegeleisen, Esther Figueroa, McCoy Fuller, Martha López, Brian Moore, Nancy Norcross, Dan O'Shea, Teresa Oyos, Ray Paquette, Francisco Rodríguez, Howard Rogers, Suzette Silva, Michael Stepler, Juan J. Sun, Susan Tapert, José Urrea, Bobby Vaughn, and Regina Vaughn.
We acknowledge the individuals and agencies who responded to the request for information on the agency surveys distributed to the community in June of 1994. These individuals and agencies are listed in Appendix 6.
Thanks are also extended to Maria Hewett, Edna Wesley and the staff of the Medical Records of the San Diego County Sheriff's Department for many hours spent pulling records to abstract data for this assessment.
Special recognition goes to Norman Brown, Steve Eldred, Michael Ann Haight, Rick Landavaso, Eric Phoombour, John Rasmussen and Alfredo Velasco for substantial efforts and contributions to this document. We would like to recognize Dean Chiasson for his contributions to the section on the biology, mechanics and physiology of injection drug use. Special thanks go to Sholita Packer for her assistance in the preparation of the document.
Finally, we wish to thank all of the other individuals who provided support to the research and collection of information presented in this report.
The term "injecting drug user" (IDU) is used in this document in place of intravenous drug user (IVDU) to include all individuals who inject substances, both legal and illegal, intravenously, intramuscularly, or subcutaneously. Practices such as tatooing and body piercing are included as injection behaviors. This definition is used since injection of any substance or skin punctures where equipment is shared carries the risk of HIV transmission. The terms "needle" and "syringe" are used interchangeably, as is common in the published literature reviewed for this report; in addition, syringes may have non-removable needles.
Public agencies, legislators, community leaders, foundations, and other funding sources no longer have the luxury of debating the relative merits of needle exchange - a less than perfect but effective intervention - while deaths from AIDS increase. Learning about successful programs abroad, the Institute of Medicine (IOM) issued a report in 1986 recommending the development of appropriate . . . "public policies to encourage the use of sterile needles and syringes by removing legal and administrative barriers to their possession and use" (Institute of Medicine, 1986). Since the IOM (1986) report there have been numerous attempts in the U.S. to reduce the HIV risks to IDUs through needle exchange, usually accompanied by active outreach, education about the risks of using non-sterile injection equipment and unsafe sexual behaviors, and referral to medically and culturally appropriate drug treatment. Among these attempts there have been notable successes in communities such as New Haven (CT), Tacoma (WA), New York City (NY), Portland (OR) and San Francisco (CA), leading to the increased use of this controversial but beneficial intervention. Ten years of evaluation research in diverse geographic areas shows that the beneficial effects of needle exchange outweigh the negative effects. Needle exchange does not increase the number of injecting drug users. It does not increase the frequency of injection. It does not increase the number of discarded syringes in public areas. Utilization of drug treatment programs does not decrease in the presence of needle exchange. If referral to treatment services is a goal of the needle exchange program, more IDUs are likely to use these services given availability, not fewer.
Californian's account for 19% of all United States AIDS cases, with a 50% higher incidence (56.4 per 100,000) than the national rate of 37.5 per 100,000 (CDC, 1993h). One in every 200 Californians is HIV infected. The estimated prevalence rate for San Francisco County is highest; 3,870 per 100,000 or one in every 26 residents is infected. San Diego has the second highest prevalence rate of 630 per 100,000 population; one in every 159 residents is infected (California Department of Health Services [CA DHS], 1994d). In California, between April 1992 and March 1994, there was an explosive increase of new AIDS cases among IDUs. New cases among heterosexuals, who represent 92% of the IDU population, increased by 62%. New cases among homosexual or bisexual males, who represent 8% of the IDU population, increased by 131%. Overall, the number of new AIDS cases with IDU risk exposure during this period increased by 90%. Populations affected most by this recent upswing are heterosexual adolescent and adult African Americans and Latinos (CA DHS, 1994a). Current data from San Diego County's Department of Health Services show that IDUs account for approximately 20% of all new AIDS cases. In the last two and one-half years, there has been a 141% increase in AIDS among San Diego's IDUs (SD DHS, 1992, 1993, 1994). Forty-three percent of AIDS cases in female heterosexuals and 32% of AIDS cases in male heterosexuals contracted the disease from an IDU sexual partner (San Diego County Grand Jury Report, 1994 - see Appendix 4). Over one-half of San Diego's pediatric AIDS cases are linked to injection drug use.
HIV is transmitted by injection drug use in a simple mechanical process. The virus in the blood of an HIV-infected drug user is transferred to a non-infected drug user through needles and or syringes. The transfer of HIV-infected blood occurs almost exclusively through "multi-person use", or sharing, of injection equipment. Two drug injection techniques introduce blood into the needle and the syringe. Initially, the user may draw blood into the syringe to verify that the needle is inside a vein prior to injection. Following injection, the user may refill the syringe with blood from the vein, "washing out" any remnants of the costly drug. Only a tiny remnant of HIV-infected blood is required to transmit the virus to the next user (CDC, 1993d). Data from the New Haven, Connecticut research shows that the probability of contracting HIV through shared drug injection equipment is three times higher than the probability of transmission per vaginal sex act, i.e., from an infected man to an uninfected woman (Kaplan and Heimer, 1992a, 1992b).
Injection Drug Use in San Diego
The California Department of Health Services reported 14,697 drug treatment admissions in San Diego County for Fiscal Year (FY) 1993 (CA DHS, 1994b). Half (7,331) were related to injection drug use. San Diego County Alcohol and Drug Services reported that 6,432 individuals were admitted to publicly funded treatment programs in the same period (Haight, 1993b). This does not include methadone treatment services or other treatment from private agencies not funded by the County.
San Diego has unique patterns of injection drug use. In 1990, San Diego received federal designation as a "high intensity drug-trafficking area" (San Diego Department of Health Services/Office of AIDS Coordination [SD DHS/OAC], 1994c). Most recent Department of Justice data place San Diego as third in the nation for heroin use, first in polydrug use and first in methamphetamine ("meth") production and use; unlike other communities where insufflation ("snorting" or "tooting") or smoking is preferred, 20% of San Diego's "meth" users prefer to inject.
Methamphetamine is the predominant stimulant used in San Diego. In FY 1993, 41% of all treatment admissions unrelated to alcohol involved methamphetamine - a 10% increase over the previous year. Twenty percent of these users reported smoking as the usual route of administration, and 20.5% reported injecting (Haight, 1993b). Among arrestees tested for drug use in San Diego, Caucasian men and women were most likely to use amphetamines; cocaine took second place. African American male and female arrestees used cocaine in preference to methamphetamines. African American female arrestees were more likely to test positive for heroin than any other population group (San Diego Association of Governments [SANDAG], 1994).
In FY 1993, 22% of publicly-funded treatment admissions were attributable to cocaine ingestion. The usual route of cocaine administration is smoking (86%), with only 20.5% injecting the drug. Injection continues to be the preferred route of administration for 96% of the FY 1993 heroin admissions (Haight, 1993b). Injection of the drug allows a smaller amount to achieve the maximum effect. While smoking heroin occurs in other U.S. urban areas where there is greater availability, this is not the case in San Diego.
According to a Robert Wood Johnson Foundation study (1993), between 85% and 90% of IDUs are not in treatment, and it appears that another 20% may be ready to commit to treatment but cannot access services (AIDS Alert, 1994e). In County-funded drug treatment programs IDUs are given priority among people seeking treatment, but treatment facilities are few, and lack culturally appropriate services. Current estimates of IDUs in San Diego County range from 7,100 to 23,000 (Green, 1993).
The social organization of IDU subculture is driven by economic deprivation and the common bond of being outcast by society. These factors create the need to share resources, including the purchase and sharing of drugs and injection equipment, as well as food, shelter, recreation and the other necessities of life. Although there is often competition among IDUs for drugs, for money, and even for injection equipment, patterns of mutual support are also common. Many believe that the illegal status of drugs and injection equipment contributes to this competition and its associated violence (Des Jarlais et al., 1988). The common bond of being outcast and economically deprived explains much of the violence against the community, society, and each other. When access to food, shelter, recreation, and the other necessities of life are denied a disenfranchised population, the result is an extremely unstable and volatile social system. Users live with the constant challenges of arrest, unstable housing, and little secure income. AIDS is not the greatest threat.
San Diego's AIDS Increase is Highest in State
Most areas in California reported an increase in AIDS cases of 5 to 6 percent in 1992. San Diego is the exception. According to the State Department of Health Services, San Diego's increase is over 18% in 1992 (SD DHS/OAC, 1994c). This high growth rate suggests that standard protocols used to estimate the prevalence of HIV infection will not work for San Diego County. Factors pointing to a higher estimate include the migration of people with HIV/AIDS to San Diego from other communities, the under-reporting of HIV in San Diego's large Latino and Asian/Pacific Islander communities by as much as 20%, and a group of 2,000 Navy and Marine personnel with HIV who temporarily reside in San Diego. In addition, San Diego is a transportation, commercial, recreation and convention center.
Communities of color are over represented among the HIV-infected, with a disproportionate impact of HIV on African American IDUs. In mid-1993, 48% of all reported AIDS cases were among African Americans and Latinos, while these populations represent only 21% of the total U.S. population (CDC, 1993). This is exacerbated by deficiencies in San Diego's healthcare delivery system, which lack culturally appropriate treatment and support programs.
The Increasing Incidence of Hepatitis B Virus in San Diego
The incidence of hepatitis B virus (HBV) nationally among IDUs has increased 30% since the mid-1980's. Zero-prevalence studies across all drug using populations show that up to 90% of long-term injecting drug users have been exposed to HBV (Isselbacher et al., 1994). Nearly 5% of those who become infected will die of fulminant hepatitis B or cancer of the liver (Hoeprich and Jordan, 1989). Ten percent will experience episodes requiring lengthy and expensive hospitalizations, and another 5% to 10% will be chronic carriers of the disease. As in HIV, the use of alcohol and toxic drugs stimulates the development of clinical abnormalities. An HIV-infected IDU is more susceptible to hepatitis B, which is present in over 95% of all HIV-infected individuals (Isselbacher et al., 1994).
