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VII. INTERFERENCE WITH OTHER MODES OF SYRINGE ACCESS

Public health experts and injection drug users in California consistently stated that syringe exchange programs are a necessary but insufficient component of a comprehensive HIV prevention strategy for injection drug users, their sex partners and their children. Just as important as syringe exchange, witnesses said, is having a legal system that does not prohibit drug users from purchasing syringes in a pharmacy without a medical prescription. As of this writing, California is one of five states in the United States that requires a prescription to purchase a hypodermic syringe; the others are New Jersey, Pennsylvania, Massachusetts, and Delaware.

It is technically possible for some injection drug users to obtain a medical prescription to purchase sterile syringes, thus complying with existing pharmacy laws. Indeed, experts have argued that prescribing and dispensing injection equipment to prevent HIV infection are “ethical, clinically appropriate, and fully consistent with current public health guidelines on disease prevention.”195 In June 2002, the American Medical Association adopted a resolution that supported “the ability of physicians to prescribe syringes and needles to patients with injection drug addiction and in conjunction with addiction counseling in order to help prevent the transmission of contagious diseases.”196 However, for individuals who either cannot obtain a medical prescription or do not have access to syringe exchange programs, nonprescription pharmacy sale of syringes is a life-saving alternative.

The need for alternatives to syringe exchange

As Human Rights Watch’s research in California indicates, there are numerous reasons why syringe exchange programs will never be a sufficient source of sterile syringes for injection drug users, even if they become legal in all fifty states. Some injectors, such as thirty-four-year-old Ted T. in Oakland, would be deterred from associating with a health service known to cater to users of illegal drugs. “I didn’t go to needle exchanges for a long time, because I thought there was a stigma attached to it,” Ted T. told Human Rights Watch. “Or somebody was going to see me in a big line out the door or something and go, ‘Okay, well there’s a drug user’.”197 Other injectors said that they did not want to be publicly identified with an HIV prevention program. “‘AIDS? That’s not me. I don’t have sex with men’,” said former user and outreach worker Hector Barrera, describing the attitude of many of his clients towards HIV prevention programs.198 The syringe exchange program coordinator in Lake County spoke of an affluent friend who “can’t somehow bring herself” to use syringe exchange.

There are injectors in very affluent places in this county. I know one, and she won’t come and exchange. We are friends, we work together, and . . . she says, “I can’t.” She shares. She told me, and I live around the corner from her, and she could come to my house day or night, and I would always. I think [she shares] every time she injects, because she doesn’t inject herself. She shares with her ex-partner and she shares with his family.199

Susan Black, a public health officer in Alameda County, sympathized with injection drug users who felt reluctant to use a service they found inconvenient and stigmatizing. “You don’t expect to go to a van on the street for a pap smear,” Black said. “Syringe access has to become like the rest of health care.”200

While it is not certain that injectors who resist syringe exchange programs would buy syringes in the pharmacy if that were a possibility, the convenience of pharmacy sales would make a difference to some. One man interviewed by Human Rights Watch said he drove three and a half hours to a syringe exchange in San Francisco in order to pick up sterile syringes for his wife. Numerous satellite exchangers said that they picked up syringes for friends or family members who did not find the syringe exchange accessible. And some injectors told Human Rights Watch that they had in the past bought syringes in pharmacies, either in states other than California or in local pharmacies that allowed over-the-counter sale of syringes.

Another advantage of nonprescription pharmacy sale of syringes is that they provide added impetus to expand options for the safe disposal of syringes201 without holding injection drug users to strict protocols that may jeopardize their health. Such protocols include “one-for-one” exchange (requiring injectors to turn in as many syringes as they receive) and “ten and under” caps (limiting the number of syringes that may be distributed) which, in the view of experts, “reflect political rather than public health imperatives.”202 At a syringe exchange program in Los Angeles, outreach worker Dyhan Cardona told Human Rights Watch of the difficulty of serving clients effectively under such rules. “If you get a new person with no syringes, are you going to tell them, ‘No’?,” she asked. “If I say, ‘Only one’, and it stops up,203 they’re still going to use somebody else’s.”204 Many syringe exchange programs visited by Human Rights Watch offered new clients a “starter pack” of more than one syringe, but those that did sometimes placed caps on the total number of syringes that could be exchanged. In such cases, Cardona said, clients had no incentive to return more than the maximum number of number of syringes that could be distributed.

