In last month's Jacksonville Medicine we published the conclusions reached by the citizens' committee assigned to study the viability of a needle exchange program for injection drug users in Duval County. Printed below are the specific suggestions for change that the group has recommended. If you have any suggestions or comments to share on this issue, please contact Dr. Jeff Goldhagen, Director of the Duval County Health Department. If you would like a complete copy of the Citizens Report on Needle Exchange as a Harm Reduction Strategy for Injection Drug Users in Duval County you can contact the DCMS office via e-mail: info@dcmsonline.org.

Phil Gilbert, EVP

Recommendations

1. The Duval County Health Department should disseminate this report, in its entirety, throughout the community. In addition, the Health Department should distribute the report, by August 1999, to appropriate elected and appointed officials at the state level and within Duval County.
2. Community-based organizations, faith-based institutions, law-enforcement officials, judicial-system officials, advocacy groups, higher-education institutions, and health-care providers should join the Duval County Health Department in reviewing the report with care and in embracing its recommendations. These entities should then seek ways, separately and through collaboration, to design, operate, and evaluate a pilot, needle-exchange program in Duval County. The pilot program should be implemented:

• as part of the continuum of harm-reduction services provided in Duval County for intravenous drug abusers; and
• in direct conjunction with drug-treatment programs available in the community.

The program should provide an opportunity for intravenous drug abusers both to avoid HIV and other infections resulting from the use of contaminated needles and to receive adequate treatment for their drug abuse.

The operation of a pilot, needle-exchange program should not impede the strict enforcement of drug-possession and drug-use laws for all persons. Exemption of program personnel and participants from arrest and prosecution under the state and city paraphernalia laws should not impede the arrest and prosecution of others who violate the paraphernalia laws.

3. Implementation of the pilot, needle-exchange program should be guided by the following four-phase strategy:

Phase 1: Community Awareness

The community should immediately develop and implement a public awareness and information campaign designed to enhance the community's understanding of:

• the nature and effects (on both individuals and the community) of drug addiction;
• the purpose of harm reduction in conjunction with treatment for drug abusers; and
• the important role an effective needle-exchange program can play as one component of a comprehensive harm- reduction program.

Phase 2: Political Advocacy

Beginning in September 1999, the community should advocate to the Duval Delegation and the Florida Legislature for the enactment of an exception to the state paraphernalia law that would allow the legal operation of the desired pilot, needle-exchange program in Duval County.

Beginning in September 1999, the community should advocate to the Mayor and City Council of Jacksonville for the enactment of an exception to the city paraphernalia ordinance that would allow the legal operation of the desired pilot, needle-exchange program in Duval County.

Phase 3: Implementation

Once the Florida Legislature and Jacksonville City Council have approved the desired exceptions, the community should establish the desired pilot, needle-exchange program.

The pilot, needle-exchange program's structure should include an oversight committee representative of the community's diversity, whose purpose is to ensure the effectiveness of the program.

To be effective, the program should include the following elements:

• scientific, case-control design so that accurate evaluation of program results can be conducted;
• strict operational controls including formal enrollment of program participants, use of marked needles, and one-for-one needle exchange;
• exemption of program staff and participants from prosecution under the paraphernalia laws but strict enforcement of drug-possession, drug-use, loitering, prostitution, and other related laws;
• a provision to limit and address potential legal-liability issues;
• detailed, measurable performance standards;
• rigorous measurement of program outcomes;
• strong linkages to adequate treatment services, including methadone, detoxification, residential treatment, and counseling; and
• provision of health-promotion outreach and testing, along with adequate referral connections with other health-care services.

Phase 4: Evaluation

The outcomes of the pilot program should be evaluated at the conclusion of the trial period. The evaluation should document the effects of the pilot needle-exchange program on:

• local HIV and hepatitis transmission rates;
• the proportion of local drug abusers receiving drug treatment; and
• trends in crime rates in the area surrounding the program site.

The evaluation should determine the effectiveness of the program and guide the subsequent decision on whether to seek to continue or to abandon needle exchange in Duval County. The program should be abandoned if program outcomes do not meet established performance standards or if the program has a negative impact on the community.

4. The Florida Legislature should consistently provide funding for substance-abuse treatment services in Duval County at a level that meets current and projected needs, so that all drug abusers benefiting from harm reduction, including needle exchange, are able also to receive the treatment they need.

October, 1999/ Jacksonville Medicine

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