The Alliance Healthcare Foundation promotes access to health services for the medically indigent and underserved, primarily in San Diego County. Approaching substance abuse as a public health problem is one of the Foundation's highest priorities. Recent research sponsored by the Centers for Disease Control and Prevention (CDC) indicate that one-third of all AIDS cases in the United States are related to injection drug use (Lurie et al., 1993b). The same study demonstrated the impact of HIV on communities of color with eight out of ten HIV-positive injecting drug users being African American or Latino. Recent evaluation studies of needle exchange programs demonstrated their usefulness as a protective factor for the IDU population. Increases in the rates of intravenous drug use, injecting patterns, or number of discarded needles/syringes were not seen in communities with active needle exchange programs (Lurie et al., 1993b; Watters et al., 1991).
In early 1994, after the arrest of a volunteer with the San Diego underground needle exchange program (NEP) and the subsequent outcry on both sides of the issue, the Alliance Healthcare Foundation convened the Injection Drug Use Study Group (April 1994), to examine the issues surrounding intravenous drug use in San Diego County, associated blood-borne diseases, and the possible need for needle exchange. In examining these issues, the Foundation considered a "harm reduction" approach, designed to assist users in reducing the harm to themselves, their families, and their communities. The Foundation continues to view needle exchange as only one component of harm reduction. Other essential components include drug treatment, referral, career and life-skills building, housing, and other resources that meet the basic personal and economic needs of disenfranchised injecting drug users.
Harm Reduction is a "set of strategies and tactics encouraging users to reduce the harm done through the use of legal and illegal substances" (National Harm Reduction Working Group, Report from October 21-23, 1993 Meeting). Stemming from the tradition of community-based, public health outreach, harm reduction presents an alternative to the more traditional, medical or criminal justice approaches to drug use. Rather than stressing an "all or nothing" approach to intervention, it equips the individual with "the knowledge, tools and motivation necessary to protect himself/herself against HIV" and other harms resulting from drug use (Harlow and Sorge, 1993). Needle exchange is only one component of harm reduction. The objective is to educate the user to decrease drug related risks in practical ways that will work for each individual. Abstinence is one choice - but there are others. Harm reduction includes the use of safer injection techniques, refraining from needle-sharing, obtaining control over one's own drug use, and seeking primary medical care on a regular basis. This approach is more flexible, encouraging the use of different strategies and approaches for different users. It acknowledges that many IDUs will not seek drug treatment, and that not all clients in treatment will achieve abstinence. As such, it has provoked a harsh response from Americans who embrace the popular "zero-tolerance" and "Just Say No" methods, which have resoundingly failed to eradicate drug use in this country.
Epidemiological Assessment of Injection Drug Use
The first decision of the Alliance Healthcare Foundation's Injection Drug Use (IDU) Study Group was to conduct an epidemiological assessment of the needs of injecting drug users in San Diego County. Study group members were selected because of their experience in working with the target populations. The assessment included an "agency survey" for organizations and agencies providing services specifically for IDUs or services that were needed by IDUs. The agency survey included 273 organizations. In the second phase of the study, semi-structured open interviews were conducted with current injecting drug users who were either in or outside of treatment. It also included IDUs using San Diego's underground needle exchange program. These interviews provided detailed information on injection equipment sharing, experiences with treatment programs, attitude toward or use of a needle exchange program and condom use. Consumer evaluation data was gathered from IDUs in treatment on the programs they were in.
The overall response rate for the agency survey was an incomparable 71%. There were few refusals for the semi-structured open interviews since community health outreach workers, who either knew the respondent or were familiar "faces" in the area where the interviews took place, conducted the interviews. Additional information was obtained by abstracting the medical records of 300 IDUs and 100 separate HIV-positive cases in San Diego County's detention facilities (FY 1994). Archival data from these records supported the well-documented connection between illicit drug use and incarceration.
The objectives of the needs assessment for San Diego's IDUs were the following:
Study staff included Linda S. Lloyd, Dr. P.H., epidemiologist and international public health consultant, and Daniel J. O'Shea, Chairperson of the San Diego HIV Care Coalition and former Executive Director of Being Alive-San Diego. Selected agencies and professional groups, such as the Association of Community Health Outreach Workers (ACHOW), were instrumental in gaining access to individuals and agencies in the study sample.
The San Diego County Grand Jury Report, June 1994
On June 28, 1994, the San Diego County Grand Jury released a report on Infectious Disease Control (HBV and HIV). Encouraged by research on needle exchange programs in other areas of the country, they formulated several conclusions and recommendations. Realizing that illegal but tolerated needle exchange programs can be instituted in California pursuant to Mayoral declarations of a state of emergency, they recommended needle exchange for San Diego County "in the same scope and manner as in San Francisco, Alameda, and Marin Counties". The Grand Jury concluded that an expanded San Diego needle exchange program would save lives of San Diego residents, as well as substantial tax dollars. They called for a countywide conference on needle exchange programs to provide participants with education on needle exchange and an improved understanding of infectious disease control.
The San Diego County Grand Jury recommended that the Board of Supervisors direct San Diego County's Director of the Department of Health Services, in cooperation with the 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 out of the Department of Health Services", including provisions for treatment programs for IDUs.
Because the Grand Jury report did not result in a call to action, the Alliance Healthcare Foundation organized such a conference for October 24 and 25, 1994.
Other Precipitating Events
On August 24, 1994, Mayor Richard Riordan of Los Angeles declared the AIDS epidemic a state of emergency. Supporting his declaration were public health experts, a member of the Hollywood Homeowner's Association and a prominent Hollywood attorney. At the direction of City Council, Mayor Riordan directed the City Attorney and Police Department to avoid needless investigation of needle exchanges. He encouraged that the programs be conducted in "stable secure locations and developed in consultation with residents of the community, business owners, and other social services agencies".
Also in August 1994, the Department of Alcohol and Drug Programs, State of California, released research conducted on the effectiveness of recovery services. The nationally known and highly reputable firms responsible for this evaluation were the National Opinion Research Center (University of Chicago) and Lewin-VHI, Inc. a health policy research firm located near Washington, D.C. The study, commonly referred to as CALDATA (see Appendix 5), investigated the effects of treatment on addictive behaviors, the cost of treatment, and the economic value of treatment to society at large. Major findings overwhelmingly supported the benefits of treatment, regardless of treatment method. The cost of treating 150,000 participants in the sample was $209 million dollars, while the benefits were valued at approximately $1.5 billion in savings to taxpayers. Much of the cost effectiveness of treatment programs was attributed to the diminished level of criminal activity, which declined by two-thirds from the beginning to the end of treatment for participants in the sample. Investigators observed an over 30% reduction in hospital utilization resulting from drug treatment. In addition, participation in treatment increased opportunities for Medi-Cal enrollment and disability payments, leading to overall improvements in health status and reimbursement for care.
Chapter 3 describes the research methods used in "Injection Drug Use in San Diego County: A Needs Assessment".
Chapter 4 includes the results of the agency survey, semi-structured open interviews and abstracts of archival records (i.e., medical records from San Diego County jails). The final section of Chapter 4 is an analysis of the public sector costs of HIV infection among IDUs, their sexual partners, and their children in San Diego County. Estimates are generated with legal (or illegal, but tolerated) needle exchange, with the existing limited underground needle exchange and without a needle exchange program. Investigators conclude that effective, countywide needle exchange could save San Diego County at least $123.5 million dollars in healthcare expenditures over the next 10 years. Even the existing underground NEP could save the County $20 million dollars in the same time period.
Chapter 5 is a discussion and summary of the contents of previous chapters. It addresses the implications of area findings for public health, crime and safety, and the economic costs of illness. Chapter 5 addresses culturally appropriate treatment programs for all sub-populations, which are more compelling and effective alternatives to services that currently exist in San Diego.
A total of 193 organizations in San Diego County responded to the agency survey questionnaire, resulting in a response rate of 71%. Four physicians in private practice also responded, giving a total of 197 responses. Of these, 53% (104) indicated that they did not provide services to injecting drug users (IDUs), did not know if IDUs accessed their services or did not record the type of information requested. The geographic distribution of the organizations providing services to the injection drug using (IDU) populations did not adequately match the geographic distribution of the IDU population, as reported anecdotally. While most agencies reported clients of all ethnicities, genders and ages, Caucasians and Latinos were the two largest ethnic groups described. Most clients were either unemployed or of very low socio-economic status. Over one quarter of the agencies reported HIV/AIDS as a significant risk to their clients.
Fifty organizations provided specific services to the IDU population. Of the approximately 3,754 IDUs seen in any given month, only 75% were in treatment or support programs. Twelve agencies provided street outreach to approximately 420 IDUs in any given month, less than 3% of the estimated 15,000 IDUs in the County. Polydrug use was frequent, with heroin, methamphetamines and cocaine the three most common drugs. Some anecdotal information was provided on vitamin, steroid, and hormone injections. Most of the agencies responding to the survey questions stated that current services were not adequate to meet the needs of the IDU population. Services most urgently needed are culturally appropriate treatment programs, housing and shelter, detoxification, and healthcare services - especially mental health.
Semi-structured open interviews were conducted with five groups of injecting drug users: IDUs currently in treatment programs, IDUs not in treatment programs, gay male IDUs in a treatment program specifically targeting the substance abusing gay and lesbian populations, IDUs accessing the San Diego underground needle exchange program (NEP), and transgender IDUs not in treatment programs. Sharing of injection equipment was frequently reported by all interview respondents. However, IDUs accessing the San Diego underground NEP reported sharing less frequently, and tended to restrict their sharing to more intimate sexual or social partners. Latinos not in treatment, interviewed in South Bay, reported cleaning their injection equipment more frequently than other respondents; however the majority indicated that they would share without cleaning when necessary. Most sharing appeared to be driven by economic (i.e., lack of resources to acquire needles and syringes) and legal (i.e., prescription laws that make it illegal to carry a needle and syringe without a physician prescription) circumstances. Particularly disturbing were the reports of sharing injection equipment with individuals who were known to be HIV-positive.
All but two IDUs interviewed stated that they would use a needle exchange program. One was unsure whether he would use it because he did not trust organized programs and the second individual did not indicate the reason. Overall, respondents were concerned about their own health and identified a needle exchange program as a necessity to maintain health status. Most of the respondents were unaware of the existing NEP because of its limited scope of operation. All respondents currently accessing the needle exchange program liked the program; most liked it because of its dependability and safety. The San Diego NEP operates illegally due to California prescription laws. After the arrest of a volunteer in February 1994, the strategy changed to in-home exchanges, largely by appointment. In-home service reduces the risk of harassment and arrest by uninformed law enforcement, but education and counseling services are also reduced. Many IDUs feel the NEP should operate more frequently and be available at multiple sites throughout the County.