Cardona’s concerns are corroborated by Burris and colleagues, who concluded that one-for-one policies and caps “may have in some instances a significant impact on the effectiveness of official [syringe exchange programs], and may explain why illegal or unofficial [syringe exchange programs] may continue to operate in states that have authorized legal programs.”205 Cardona added that policies limiting syringe distribution were dictated in part by fiscal considerations, which in turn may be linked to the federal government’s continued ban on syringe exchange funding.206 This demand for additional avenues of syringe access may be met at no cost to the state by allowing nonprescription pharmacy sale of syringes.

Opposition to nonprescription pharmacy sales in California

To date, proponents of expanded syringe access have not been able to secure legislation in California that would authorize the nonprescription pharmacy sale of sterile syringes. Opponents of nonprescription pharmacy sales have continued to argue that such legislation is not needed because of the existence of syringe exchange programs. In a letter to Governor Gray Davis urging a veto of SB 1785, legislative counsel John Lovell summarized these concerns on behalf of the California Police Chiefs’ Association and the 4,000-member California Peace Officers’ Association:

The best that can be said about this bill is that it is unnecessary. California already has a statutory scheme for needle distribution programs. Those statutory provisions were enacted as Assembly Bill 136 in 1999 and had the support of both the law enforcement and public health communities.207

Sacramento county health officer Glennah Trochet described this as “the hidden agenda of supporting AB 136 globally so that you can go jurisdiction by jurisdiction and oppose it locally.” Indeed, in a letter sent to all county boards of supervisors on May 8, 2000, the president of the California Narcotic Officers’ Association, Walt Allen III, cautioned against any declaration of a local emergency that would authorize syringe exchange. “I need to be clear with you,” Allen wrote. “[T]he California Narcotic Officers’ Association strongly opposes needle exchange programs.”208 The major law enforcement associations in California also opposed AB 136’s earlier version, AB 518, which would have protected both providers and users of syringe exchange from prosecution for possession and distribution of drug paraphernalia.209



195 S. Burris, P. Lurie, D. Abrahamson, and J. Rich, “Physician Prescribing of Sterile Injection Equipment To Prevent HIV Infection: Time for Action,” Annals of Internal Medicine, vol. 133 (2000), pp. 218-226.

196 C. Marwick, “Prescribing Sterile Needles Is Not Only Beneficial but (Mostly) Legal,” Journal of the American Medical Association, vol. 284, no. 10(2000).

197 Human Rights Watch interview with Ted T., Hayward, California, January 25, 2003.

198 Human Rights Watch interview with Hector Barrera, Sacramento, California, February 4, 2003.

199 Human Rights Watch interview with coordinator of Lake County syringe exchange, Clearlake, California, February 1, 2003.

200 Human Rights Watch interview with Susan Black, January 29, 2003.

201 See, e.g., Susan J. Klein, George R. Estel, Alma R. Candelas, and Hope A. Plavin, “Promoting Safe Syringe Disposal Goes “Hand in Hand” with Expanded Syringe Access in New York State,” Journal of the American Pharmaceutical Association, vol. 42, no. 6, Suppl. 2 (2002), pp. S105-S107.

202 Burris et al., “Syringe Access Law...”, pp. 33-34.

203 “Stops up” means the syringe gets clogged by solid matter or impurities in the injected preparation.

204 Human Rights Watch interview with Dyhan Cardona, Bienestar syringe exchange, Los Angeles, California, February 7, 2003.

205 Burris et al., “Syringe Access Law...”, p. 34.

206 See “IV. Background,” above.

207 Letter from John Lovell, Government Relations Manager for the California Peace Officers’ Association and the California Police Chiefs’ Association, to Governor Gray Davis, September 3, 2002.

208 Letter from Walt Allen III, president of the California Narcotic Officers’ Association, to members of the board of supervisors of Sacramento County, May 8, 2000.

209 Letter from California State Sheriffs’ Association, California Police Chiefs’ Association, California Peace Officers’ Association, California Narcotics Officers’ Association, and Association for Los Angeles Deputy Sheriffs to Assembly Member Kerry Mazzoni, September 3, 1999.


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September 2003