San Francisco is unique in that a group of community activists started an underground needle exchange before HIV became widespread among the injection drug community. For several years, the needle exchange remained illegal. At some point, the San Francisco Board of Supervisors agreed to declare a State of Emergency every few weeks, protecting one of San Francisco's needle exchange efforts from harassment and arrest by the police. What we have now, then, is a kind of bizarre mix of the "legal" needle exchange, run by HIV Prevention Project (HPP), an organization affiliated with the AIDS Foundation, and several illegal exchanges throughout the city, including secondary exchange.

Secondary exchange is when someone collects needles and hands out clean ones and then exchanges them at a formal site. These secondary exchangers can be outreach workers, or someone who takes on exchanging for their group of friends, or the only able-bodied person in a residential hotel who can make the walk to the exchange site. In truth, most people are secondary exchangers — almost everyone exchanges for themselves AND a friend or lover or neighbor at least some of the time.

The existence of various levels of exchange can set up some weird dynamics. Perhaps it is obvious that clean needles are valuable and are bought, sold and traded by people who use. Now, however, dirty needles are now worth a clean one because of needle exchange. You can use dirty needles to "buy" clean ones. And while I don't think this is a problem — needle exchange is a wonderful idea even if it leads to some weird dynamics — it is interesting how this activist effort to prevent the spread of HIV (and now Hepatitis B and C as well) becomes another place for "the market" or a kind of commerce.

Volunteering with HPP has not made me re-think the world. I did expect both the well-dressed businessmen and the person who hasn't washed in weeks. I did expect that some people would be polite and grateful on the one hand while others would come in drunk or angry and try to trick us on the other hand. I knew that needle exchange would pull together people from the diverse range of injection drug users and that while most would be poor, homeless, or housed in bad housing, there would still be several kinds of people. Perhaps ironically since I do work on youth health, I didn't expect so many young people. (But I am glad that they are coming to the exchange.) What I have mostly been surprised by, however, are the people who think needle exchange doesn't help or doesn't work.

I interviewed Noah Feinstein, a young person who is currently volunteering in San Francisco's Polk district, about his experiences as an exchanger. He had a lot of great knowledge about how needle exchanges do work.

Where do you volunteer?

I started in September [1999] and volunteer at the Hemlock Alley site. It's an outdoor site in the Polk Gulch area of SF.

Why did you start?

It was sort of roundabout — through work. The company I work for, Sociometrics Corporation, identifies effective AIDS prevention programs by looking at studies that have been done and then contacting the people who run the program in order to develop a way for other people to create the same kind of program. I was assigned the HIV Prevention Project (HPP). Also, I feel more comfortable living somewhere where I am involved in something that is part of the substance of the city. I think needle exchange provides a valuable contrast to the other impression one gets of San Francisco-the lofts and dot.coms.

Tell me some stories from Hemlock Alley.

Well, it's an outdoor site, which determines some of the feel of the site. Some of the exchangers wouldn't feel comfortable going to an indoor sight, even a storefront. They just wouldn't enter anywhere to exchange. We have a very distinct cast of characters. One transgender woman says "T for transgender" every time so that we mark it right on our data sheet. [We have to mark "M" for male, 'F' for female or 'T" for transgender for everyone who exchanges needles.] Lots of people do secondary exchange. We really get a window on the people who exchange, watching their ups and downs. One guy was totally self-assured when I first met him. He was always blunt, but would bring in 100-200 points [needles] to exchange for several people. He was taking care of them. But then he didn't show up for a while. Maybe he was busted. Maybe in the hospital. I don't know. But now he comes with only a few points each time. And his confidence is gone. He was a user before and is one now, but there is a world of difference in his life.

Do you have any positive stories?

People don't usually get healthier. If they have, maybe they aren't coming to the exchange anymore. But we definitely see the other wonderful things in their lives. Right now, one exchanger just got a new place and is renovating it with her partner. Every week we hear about the latest thing they have done to fix up their place. And of course, every week we see examples of people supporting each other. Even if it's only that people exchange for others. Or that we are there in the first place.

How do you feel as a volunteer?

One of the things that's important to communicate is that my own background made me nervous. I came from very privileged, white suburban background. I wasn't sure how exchangers would react to me. I was afraid it would feel paternalistic. But it's not charity. I don't think the exchangers feel it's charity. They recognize that it's a public health need for them and for all of us, that we are doing this for each other together. You don't have to be a injection drug user to benefit from Needle Exchange.

What do you think of the difference between HPP, the "legal needle exchange" and the other exchanges in the city?

We always run into people who want to work the system, or feel entitled to work it, or feel the only way to survive is to work it. And sometimes people see Needle Exchange as a part of the system. Especially as compared to the more underground needle exchanges. Overall, though, the image that needle exchanges are illegal can be an advantage. We are less likely to be seen as one with "the Man." And, if you give them extra needles or extra supplies, someone else will use them, which is the point.

You did the research for your job on how needle exchanges work. Can you tell me more about that?

There have been about six major federally funded studies that show that needle exchange, when done properly, does reduce transmission of HIV without increasing drug use.

Why do people still oppose needle exchange?

Sometimes because of ignorance. They aren't familiar with the research or they have a mistrust of science when it contradicts their own instincts. Sometimes because of prejudice — "They are only drug users. Give them dirty needles and let them die." Sometimes because of image — supporting needle exchange makes politicians appear soft on drugs even though polls show support for needle exchanges. People who have to deal with injection drug users everyday DO support needle exchange — certain factions of police officers, the AMA, the council of Mayors. These people now that needle exchange makes a difference and helps them face the challenges of running a city, preventing crime or keeping people healthy. In the end, though, we need to address the root problems of drug use. Meanwhile, needle exchange is a powerful program which ought to be supported.

For more information:

Drug Policy Alliance
www.drugpolicy.org

Harm Reduction Coalition
www.harmreduction.org

article from Reality 16, the final issue, summer 2000

Telling people you're hiv+ can be hard, especially when you're interested in hooking up w/ them. some people believe that if [your partner] doesn't ask, then the only obligation you have is 2 do everything in your power 2 reduce the level of transmission risk, however you define that, 2 as low as possible. meanwhile, some [people] are real up front about their status and discuss it openly w/ friends and sex partners. some [people] are selective and careful about who they tell. unfortunately, still, others are in denial about their status, while some plain out lie about it. what makes people think these things, act these ways??

well, living with hiv/aids is hard, and our communities aren't always cool w/ hiv+ gente. revealing your hiv status 2 some1 can lead 2 people gossiping about you, some people might discriminate against you, some people may discriminate against your family or loved ones b/c of your hiv, you may be rejected in social, dating, or sexual situations, people might react violently, abusively, or in ways that are dangerous 2 your safety and bienestar when they find out about you. the truth is disclosure isn't always as easy as it may sound. at the same time, telling others about yourself can be good. you can get love and support 2 help you deal w/ your health. you can keep close friends and loved ones informed about issues that are important 2 you. you can get the most appropriate health care. you can make connections w/ other hiv+ people. you can reduce the chances of transmitting the disease 2 others. and you don't have 2 hide!! ideally, we'd talk about our hiv statuses, about risk and safety, about what we like and what we don't like prior 2 getting it on. but we don't always live in an ideal world.

here are sum guiding principles 4 disclosure--take 'em or leave 'em:
1) try not 2 lie
2) you don't have 2 tell everybody, take your time 2 decide who 2 tell and how you will approach them
3) treat others the way you would like 2 be treated, and
4) critical thinking is central 2 good, informed health decision making.
orale.

article from Reality 15