While knowledge of safer injecting behaviors was evident among most IDUs interviewed, both the knowledge and the actual practice of safer sexual behaviors was universally low. Many respondents stated that they were in monogamous relationships, although some of these reported relationships were anywhere from less than one year to five years. Others reported using physical appearance of or familiarity with the individual to determine whether or not to use a condom. Only one individual of the 117 IDUs interviewed stated that he used condoms for oral sex. For many of the respondents, oral sex was considered to be "safe", and, for this reason, it appears to be replacing insertive anal or vaginal sex among some groups. CDC guidelines, however, classify oral sex as high-risk and recommend condom use.
Although most respondents not currently in a treatment program had been in treatment at least once, they reported little incentive to remain in the program. Programs often did not address their specific needs, such as culture, language, gender, sexual orientation and financial. In addition, the lack of affordable and available treatment options was cited as a critical problem. Among those in recovery, the rate of relapse was very high, with similar reasons cited.
The review of the medical records from San Diego County jails supported data that links injection drug use to incarceration and patterns and geographic distribution of drug use in San Diego. Significant numbers indicated medical problems associated with injection drug use, including HIV/AIDS. The cost of treating IDUs in the jail system places a significant financial burden on the County of San Diego; these are primarily uncompensated care costs which healthcare providers must absorb.
The economic costs and public health impact of high-risk injection behaviors among IDUs were estimated for the HIV/AIDS epidemic with and without a needle exchange program. Calculations were based on limited data to illustrate potential effects and savings. It was concluded that effective needle exchange has the potential to save San Diego County at least $123.5 million in direct healthcare expenditures for IDUs, their sexual partners, and their children over the next ten years. The existing illegal underground NEP is projected to save the County almost $20 million over the same time period. If there is no NEP in place, the projected costs to the County of San Diego could be as high as $137.2 million over the next ten years. With minimal operating costs relative to the projected savings, NEPs can be extremely cost-effective.
After reviewing the results of this epidemiological study of injection drug use in San Diego County, the IDU Study Group developed a series of recommendations on public health issues, crime and safety and the economic costs of injection drug use. These recommendations are on the following page.
In response to expressed concerns regarding (1) public health, (2) crime and safety and (3) economic costs, this study examined the impact of injection drug use on the community as well as affected individuals in San Diego County. The following recommendations are made with consideration for creating maximum benefits in each of these three areas. The pages following address expected specific benefits in each area.
Expected Benefits of Recommendations
Expected Public Health Benefits
Expected Crime and Safety Benefits
Expected Economic Benefits
The literature review and research conducted for this study indicate several trends regarding injecting drug users (IDUs), their culture, behaviors, needs (such as economic assistance), treatment and treatment options, including harm reduction, and the attitudes and perceptions of our society toward these issues. The dynamics of the biology and mechanics involved when substances are injected into the body are rarely known or discussed in our society. However, this information provides an important key to understanding why individuals inject and how it is possible for harm reduction activities, including needle exchange and treatment, to move an individual toward breaking a biological cycle within the body. Public education is needed to provide accurate information both on injection drug use and on treatment; this will enable society to better understand the complex issues surrounding addiction and to support the development of culturally appropriate harm reduction and treatment programs. There is a need for public awareness that any form of using (or sharing) injection equipment outside of healthcare facilities is risky, including injecting steroids, hormones, vitamins and antibiotics, and body piercing and tattooing. Because of their sharing behaviors, IDUs are at high risk of acquiring deadly blood-borne diseases, such as HIV and hepatitis, and of spreading them to the community through contact with injection sharing partners, sexual partners and perinatally to their children. Injecting drug users must be educated about the risk not only of sharing injection equipment, but also of unsafe sexual behaviors.
Societal attitudes have dictated community responses not only to IDUs, but also to efforts to treat the addictions related to injection drug use. With the spread of the deadly HIV/AIDS epidemic worldwide over the past decade, and the impact of injection sharing behaviors emerging as the second highest risk factor for HIV transmission, these attitudes are being re-evaluated. However, special challenges and circumstances exist within disenfranchised communities, including communities of color. These communities have been disproportionately impacted by the HIV/AIDS epidemic partially due to limited economic resources and opportunities, and a lack of education, support and health services. In the pockets of poverty that exist within these communities, the economic and legal circumstances dictate a need for continued sharing of injection equipment. Additionally, within the African American community, an historic mistrust of public health dates back to the Tuskegee "experiment". For many African Americans, the twin epidemics of drug addiction and HIV/AIDS plaguing their communities are considered a "conspiracy" by society at large to control African Americans and other disenfranchised groups. Because of the multitude of issues facing this community, AIDS in not the highest priority. Harm reduction efforts to address health issues, such as drug treatment and needle exchange, that originate from outside the African American community, are viewed with suspicion.
Treatment offers the opportunity for IDUs to begin the recovery process. Results from the agency surveys and individual interviews, however, indicate that the treatment options currently available in San Diego County are not adequate to meet the needs of the IDU population. These "needs" encompass not only immediate placement in a program - when the IDU is ready to enter treatment - but also placement in programs that can adequately treat the drug(s) of addiction and address the cultural diversity (ethnicity, language, sexual orientation, gender, health status, age) and individual qualities/characteristics of the IDU. Treatment needs to be considered as part of a broader series of harm reduction strategies, addressing IDUs on a continuum from actively injecting drugs to abstinence from drugs. Harm reduction strategies address not only IDUs outside of treatment, but also act to protect and support IDUs throughout their recovery process. For the latter, harm reduction encompasses job training and placement, education, life skills training, case management and other long-term support services. For the former, harm reduction strategies reach out to the estimated 90% of IDUs outside of treatment to ensure that they have the knowledge and opportunities to maintain their own health and welfare through access to health and social services. These strategies, including non-judgmental street-based outreach and case management, also provide a link and support for IDUs to move along the continuum toward detoxification and/or treatment, when they are ready. Needle exchange, as a harm reduction strategy, has proven effective in allowing IDUs to maintain or improve their health status, while preventing transmission of blood-borne diseases to the larger society, and offering IDUs support as a bridge to treatment. The ultimate value to society for supporting IDUs with a comprehensive continuum of harm reduction is reflected in the multiple benefits of improved and enhanced public health and safety, reduced crime, and dramatic economic savings.
Injection Drug Users: Perceptions and Reality
Society has generally characterized injecting drug users as "immoral dope fiends" who are irresponsible, diseased, unable to control their lives, and whose primary concerns are based on their drug using needs (Hassin, 1994). Society views their immorality as contagious and believes that addicts spend their time encouraging the young and innocent to become "dope fiends" (Jeanette Hassin, Social Identity, Gender, and the Moral Self: The Intravenous Drug User and the Impact of AIDS, Doctoral dissertation, University of Arizona, 1993). Injecting drug users are even more disenfranchised from mainstream society than other substance abusers. Society has accepted, or is at least more supportive of treating, the abuse of substances that are ingested either orally (such as alcohol, prescription medications ["pill-poppers"], tobacco chewing) or through inhalation (tobacco, marijuana, cocaine). This may be due to the fact that the route of ingestion - eating, drinking or smoking - is a "normal" activity while the injection of a substance is considered to be an "abnormal" activity beyond the imagination of most people. The images of the injecting drug user are based primarily on fiction, not fact, and are reinforced through the popular culture and academic literature (J. Hassin, Doctoral dissertation, 1993). According to Hassin, IDUs form their identities on the same core values embodied by mainstream society; this directly affects injecting drug users' perceptions of themselves and their reconciliation of their drug-using behavior with mainstream norms and values.
Research shows that injecting drug users are not "irresponsible" drug addicts who care little about their own health. In fact, IDUs will change injecting behaviors when provided with the opportunity to do so (Feldman and Biernacki, 1988; Des Jarlais et al., 1988; Des Jarlais et al., 1991). IDUs also exhibit patterns of strong and long-term social bonding and mutual support, often sharing not only injection equipment, but also housing, food, money and child care (Grund et al., 1992). This is partly due to social bonds forged through sharing needles, to economic deprivation and to common identification as outcasts from society (Feldman and Biernacki, 1988). Understanding the complex social support networks of IDUs is key to effective and rapid implementation of harm reduction strategies (Des Jarlais et al., 1988).
The "Just Say No" approach to "treating" substance abuse fails to take into account not only these factors, but also the biology and mechanics of injection drug use. Addiction is a physiological and psychological disease, not a psychological phenomenon, and most IDUs cannot stop using drugs just because they decide to "say no to drugs". Appropriate treatment and harm reduction strategies are needed which can begin the challenging process of behavior modification to reverse both the physiological as well as psychological aspects of this disease (substance abuse/injection drug use). Until IDUs are willing or able to begin the treatment process, comprehensive harm reduction will enable IDUs to practice healthier behaviors that benefit not only themselves and their families, but also society at large.
Size and Geographic Spread of the IDU Population in San Diego County
Research has shown that, nationally, only about 10% of IDUs are in treatment at any given time, with another 20% ready to enter but unable to access the system (AIDS Alert, 1994e). There is no reliable estimate of the size of the IDU population in San Diego County; estimates range from 7,153 to 23,381 (Green, 1993), with the average of 15,000 (a mid-point between these estimates) used most frequently. According to information received from agencies providing services to IDUs in San Diego County (see Chapter 4, Section A), approximately 2,800 IDUs are seen in treatment and support programs on a monthly basis. San Diego County Alcohol and Drugs Services in the Department of Health Services reported 5,283 individual injection drug use-related treatment admissions to County-funded programs for a three-year period from 1991 to 1994 (Michael Ann Haight, SD DHS/ADS, personal communication, September 1994); however, this number does not include the methadone clinics. Using the assumption that approximately 10% of IDUs are in treatment at any given time, an estimate of the total IDU population in San Diego County could be as high as 25,000 to 28,000. Factors that support the estimates of higher numbers of IDUs in San Diego are the moderate climate, easy access into the County and its location as a transportation, commercial, recreation and convention center. Data from the Drug Use Forecasting (DUF) program of the Department of Justice indicates that San Diego is consistently one of the top three metropolitan areas in the country for rates of heroin or polydrug use at the time of intake into County jails, as well as the highest in methamphetamine use (National Institute of Justice, 1993). Anecdotal information from the Agency Survey Results (Chapter 4, Section A) indicates that injection drug use is widespread throughout the large geographic area of San Diego County, with large pockets noted in Central San Diego, North County, East County and South Bay, encompassing both urban and rural areas.
Trends of Injection in San Diego County
There are several unique patterns of injection of both illicit drugs and other substances throughout San Diego County. According to the Agency Survey Results (Chapter 4, Section A), the County Jails Medical Records Survey (Chapter 4, Section C) and the Review of the Literature (Chapter 2, Section A), heroin is the most commonly injected drug locally, followed by methamphetamines. The use of cocaine is also very high and polydrug use was frequently reported. San Diego has led the country in identifying methamphetamine production within the County; this was supported by anecdotal data from the interviews. These usage trends are alarming in light of the course of the local HIV/AIDS epidemiology, particularly when coupled with information that there seems to be little in the way of safer injection (non-sharing) behaviors occurring among IDUs outside of treatment and those accessing the San Diego underground NEP. Approximately 20% of recent AIDS cases in San Diego County are related to injection drug use, representing an increase of 141% over the past two and one-half years (SD DHS, 1992-1994). All these factors create an environment ripe for an explosion of HIV similar to that which has occurred on the East Coast.
HIV infection is often associated primarily with the use of illegal drugs and not the sharing of needles and syringes. Substance abuse impairs the judgement of the individual, leading to increased risk of HIV through unsafe sexual and injecting behaviors. However, individuals injecting substances other than illicit drugs are also at risk for HIV or hepatitis B through shared needles and syringes. The injection of vitamins was reported anecdotally by a number of agencies responding to the survey (Chapter 4, Section A). It has been reported that these types of injections occur in several cultures; for example, mothers may inject their children or themselves as preventive strategies for health maintenance or to treat common illnesses. This fairly common cultural practice is not viewed as risky since the substances being injected (such as antibiotics or vitamins) can be prescribed by a physician and most injections take place within the family or home environment. Since injectable vitamins and antibiotics, as well as needles and syringes, can be purchased in pharmacies in Tijuana, Mexico, this population remains outside the medical services of San Diego County. In addition, these injections occur outside of the healthcare system, even when prescribed by a physician. Although this population may be small, this may be their primary risk factor for HIV transmission.
A number of "stories" of HIV transmission through sharing of injection equipment for vitamin injections exist. While none were confirmed by County or State health officials, the anecdotal sources are agency respondents working with the populations most associated with vitamin injection. An example of the impact this mode of transmission of HIV can have on one family is demonstrated in the following anecdote: An agency survey respondent (Chapter 4, Section A) related that she had been informed by an outreach worker, who worked with Latinos in Southern California, of a family in which all of the 6 or 8 children (ranging in age from approximately 18 months to 18 years) had become HIV-positive, although both parents were HIV-negative. The eldest child had apparently acquired HIV through unsafe sexual activity and, after the mother provided vitamin B12 injections to all of her children with the same needle, HIV was transmitted to the rest of the children. Confirmation is difficult given the fact that HIV infection is not a reportable disease (AIDS is) and the possibility that some affected individuals might be undocumented and, therefore, reluctant to use services.
When appropriate, treatment programs can provide substantial benefits not only to individual IDUs, but also to society at large. Data from the recent "Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA)" study (see Appendix 5) demonstrate the effectiveness of treating individuals and its overall value to our community. The study found that substance abusers who had been in treatment for one year or more experienced a two-thirds decline in criminal activity, a two-fifths decline in alcohol and drug use, reduction in hospitalizations, and longer periods of employment.
Relapse rates and recidivism for IDUs in treatment are high, as reported in the literature and demonstrated through the interviews in this study; 34% of IDUs entering treatment programs in a three-year period from 1991 to 1994 in San Diego County entered more than once (M. Haight, SD DHS/ADS, personal communication, September 1994). Many of the IDUs interviewed in treatment (Chapter 4, Section B) reported numerous attempts at recovery before finally being "ready" to enter treatment or before finding a program that met their needs. Since recovery from any addiction is a life-long process, IDUs in recovery need long-term support services to help them stay in recovery. Considering that an individual may relapse after a number of years in recovery (one respondent reported being in recovery for three years before starting to inject drugs again), longer term case management, more extensive peer support systems and integrated service provision (e.g., health and housing) may be effective means by which to prevent such relapses.
In the interviews with injecting drug users who had entered treatment but relapsed, a reason frequently given for the relapse was the inability to find employment - sometimes due to their history of illicit drug use or a jail record. The frustrations of underemployment, lack of employment possibilities, continued stigma of past drug use and/or jail record and personal challenges facing the IDU as he/she tries to maintain recovery, contribute to a cycle of drug abuse, treatment and relapse that is difficult to break. Programs providing IDUs in recovery with specific job training and placement, general education and life skills training will greatly increase the ability, and probability, of the IDU to stay in recovery. Extrapolating from the results of the California drug and alcohol treatment study (Appendix 5), the longer an IDU stays in recovery, the greater are the benefits both to the individual and to society.
There were not many significant differences, in the semi-structured open interviews with IDUs (Chapter 4, Section B), between IDUs in treatment and IDUs not in treatment. However, IDUs who were in treatment often expressed greater levels of "despair", frequently indicating that they had "hit bottom" and had nowhere else to go. Harm reduction programs can provide IDUs with the links to services and treatment and self-help groups sooner so that they do not have to arrive at such levels of desperation before they enter treatment.
Culturally Appropriate Treatment and Disenfranchised Populations
As evidenced by existing high rates of relapse and recidivism (M. Haight, SD DHS/ADS, personal communication, September 1994), in order to be effective, treatment programs need to be diversified to reflect not only the appropriate drug of choice, but also the individual's personality and the culture or cultures with which the IDU identifies. Treatment must also take into consideration the larger social system to which the individual belongs. This calls for community dialogue about the types of programs that might be appropriate, acknowledging the fears of community members most affected by substance abuse and addressing commonly held myths about the IDU population. The design and establishment of novel and innovative treatment programs can result from a review of scientifically rigorous evaluations (see Chapter 2, Review of the Literature), and from ethnographic studies examining the cultural and societal frameworks within which injection drug use behaviors occur.
This needs assessment identified subpopulations within the injection drug using community that are significantly different from one another and, therefore, require different outreach and treatment strategies. One population that this needs assessment was not as successful in reaching was adolescents involved in needle-related sharing behaviors (such as injection drug use, tattooing, body piercing, etc.), even though significant efforts were made to reach them through a variety of sources, including youth-oriented programs, substance abuse programs for adolescents, and individuals working with adolescents on probation. Many agencies responding to the survey pointed out that the adolescent substance abuser, especially the injecting drug user, was in dire need of treatment services. Although this population is particularly difficult to reach, it is critical to try since the number of cases of AIDS diagnosed in adolescents is increasing rapidly.
Among cases of AIDS in U.S. adolescents (13 to 19 years) through September, 1993, 10% were due to injection drug use (CDC, 1993e). Both nationally and locally, almost 20% of the diagnosed AIDS cases have also been among individuals from 20 to 29 years of age (CDC, 1993e, 1993h; SD DHS, 1994a); since an AIDS diagnosis is only the trailing indicator of HIV disease and it may take ten years or more for an individual infected with HIV to develop AIDS, most of these individuals probably became infected as adolescents. These facts further underscore the need for specialized programs for adolescents; appropriate treatment models will need to be tested in order to evaluate their effectiveness in addressing not only the addiction, but also the other unique needs of this population. Creative strategies to access adolescents who are injecting drugs need to be developed. These strategies could include increased use of established parental networks (such as church, school and neighborhood organizations), street-based outreach activities and peer support programs which engender trust and build self-esteem among adolescents.
Another hardly reached subpopulation is the gay male injecting drug user. This group experiences higher levels of stigmatization not only from mainstream society due to their sexual orientation and injection drug use, but also from the gay community itself for injection drug use. Consequently, they are even more hidden than the heterosexual IDU population. David Purchase, one of the founders and the Executive Director of the Point Defiance AIDS Projects and the North American Syringe Exchange Network of Tacoma, Washington, identified gay male IDUs as a group that the Tacoma NEP has had the most difficulty accessing (personal communication, July 1994). Since gay male IDUs are at a "double" risk for contracting HIV through needle sharing and unprotected sex with men who may be infected, it is critical that outreach and treatment programs be developed specifically for them. According to information obtained in the interviews with gay male IDUs in the only treatment program that exists for substance abusing gay individuals in San Diego County, there are several characteristics that set this population apart from heterosexual IDUs. First, the relationship between sexual activity and drug use is very different from that seen in the heterosexual IDU population. While selling sex for drugs was fairly common for heterosexual IDUs, and several stated that sex was secondary to "getting high", the explicit use of drugs to have sex was expressed by many gay male IDUs. Sex was considered to be the primary activity and the drug use was either a part of the sexual ritual or a means by which to enhance the sexual encounter; drug use often took place in sex-oriented establishments, such as bathhouses or adult bookstores. Second, the drug of choice was primarily methamphetamine ("crystal") as opposed to heroin or cocaine, other drugs that are commonly injected locally; consequently, specialized treatment for addiction to "crystal" needs to be considered. Third, gay male IDUs in treatment perceived oral sex as being less risky than anal sex, and therefore did not use condoms. While the number of respondents was too small to generalize from, it appears that oral sex may be practiced as an alternative to other "riskier" sex acts; knowledge was low among this group that the CDC does, in fact, classify oral sex as risky and recommends condom use.
An IDU will only be referred into this unique program if he/she has identified him/herself as gay to the person making the referral. Therefore, individuals who may still be struggling with sexual identity issues, and whose drug use may be the external manifestation of this, would not be referred to the program. However, because the program specifically targets substance abusing gay individuals, it can provide the necessary services and support systems that would enable the IDU to address these issues. Within the gay injection drug using population, there may be further differences related to ethnicity, gender and health status (HIV-negative vs. HIV-positive vs. AIDS-diagnosed). Ethnographic studies could provide some of the information needed for the expansion of culturally-appropriate treatment programs for the diverse gay injection drug using population.
A population that can be difficult to identify, and is even more marginalized than the general IDU population, is the transgender drug injecting population. This group is at significant risk for HIV transmission due to their injection of illicit drugs, sexual behaviors, and the injection of hormones or steroids. Interviews with three transgender individuals outside of treatment programs provided insight into the issues that affect this population. The two HIV-positive individuals felt isolated and unable to access treatment or other services due to their HIV seropositivity status. Sharing injection equipment was frequent, as seen in the interviews with other IDUs. Two HIV-positive individuals who work as prostitutes both stated that they use condoms every time in order to protect their clients while the third reported no condom use when she was sexually active. One provided information on hormone injection practices. She stated that sharing was common in San Diego, especially when needles were unavailable, among those transgender individuals with limited resources. Groups of three or four individuals would "get together and do it (inject hormones)". Most went to pharmacies in Tijuana to buy the hormones and would inject themselves.
Communities of color have historically been economically deprived and disenfranchised from mainstream society. Economic deprivation and a resulting impoverished lifestyle are also common among IDUs, factors which dramatically increase the likelihood of high risk behaviors such as sharing injection equipment. As a consequence, communities of color have been dramatically impacted by both injection drug use and HIV/AIDS. There are varied perceptions within communities of color of the impact of drug abuse and how to deal with it. In the case of African Americans, there is a strong historical context, including enslavement, abrupt movement from one culture and/or geographic area to another with destruction of family units and the Tuskegee experience, within which to place these perceptions. Many African Americans recognize the dramatic impact of substance abuse and of HIV/AIDS within their community and the crucial need for prevention and treatment; however, there are many barriers to accomplishing this, including the lack of economic resources and opportunities within the community to develop effective and culturally sensitive programs to break the cycle of substance abuse, the historic mistrust of public health and "outside help" and the multitude of other pressing, life threatening issues confronted on a day-to-day basis. To be effective, prevention and treatment programs need to be culturally competent and able to address the cultural context of substance abuse and HIV/AIDS. As part of larger, comprehensive harm reduction and treatment strategies, institutionalized discrimination and racism must be acknowledged and worked through.
Although drug use has affected the local Latino community dramatically, according to Alfredo Velasco, Ph.D., (personal communication, September 1994) the impact is no more nor no less than in other communities. As in most communities, many Latinos consider "dope fiends" to be at the bottom of society, and to pull down the quality of life wherever they congregate. There is little support for treatment programs; most Latinos just want the problem to disappear, but have no suggested solutions. Latino drug injecting individuals interviewed in this needs assessment reported higher levels of safer injection practices, yet lower utilization of social and medical services. In addition, the respondents were more comfortable responding to the questions in Spanish, a factor that might limit their ability to enter and/or remain in a treatment program since there are no Spanish-language treatment programs in the County. Some programs have Spanish-speaking staff, but most program activities are carried out in English. In addition, the South Bay/San Ysidro area lacks treatment programs, leading to limited access for many Spanish-speaking IDUs living in that area. This lack of diversity in bilingual programs will also affect other, non-English speaking IDU populations. Treatment programs for Latino IDUs need to address issues of language, as well as community apathy and denial.
The Asian/Pacific Islander (A/PI) communities in San Diego have been difficult to access for the purposes of this survey. According to Eric Phoombour, Project Director, Asian/Pacific Islander Community AIDS Project in San Diego (personal communication, July 1994), there is a high level of denial within the A/PI communities that HIV and AIDS is affecting them; and many HIV-positive individuals delay seeking treatment due to fear of community rejection. Annual increases in the incidence rates of HIV infection for A/PIs are the highest for any ethnic group (SD DHS, 1994a). In addition, reported behaviors associated with increased risk of HIV transmission, such as unprotected sex with prostitutes, are common (Loue et al., 1994). In a child and adolescent health outreach project targeting nine of the A/PI communities in San Diego, researchers investigated the means by which culturally appropriate HIV education and prevention messages could be disseminated. This study indicated that reliable sources of information for the A/PI communities on HIV/AIDS are healthcare professionals. Educational and outreach strategies used for gay men or Caucasian heterosexuals are unacceptable to the A/PI communities (Sana Loue, personal communication, January 1994). For example, 48% of the survey respondents indicated that they would not accept a condom if it was offered to them on the street; some indicated that while they might accept it, they would throw it away later because they did not know the person who gave it to them. Many indicated that they would accept and use a condom if it was given to them by their physician. Acceptance of HIV testing was similar, in that more respondents stated they might accept an HIV test if it was conducted by their physician. However, this project also determined, anecdotally, that there was misinformation about HIV and AIDS among some A/PI healthcare professionals. For these reasons, public education on HIV prevention and harm reduction strategies specifically targeting the A/PI communities is needed. One program, the Asian/Pacific Islander Community AIDS Project in San Diego (APICAP) is a model program for such activities.
Although this needs assessment did not provide much information on the Native American population, isolation and cultural autonomy, as seen in other communities of color, have enhanced injection drug use. Native American youth were reported as especially affected. In "Community Vision", a recent San Diego County Indian Community assessment of both urban and rural/reservation-based Native Americans (Lori Beaulieu and Tom Lidot, San Diego Indian AIDS Taskforce, 1993), a needle exchange program was listed as a need for HIV intervention, and the "Substance Abuse Community Plan" called for increased community support for sobriety and recovery, culturally-based education, more treatment centers, comprehensive care, child care for those in treatment, transportation to treatment and "aftercare" for individuals diagnosed with substance abuse and/or HIV/AIDS.
Treatment cannot be viewed as isolated interventions that begin after an IDU joins a recovery program, but should be considered in the broader continuum of injection drug use. All individual IDUs along that continuum (from actively using to actively recovering or abstaining) need to be included in a comprehensive, multifaceted approach of harm reduction. Harm reduction strategies, in particular, reach out to the 90% of IDUs who are not in treatment. Thus, harm reduction also benefits society at large by reducing blood-borne transmissible diseases such as HIV and hepatitis B in IDUs and their families, and provides support to individuals entering treatment.
This approach recognizes that there are individuals who may not identify their own drug use as a "problem", others who may recognize that they have a problem but are unable or unwilling to seek treatment, some who may enter a treatment program but relapse, and still others who enter treatment and are successful in maintaining their recovery. Harm reduction strategies provide a means by which IDUs not yet ready to enter the recovery process can take specific actions to address their own health needs without entering a formal treatment program. These strategies are particularly relevant for difficult-to-reach populations who have little contact with public or private services. Harm reduction programs provide these populations with a connection to the available services and support as they move along the continuum into treatment and recovery. Street-based outreach, case management, needle exchange and bleach programs, particularly those originating within or staffed by individuals from within the communities of the IDUs, can play a key role in linking IDUs with these services. By establishing frequent, non-judgmental and ongoing contact with IDUs outside of treatment and by seeking to proactively assist IDUs in addressing their day-to-day immediate needs, street-based outreach workers can establish a trusting relationship with IDUs. While encouraging IDUs to care for themselves and others, these programs also serve as a continuing resource for information and support when an IDU may decide to enter recovery.
Harm reduction strategies can provide IDUs with a number of options for behavior modification, such as exchanging used needles and syringes for new sterile ones at a needle exchange, using bleach to disinfect when a sterile needle is unavailable, and using a condom during sex. Providing an IDU with the opportunity to make a decision, such as "I will not share my injecting equipment unless I can disinfect with bleach after each use", and the means by which to carry it out, helps that individual to gain control and to accept responsibility for his/her actions (Sorge, 1991; Feldman and Biernacki, 1988). Not providing IDUs with the means by which to carry out the suggested behavior, such as by not providing bleach or needle exchange, limits the ability of IDUs to take the healthier course of action.
The implementation of a pilot needle exchange program in San Diego County, with an evaluation-research component, is an opportunity to offer multiple harm reduction strategies to injecting drug users. It also presents an opportunity to benefit communities and society at large by preventing the spread of HIV, improving public health overall and supporting IDUs who move into treatment and recovery. The San Diego Clean Needle Exchange Program (NEP) not only exchanges needles and syringes, but also provides education on HIV prevention, community resources and support, and referrals to social services and treatment programs. These education and referral services, however, have been hindered by uninformed law enforcement, leading to decreased interactions. The San Diego NEP serves as a point of contact for a population that has traditionally been considered "disposable" by mainstream society. With their continued presence in the community, needle exchange outreach workers establish a sense of trust with their clients that may ultimately lead the IDUs to seek assistance to begin a recovery process. The mechanics of this process and its beneficial effects have been clearly demonstrated in many existing NEPs in the United States, and cited in the recent study sponsored by the Centers for Disease Control and Prevention on NEPs (Lurie et al., 1993a, 1993b). Several studies and evaluations of the existing NEPs (see Chapter 2, Section E) also indicate that none of the negative effects that NEPs are purported to foster actually occur (i.e., increased injection drug use, increased initiation of new injection users, increase in discarded syringes in public areas); in fact, all of these factors have been shown to decrease. Subsequently, needle exchange can help to break the IDU/HIV link while culturally-appropriate treatment and support programs are established.
As seen in the interviews with current and former IDUs, many are employed, provide for their families and are concerned with not only their own health, but that of their family. Harm reduction is an opportunity to offer IDUs a chance to make and carry out healthier decisions for modifying behaviors and to provide necessary assistance as they move along the drug use continuum towards recovery. Through continued support offered by street-based outreach, education, case management and needle exchange, IDUs will start to adopt safer injection behaviors and/or begin recovery. For children and adolescents, enhancing parental involvement through support systems for parents and the use of established parental networks, is a critical component of harm reduction. In turn, safer injection behaviors for IDUs lead to healthier behaviors in other areas of their lives (Sorge, 1991). These include practicing safer sexual behaviors (Moss et al., 1994; Reinfeld, 1994), raising self-esteem, caring about themselves and others, improving both physical and emotional health (Sorge, 1991), developing better personal hygiene and seeking healthier living environments. Gay male injecting drug users as well as other IDUs both in and outside of treatment, in particular prostitutes, justified not using a condom by stating that they were involved primarily in oral sex. It appears that oral sex is considered to be "safer" than insertive anal or vaginal sex, although the Centers for Disease Control and Prevention recommend condom use for oral sex as well (CDC 1993c). These misperceptions are addressed through appropriate harm reduction strategies, which include education and prevention. Collectively, these actions will result in the reduction of harm and an improvement in quality of life for IDUs, while benefitting society as a whole.
HIV/AIDS and hepatitis B virus continue to pose serious threats to the public health of our community. Injection behaviors have become a major route of transmission for spreading these deadly viruses throughout our community. In order to effectively prevent the spread of the blood-borne diseases, specific risk behaviors need to be addressed, not the groups which have been affected.
In light of these considerations, a comprehensive and coordinated system of public education and harm reduction strategies is desperately needed to address injection drug use in San Diego County. Such a system can effectively break the cycle of injection drug use and related addictive behaviors and stem the projected costly consequences in terms of the HIV/AIDS epidemic.
AIDS (1992): Needle Exchange for IV Drug Users: The Right Message or the Wrong One? AIDS, Vol 4 (2):1-3.
AIDS Alert (1994a): Alcohol and HIV: High Rate of Infection in Clinics Raises Questions About Screening. AIDS Alert, Vol. 9(5):67-69.
AIDS Alert (1994b): Common Sense About AIDS: Avoiding Alcohol, Illegal Drugs May Reduce HIV Exposure Risk. AIDS Alert, Vol. 9(5), Insert.
AIDS Alert (1994c): Counselors Urged to Screen for Alcohol and Non-Injection Drugs. AIDS Alert, Vol. 9(5):71-73.
AIDS Alert (1994d): Needle Exchange Programs Gain Support; CDC Evaluating Studies for Recommendation. AIDS Alert, Vol. 9(5):65-67.
AIDS Alert (1994e): Physicians Urged to Increase Screening for Drug Abuse, HIV. AIDS Alert, Vol. 9(5):69-71.
Astemborski J, D Vlalov, D Warren, L Solomon, KE Nelson (1994): The Trading of Sex for Drugs or Money and HIV Seropositivity among Female Intravenous Drug Users. American Journal of Public Health, Vol. 84(3):382-387.
Ball JC, WR Lange, CP Myers, SR Friedman (1988): Reducing the Risk of AIDS Through Methadone Maintenance Treatment. Journal of Health and Social Behavior, Vol. 29:214-226.
Birkel RC, T Golaszewski, JJ Koman III, BK Singh, V Catan, K Souply (1993): Findings from the Horizontes Acquired Immune Deficiency Syndrome Education Project: The Impact of Indigenous Outreach Workers as Change Agents for Injection Drug Users. Health Education Quarterly, Vol. 20(4):523-538.
Blatherwick J (1989): How to "Sell" a Needle Exchange Program. Canadian Journal of Public Health, Vol. 80, Supplement 1:S26-27.
Bloom DE and G Carliner (1988): The Economic Impact of AIDS in the United States. Science, Vol. 239 (4840): 604-10.
Brettle R (1991): HIV and Harm Reduction for Injection Drug Users. AIDS, Vol. 5(2): 125-136.
Britton CB (1993): HIV Infection. Neurologic Complications of Drug and Alcohol Abuse, Vol. 11(3):605-624.
Brunswick AF, A Aidala, J Dobkin, J Howard, SP Titus, J Banaszak-Holl (1993): HIV-1 Seroprevalence and Risk Behaviors in an Urban African-American Community Cohort. American Journal of Public Health, Vol. 83(10):1390-1394.
Buning EC (1991): Effects of Amsterdam Needle and Syringe Exchange. The International Journal of Addictions, 26(12):1303-1311.
California Department of Alcohol and Drug Services (1994): Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA): Executive Summary, prepared by the National Opinion Research Center (University of Chicago) and Lewin-VHI, Inc., (Washington, D.C.) State of California, Sacramento, CA, July.
California Department of Health Services (1992a): Epidemiologic Overview of HIV/AIDS Among African-Americans in California. California Department of Health Services, Office of AIDS, Sacramento, CA, October.
California Department of Health Services (1992b): Epidemiologic Overview of HIV/AIDS Among Latinas/os in California. California Department of Health Services, Office of AIDS, Sacramento, CA, July.
California Department of Health Services (1993a): Epidemiologic Overview of HIV/AIDS Among Native Americans in California. California Department of Health Services, Office of AIDS, Sacramento, CA, August.
California Department of Health Services (1993b): HIV/AIDS Epidemiology Summary. California Department of Health Services, Office of AIDS, Sacramento, CA.
California Department of Health Services (1993c): Epidemiologic Overview of HIV/AIDS Among Asian/Pacific Islanders in California. California Department of Health Services, Office of AIDS, Sacramento, CA, February.
California Department of Health Services (1994a): California HIV/AIDS Update. California Department of Health Services, Office of AIDS, Sacramento, CA, April.
California Department of Health Services (1994b): Local AIDS Surveillance Assessment Data and HIV/AIDS Epidemiology Summary, San Diego County and Imperial County. California Department of Health Services, Office of AIDS, HIV/AIDS Epidemiology Branch, Sacramento, CA.
California Department of Health Services (1994c): Ryan White Comprehensive Emergency Resources (CARE) Act of 1990 Year 04 Title II Grant Application. State of California Department of Health Services, Office of AIDS, Sacramento, CA.
Calsyn DA, AJ Saxon, G Freeman, S Whittaker (1991): Needle-use practices Among Intravenous Drug Users In An Area Where Needle purchase Is Legal. AIDS, Vol. 5(2):187-193.
Celentano DC, D Vlahov, S Cohn, JC Anthony, L Solomon, KE Nelson (1991): Risk Factors for Shooting Gallery Use and Cessation among Intravenous Drug Users. American Journal of Public Health, Vol. 81(10):1291-1295.
Centers for Disease Control and Prevention (CDC) (1993a): National HIV Surveillance Summary: Results Through 1992, Volume 3. CDC, Atlanta, GA.
Centers for Disease Control and Prevention (CDC) (1993b): Facts about The Human Immunodeficiency Virus and Its Transmission. CDC, Atlanta, GA, February.
Centers for Disease Control and Prevention (CDC) (1993c): Facts about Condoms and Their Use in preventing HIV Infection and Other STDs. CDC, Atlanta, GA, July.
Centers for Disease Control and Prevention (CDC) (1993d): Facts about Drug Use and HIV/AIDS. CDC, Atlanta, GA, September.
Centers for Disease Control and Prevention (CDC) (1993e): Facts about Adolescents and HIV/AIDS. CDC, Atlanta, GA, October.
Centers for Disease Control and Prevention (CDC) (1993f): Facts about Women and HIV/AIDS. CDC, Atlanta, GA, October.
Centers for Disease Control and Prevention (CDC) (1993g): Facts about HIV/AIDS and U.S. Blacks. CDC, Atlanta, GA, October.
Centers for Disease Control and Prevention (CDC) (1993h): National HIV/AIDS Surveillance Report, Third Quarter Edition. CDC, Atlanta, GA, October.
Centers for Disease Control and Prevention (CDC) (1993i): Facts about HIV/AIDS and Race/Ethnicity. CDC, Atlanta, GA, November.
Centers for Disease Control and Prevention (CDC) (1993j): Facts about The Scope of the HIV/AIDS Epidemic in the United States. CDC, Atlanta, GA, November.
Chiasson MA, RL Stoneburner, E Telzak, D Hildebrandt, S Schultz, H Jaffe (1989): Risk Factors for HIV-1 Infection in STD Clinic patients: Evidence for Crack-Related Heterosexual Transmission. resented at the 5th International AIDS Conference, Montreal, Canada, June.
Clark GL, M Downing, H McQuie, D Gann, R Dietrich, P Case, J Haber, P Ferguson (1989): Street Based Needle Exchange Programs: The Next Step in HIV Prevention. Paper resented at the Fifth International Conference on AIDS, Montreal, Quebec, Canada, June.
Cohen JB (1991): Why Women partners of Drug Users Will Continue to Be at High Risk for HIV Infection. Journal of Addictive Diseases, Vol. 10(4):99-110.
Des Jarlais DC, S Friedman and D Strug (1986): AIDS and Needle-Sharing Within the IV-Drug Use Subculture. In: The Social Dimensions of AIDS: Methods and Theory, ed. Feldman, Douglas and Johnson. Praeger, New York.
Des Jarlais DC, SR Friedman, JL Sotheran, R Stoneburner (1988): The Sharing of Drug Infection Equipment and the AIDS Epidemic in New York City. in: Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives, Institute on Drug Abuse Research Monograph Series.
Des Jarlais DC, C Eaton, et al. (1990): Drug Use and AIDS in New York City (from a panel discussion hosted by Health/PAC on July 25, 1990). Health/PAC Bulletin, Fall:23-31.
Des Jarlais DC, A Abu-Quader, S Tross (1991): The Next Problem: Maintenance of AIDS Risk Reduction Among Intravenous Drug Users. The International Journal of the Addictions, Vol. 26(12):1279-1292.
Des Jarlais DC and Case (1992): Increasing Access to Injection Equipment: Syringe Exchange and Other Examples of Harm Reduction Strategies. AIDS In the World:685-703. In: ACLU Briefing Book - Needle Exchange, Harm Reduction, and HIV Prevention in the Second Decade, R Harlow and R Sorge, editors, ACLU AIDS Project, New York, NY., 1994: 118-135.
Des Jarlais DC and SR Friedman (1992): AIDS and Legal Access to Sterile Drug Injection Equipment. The Annals of the American Academy of Political and Social Science, Vol. 521:42-65.
Des Jarlais DC and SR Friedman (1994): AIDS and the Use of Injected Drugs. Scientific American, February:82-88.
Feldman HW and P Biernacki (1988): The Ethnography of Needle Sharing Among Intravenous Drug Users and Implications for Public Policies and Intervention Strategies. in: Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives, National Institute on Drug Abuse, Research Monograph Series, .28-39.
Firlik AD and K Schreiber (1992): AIDS Prevention by Needle Exchange. New York State Journal of Medicine, Vol. 92(10):426-430.
Gillman C (1990a): Genesis of New York City's Experimental Needle Exchange Program: A Denigrated Group Makes It To The Government Agenda. The International Journal On Drug Policy, Vol. 1(5): 28-32.
Gillman C (1990b): After One Year: New York City's Needle Exchange Pilot Program. The International Journal On Drug Policy, Vol. 1(5):18-21.
Green JO (1993): Estimates of Drug Users in San Diego County, 1990-1992, Final Report. Prepared for the San Diego County Department of Health Services, Alcohol and Drug Services, San Diego, CA, June.
Grund JPC, CD Kaplan, NFP Adriaans (1991): Needle Sharing in The Netherlands: An Ethnographic Analysis. American Journal of Public Health, Vol. 81(12): .
Grund JPC, P Blanken, NFP Adriaans, CD Kaplan, C Barendregt, M Meeuwsen (1992): Reaching the Unreached: Targeting Hidden IDU Populations with Clean Needles via Known User Groups. Journal of Psychoactive Drugs, Vol. 24(1):41-47.
Grund JPC, LS Stern, CD Kaplan, NFP Adriaans, E Drucker (1992): Drug Use Contexts and HIV- Consequences: The Effect of Drug Policy on Patterns of Everyday Drug Use in Rotterdam and the Bronx. British Journal of Addiction, Vol. 87:381-392.
Guydish J, G Clark, D Garcia, M Downing, P Case, JL Sorenson (1991): Evaluating Needle Exchange: Do Distributed Needles Come Back? American Journal of Public Health, Vol. 81(5):617-619.
Guydish J, G. Clark, D. Garcia, J. Yee, J.S. Greenspan, N. Hearst (1992): Detecting HIV Antibodies in Needle-Exchange Syringes (Letter to the Editor). AIDS, Vol. 6(7):739-740.
Guydish J, J Bucardo, M Young, W Woods, O Grinstead, W Clark (1993): Evaluating Needle Exchange: Are There Negative Effects? AIDS, Vol. 7(6):871-876.
Hagan H, T Reid, D Purchase, H Jensen, JS Woods, SR Friedman, DC Des Jarlais (1988): Needle Exchange in Tacoma, Washington - Initial Results. The Newsletter of the International Working Group on AIDS and IV Drug Use, Vol. 3(3/4):4-6.
Hagan H, DC Des Jarlais, D Purchase, T Reid, SR Friedman (1991): The Tacoma Syringe Exchange. Journal of Addictive Diseases, Vol. 10(4):81-88.
Hagan H, D.C. Des Jarlais, S.R. Friedman, D. Purchase, T.R. Reid (1992): Multiple Outcome Measures of the Impact of the Tacoma Needle Exchange. Poster resented at the 8th International AIDS Conference, Amsterdam, The Netherlands, July.
Haight MA (1993a): Alcohol and Drug Services Utilization Report, Fiscal Year 1992-1993. San Diego County Department of Health Services, Alcohol and Drug Services, San Diego, CA, November.
Haight MA (1993b): Drug Abuse Trends in San Diego County. Community Epidemiology Work Group, San Diego Department of Health Services, San Diego, CA, December.
Harlow R and R Sorge, editors (1994): ACLU Briefing Book - Needle Exchange, Harm Reduction, and HIV Prevention in the Second Decade. ACLU AIDS Project, New York, NY.
Hart GJ, ALM Carvell, N Woodard, AM Johnson, Williams, JV Parry (1989): Evaluation of Needle Exchange in Central London: Behaviour Change and Anti-HIV Status Over One Year. AIDS, Vol. 3(5):261-265.
Hart GJ, N Woodward, AM Johnson, J Tighe, JV Parry, Michael W. Adler (1991): Prevalence of HIV, Hepatitis B and Associated Risk Behaviours in Clients of a Needle-Exchange in Central London. AIDS, Vol. 5(5):543-547.
Hartgers C, EC Buning, GW van Santen, AD Verster, RA Coutinho (1989): The Impact of the Needle and Syringe-Exchange Programme in Amsterdam on Injecting Behavior. AIDS, Vol. 3:571-576.
Hassin J (1994): Living a Responsible Life: The Impact of AIDS on the Social Identity of Intravenous Drug Users. Social Science and Medicine, Vol. 39(3):391-400 .
Haynes KC (1988): Minorities, Intravenous Drug Use, and AIDS: A Review. MIRA (Multicultural Inquiry and Research on AIDS, Vol. 2(4):1-2,4-5.
Heckmann W (1991): HIV revention among IVDUs in the Federal Republic of Germany: Stability and Change. The International Journal of Addictions, Vol. 26(12):1321-1331.
Heimer R, EH Kaplan, K Khoshnood, B Jariwala, EC Cadman (1993): Needle Exchange Decreases the Prevalence of HIV-1 Proviral DNA in Returned Syringes in New Haven, Connecticut. The American Journal of Medicine, Vol. 95:214-220.
Hoeprich and MC Jordan (1989): Infectious Diseases: A Modern Treatise of Infectious Processes. J.B. Lippincott Company, Philadelphia, A.
Hellinger FJ (1993): The Lifetime Cost of Treating a Person With AIDS. Journal of the American Medical Association, Vol. 270(4):474-478.
Institute of Medicine, National Academy of Sciences (1986): Confronting AIDS: Directions for Public Health, Health Care, and Research. National Academy Press, Washington, D.C.: 112.
Isselbacher KJ, E Braunwald, D Wilson, JB Marin, AS Fauci, DL Kasper, editors (1994): Harrison's Principles of Internal Medicine, 13th Edition. McGraw-Hill, Inc., New York, NY.
Jose B, SR Friedman, A Neaigus, R Curtis, JPC Grund, MF Goldstein, TP Ward, DC Des Jarlais (1993): Syringe-Mediated Drug-Sharing (Backloading): A New Risk Factor for HIV among Injecting Drug Users. AIDS, Vol. 7(12):1653-1660.
Kaplan EH (1992): Evaluating Needle-Exchange Programs via Syringe Tracking and Testing (STT). AIDS & Public Policy Journal, Vol. 6(3):109-115.
Kaplan EH and R Heimer (1992a): A Model-Based Estimate of HIV Infectivity via Needle Sharing. Journal of Acquired Immune Deficiency Syndromes, Vol. 5(11):116-118.
Kaplan EH and R Heimer (1992b): HIV revalence Among Intravenous Drug Users: Model-Based Estimates from New Haven's Legal Needle Exchange. Journal of Acquired Immune Deficiency Syndromes, Vol. 5(2):163-169.
Kaplan EH and R Heimer (1994): HIV Incidence Among Needle Exchange Participants: Estimates from Syringe Tracking and Testing Data. Journal of Acquired Immune Deficiency Syndromes, Vol. 7(2):182-189.
Keene J, GV Stimson, S Jones & N arry-Langdon (1993): Evaluation of Syringe-Exchange for HIV Prevention among Injecting Drug Users in Rural and Urban Wales. Addiction, Vol. 88:1063-1070.
Koester S (1989): "When Push Comes to Shove": overty, Law Enforcement and High Risk Behavior. Paper Presented at the Society for Applied Anthropology Meeting, Santa Fe, NM, April.
Koester S (1990): "Don't Share": Extending the Message Beyond Syringes. The Newsletter of The International Working Group on AIDS and Drug Use, Vol. 5(1):22-24.
Koester S, R Booth, W Wiebel (1991): The Risk of HIV Transmission from Sharing Water, Drug Mixing Containers and Cotton Filters among Intravenous Drug Users. The International Journal On Drug olicy, Vol. 1(6):28-30.
Lampinen TM, E Joo, S Seweryn, RC Hershow, W Wiebel (1992): HIV Seropositivity in Community-Recruited and Drug Treatment Samples of Injecting Drug Users. AIDS, Vol. 6(1):123-126.
Lee R and EN Goplerud (1994): Substance Abuse Services In Health Care Reform. Connection, a Publication of the Foundation for Health Services Research, Vol. 2(2):1-2.
Lhomme JP, A Edwige, C Ilie, F Regnier-Aeberhard, F Gehant, M Benslimane (1992): Evaluating the First Syringe Exchange Program in Paris. Poster Presented at the 8th International Conference on AIDS, Amsterdam, The Netherlands, July.
Lichty (1990): 'The Point Is to Save Lives': Needle Exchange In Hawaii. Health/PAC Bulletin, Fall:11-15. Longshore D (1992): HIV/AIDS and Drug Use Epidemiology in California: Directions for Research and Disease Surveillance. A Meeting Sponsored by the California Department of Health Services, Office of AIDS, February 26.
Loue S, E Phoombour, R Mirano, LS Lloyd (1994): Use of Prostitutes as a Risk Factor for HIV Injection Among Asian/Pacific Islander Men in San Diego County: Preliminary Findings. Paper Presented at the Society for Behavioral Medicine Annual Meeting, Boston, MA, April.
Lurie , AL Reingold, R Lee, B Bowser, D Chen, J Foley, J Guydish, JG Kahn, S Lane, J Sorenson (1993a): The Public Health Impact of Needle Exchange Programs in the United States and Abroad, Volumes 1 and 2. Prepared for The Centers for Disease Control and Prevention (CDC) by the School of Public Health, University of California, Berkeley and the Institute for Health Policy Studies, University of California, San Francisco. CDC, Atlanta, GA, October.
Lurie , AL Reingold, R Lee, B Bowser, D Chen, J Foley, J Guydish, JG Kahn, S Lane, J Sorenson (1993b): The Public Health Impact of Needle Exchange Programs in the United States and Abroad: Summary, Conclusions and Recommendations. Prepared for The Centers for Disease Control and Prevention (CDC) by the School of Public Health, University of California, Berkeley and the Institute for Health Policy Studies, University of California, San Francisco. CDC, Atlanta, GA, October.
Lurie and D Chen (1993): A Review of Programs in North America. In: Dimensions of HIV Prevention: Needle Exchange, ed. J Stryker and MB Smith. The Kaiser Forums, The Kaiser Family Foundation, Menlo ark, CA.
Mandell W, D Vlahov, C Latkin, M Oziemkowska and S Cohn (1994): Correlates of Needle Sharing among Injection Drug Users. American Journal of Public Health, Vol. 84(6):920-923.
Moss AR, K Vranizan, R Gorter, Bacchetti, J Watters and D Osmond (1994): HIV Seroconversion in Intravenous Drug Users in San Francisco, 1985-1990. AIDS, Vol. 8(2):223-231.
National Commission on AIDS (1991a): America Living With AIDS: Transforming Anger, Fear and Indifference into Action. National Commission on AIDS, Washington, D.C.
National Commission on AIDS (1991b): The Twin Epidemics of Substance Use and HIV. National Commission on AIDS, Washington, D.C., July.
National Commission on AIDS (1993): AIDS: An Expanding Tragedy. Final Report of the National Commission on AIDS, Washington, D.C., June.
National Institute of Justice (1993): 1992 Annual Report - Drugs and Crime in America's Cities, Drug Use Forcecasting (DUF). United States Department of Justice, Office of Justice Programs, Washington, D.C.
Neaigus A, SR Friedman, R Curtis, DC Des Jarlais, RT Furst, B Jose, Mota, B Stepherson, M Sufian, T Ward, JW Wright (1994): The Relevance of Drug injectors' Social and Risk Networks for Understanding and Preventing HIV Infection. Social Science and Medicine, Vol. 38(1):67-78.
Nwanyanwu OC, SY Chu, TA Green, JW Buehler, RL Berkelman (1993): Acquired Immune Deficiency Syndrome in the United States Associated with Injecting Drug Use, 1981-1991. American Journal of Drug Abuse, Vol. 19(4):399-408.
Oliver K, SR Friedman, H Maynard, DC Des Jarlais, D Fleming (1992): Comparison of Behavioral Impacts of Syringe Exchange and Community Impacts of an Exchange. Poster Presented at the 8th International Conference on AIDS, Amsterdam, The Netherlands, July.
Oliver KJ, SR Friedman, H Maynard, L Magnuson, DC Des Jarlais (1992): Impact of a Needle Exchange Program on Potentially Infectious Syringes in Public Places (Letter to the Editor). Journal of Acquired Immune Deficiency Syndromes, Vol. 5(5):534.
O'Shea D and E Shatz, editors (1994): CARING's 1994 Data Pak for HIV/AIDS and Other Health and Human Care Services, 4 Volumes. Community AIDS Response to Increase Grants, San Diego, CA.
Peters AD, MM Reid and SG Griffin (1994): Edinburgh Drug Users: Are They Injecting and Sharing Less? AIDS, Vol. 8(4):521-528.
Purchase D, H Hagan, DC Des Jarlais, T Reid (1989): Historical Account of the Tacoma Syringe Exchange. resented at the 5th International Conference on AIDS, Montreal, Quebec, Canada, June.
Ray O and C Ksir (1990): Drugs, Society and Human Behavior. Times Mirror/Mosby College Publishing, St. Louis, MO.
Reinfeld, M (1994): Harm Reduction Theory in Practice: An Update on AmFAR's Syringe Exchange Program. The AmFAR Report, American Foundation for AIDS Research, Spring:6-8.
Robert Wood Johnson Foundation (RWJF) (1993): Substance Abuse: the Nation's Number One Health Problem. Key Indicators for Policy. Prepared by the Institute for Health Policy, Brandeis University, October.
San Diego Association of Governments (SANDAG) (1994): Crime In the San Diego Region 1993 (includes San Diego Drug Use Forecasting [DUF]). Criminal Justice Research Division, SANDAG, San Diego, CA.
San Diego County Department of Health Services (1992): County Monthly AIDS Surveillance Reports. San Diego County Department of Health Services, Office of AIDS and Epidemiology, San Diego, CA.
San Diego County Department of Health Services (1993a): Baseline HIV Needs Assessment for San Diego County. San Diego County Department of Health Services, Office of AIDS Coordination, San Diego, CA, September. San Diego County Department of Health Services (1993b): County Monthly AIDS Surveillance Reports. San Diego County Department of Health Services, Office of AIDS and Epidemiology, San Diego, CA.
San Diego County Department of Health Services (1994a): County Monthly AIDS Surveillance Reports. San Diego County Department of Health Services, Office of AIDS and Epidemiology, San Diego, CA.
San Diego County Department of Health Services (1994b): San Diego County Resident Reported Cases of AIDS, Cumulative (through 1/94) and Recent (2/92-1/94). San Diego County Department of Health Services, Office of AIDS Coordination, San Diego, CA, February.
San Diego County Department of Health Services (1994c): County of San Diego FY 1994 Supplemental Application for Ryan White Comprehensive Emergency Act of 1990 Emergency Relief Grant Program. San Diego County Department of Health Services, Office of AIDS Coordination, San Diego, CA, January 11.
San Diego County Grand Jury (1994): Grand Jury Report No. 9: "Infectious Disease Control (HBV and HIV)", A Report by the 1993/94 San Diego County Grand Jury, San Diego, CA, June 28.
San Diego Youth & Community Services (1993): HIV & Youth Education Project - Video-Based HIV Prevention Research Project Data Package. Centers for Disease Control and Prevention (CDC), National Network of Runaway and Youth Services, Inc. and San Diego Youth & Community Services, Inc., San Diego, CA.
Schiller NG, S Crystal, D Lewellen (1994): Risky Business: The Cultural Construction of AIDS Risk Groups. Social Science and Medicine, Vol. 38(10):1337-1346.
Schwartz RH (1993): Syringe and Needle Exchange Programs: art I. Southern Medical Journal, Vol. 86(3):318-322.
Schwartz RH (1993): Syringe and Needle Exchange Programs Worldwide: art II. Southern Medical Journal, Vol. 86(3):323-327.
Scitovsky AA and DP Rice (1988): Estimates of the Direct and Indirect Costs of Acquired Immune Deficiency Syndrome in the United States, 1985, 1986, and 1991. Siddiqui NS, LS Brown, RY Phillips, O Vargas, RW Makuch (1992): No Sero-Conversions among Steady Sex Partners of Methadone-Maintained HIV-1-Seropositive Injecting Drug Users in New York City. AIDS, Vol. 6(12):1529-1533.
Singer M (1994): The Politics of AIDS: Introduction. Social Science and Medicine, Vol. 38(10):1321-1324.
Sorenson JL, J London, C Heitzmann, DR Gibson, ES Morales, R Dumontet, M Acree (1994): Psychoeducational Group Approach: HIV Risk Reduction in Drug Users. AIDS Education and Prevention, Vol. 6(2):95-112.
Sorge R (1990): A Thousand Points ... Needle Exchange Around the Country. Health/PAC Bulletin, Fall:16-22.
Sorge R (1991): Harm Reduction: A New Approach to Drug Services. Health/PAC Bulletin, Winter:22-27.
Strang J (1992): Harm Reduction for Drug Users: Exploring Dimensions of Harm, Their Measurement, and Strategies for Reductions. AIDS & Public Policy Journal, Vol. 7(3). In: ACLU Briefing Book - Needle Exchange, Harm Reduction, and HIV Prevention in the Second Decade, R Harlow and R Sorge, editors, ACLU AIDS Project, New York, NY., 1994: 80-87.
Stevenson HC and JJ White (1994): AIDS Prevention Struggles in Ethnocultural Neighborhoods: Why Research partnerships with Community Based Organizations Can't Wait. AIDS Education and Prevention, Vol. 6(2):126-139.
Stryker J (1989): IV Drug Use and AIDS: Public Policy and Dirty Needles. Journal of Health Politics, Policy and Law, Vol. 14(4):719-740.
Stryker J and Smith MD, editors (1993): Dimensions of HIV Prevention: Needle Exchange. The Kaiser Forums, The Kaiser Family Foundation, Menlo ark, CA.
Tabbush V (1986): The Effectiveness and Efficiency of publicly Funded Drug Abuse Treatment and Prevention Programs in California: A Benefit-Cost Analysis. University of California, Los Angeles, Los Angeles, CA.
Thomas SB and SC Quinn S (1991): The Tuskegee Syphilis Study, 1932 to 1972: Implications for HIV Education and AIDS Risk Reduction Programs in the Black Community. American Journal of Public Health, Vol. 81(11):1498-1505.
Thomas SB and SC Quinn (1993a): Understanding the Attitudes of Black Americans. in: Dimensions of HIV Prevention: Needle Exchange, eds. J Stryker and MD Smith. The Kaiser Forums, The Henry J. Kaiser Family Foundation, Menlo ark, CA.
Thomas SB and SC Quinn (1993b): The Burdens of Race and History on Black Americans' Attitudes Toward Needle Exchange Policy to Prevent HIV Disease. Journal of Public Health Policy, Vol. 14(3):320-347.
United States General Accounting Office (1993): Needle Exchange Programs: Research Suggests an AIDS Prevention Strategy. Report to the Chairman, Select Committee on Narcotics Abuse and Control, House of Representatives. GAO, Washington, DC.
van Ameijden JC, JAR van den Hoek, HJA van Haastrecht, A Coutinho (1992): The Harm Reduction Approach and Risk Factors for Human Immunodeficiency Virus (HIV) Seroconversion in Injecting Drug Users, Amsterdam. American Journal of Epidemiology, Vol. 136(2):236-243.
Velleman R and J Rigby (1990): Harm Minimisation: Old Wine in New Bottles? The International Journal on Drug Policy. In: ACLU Briefing Book - Needle Exchange, Harm Reduction, and HIV Prevention in the Second Decade, R Harlow and R Sorge, editors, ACLU AIDS Project, New York, NY., 1994: 76-79.
Watters JK, Y-T Cheng, JJ Lorvick (1991): Drug-Use Profiles, Race, Age, and Risk of HIV Infection among Intravenous Drug Users in San Francisco. The International Journal of Addictions, Vol. 26(12):1247-1261.
Wenger L, L Moore, L Hasbrouk, Case, G Clark, D Garcia (1990): Ethnography of the San Francisco Needle Exchange. Needle Exchange Programs, art III: North America, International Working Group on AIDS & IV Drug Use, Narcotic and Drug Research, Inc., New York, NY.
Wolk J, A Wodak, JJ Guinan, Macaskill, JM Simpson (1990): The Effect of a Needle Exchange on a Methadone Maintenance Unit. British Journal of Addiction, Vol. 85:1445-1450.
Yano E, D Longshore, M Gorman, M Hughes, MD Anglin (1991): HIV Infection Among Intravenous Drug Users. Prepared by the UCLA Drug Abuse Research Group for the California Department of Health Services, Office of AIDS.
For more details on this study, e-mail rhenderson@alliancehf.org for information on obtaining a copy
of the full 237 page report.
Back to SDCNE Home Page