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A Public Emergency: "Legal sanctions on injection equipment do not reduce illicit drug use, but they do increase the sharing of injection equipment and hence the spread of AIDS." 1 It's not hard to see why the public feels ambivalent about syringe exchange programs and the harm reduction model behind them. People fear that offering drug users access to clean needles will encourage drug use, increase the number of discarded syringes in the community and promote intravenous drug injection among young people. In other words, syringe exchange programs seem to be tantamount to state endorsement of drug abuse. Moreover, people are often not particularly concerned with the safety and health of intravenous drug users, because they mistakenly believe that the spread of disease among injection drug users will not adversely affect anyone but drug users themselves. Therefore, programs that have been set up to help provide services to intravenous drug users, or IDUs, by providing them with sterile injection equipment and access to health care and medical referrals are often not supported or funded by local, state or federal government in the United States. Indeed, in many parts of the country such programs are illegal, and staff and volunteers of these programs are regularly detained and arrested for providing services to intravenous drug users. These programs, which are commonly called Syringe Exchange Programs, or SEPs, are based on the idea of harm reduction, which encompasses a group of practical strategies used in coping with the needs of intravenous drug users. Harm reduction tactics favor compassionate common sense over didactic idealism, by "meeting users where they are at"2 by offering the level of help these users are ready to accept. The principles of harm reduction include accepting that, for better and for worse, licit and illicit drug use is present in our society, and that it is more practical to work to lessen the detrimental effects of drug use than to simply ignore or condemn the behavior. Harm reduction also calls for the "non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harms."3 These are the basic principles on which most syringe exchange programs are based. While harm reduction acknowledges that abstinence may be the ultimate objective, it also recognizes that this is not a pragmatic short-term goal for many drug users. Therefore, it seeks to reduce the risks associated with drug use, rather than setting the threshold for services so high-requiring total abstinence, for example-that the majority of drug users will fall short and fail to receive any help at all. Syringe exchange programs are a leading example of harm reduction. SEPs function as means of reducing harm, including the transmission of HIV, the virus that causes AIDS, as well as hepatitis and other health concerns that affect IDUs. In the United States, 97% of syringe exchange programs offered referrals to detoxification and drug treatment 4, and most SEPs offered other educational services and primary health care or referrals to apposite medical facilities. For instance, the San Francisco Needle Exchange--which is one of a handful of syringe exchange programs operating in San Francisco--serves a relatively youthful and primarily unhoused population in the Haight, and offers a range of services which include not only syringe exchange but health care, health referrals, detoxification and rehabilitation referrals, overdose prevention training and vein care workshops. The San Francisco Needle Exchange was also the target of the first needle exchange arrest in 8 years in the city of San Francisco, when its founders were arrested and charged with B&P code violations of possession of hypodermic syringes, illegal distribution of hypodermic syringes, sale of hypodermic syringes and sale without a permit. 5 In the United States today, the Center for Disease Control estimates that there are approximately one million intravenous drug users, and that they, their sex partners, and their children account for approximately one-third to one-half of new AIDS cases each year, and at least one-half of all hepatitis C cases.6 Thousands of deaths each year result from the transmission of disease through unsafe injection practices, as well as millions of dollars in avoidable health care expenditures. In response, the CDC claims that in order to "minimize the risk of HIV transmission, IDUs must have access to interventions that can help them protect their health."7 Syringe exchange programs, of course, not only protect the health of the drug user, but also that of his or her partner, and their children. Minimizing health risks related to intravenous drug use additionally includes reducing the incidents of discarded syringes in the community and accidental needle stick injuries by sanitation workers, firefighters and law enforcement personnel. This in turn affects the health of the community as a whole. Reducing the risk of disease transmission from intravenous drug use is also a societal concern in terms of the financial cost of medical care. The lifetime cost of treating just one person with AIDS is over $100,000,8 with the cost rising as new drugs allow for much longer life spans. The median cost of a city-wide syringe exchange program, by contrast, is only $169,000.9 This means that if just two people do not contract HIV due to services offered by their local syringe exchange program, the program has actually saved the public money. In fact, one study in the British medical journal Lancet estimates that up to 10,000 HIV infections could have been avoided in the United States between 1987 and 1995 if the federal government had implemented national syringe exchange programs. This would have saved over $500 million in health care costs. The group went on to suggest that between 1997 and 2000, 11,000 further infections could have been prevented, saving over $600 million of taxpayers' money.10 Although the CDC cautions that intravenous drug users "must be advised to always use sterile injection equipment," they stop short of calling for the actual provision of this equipment. HIV transmission among IDUs is primarily due to the scarcity of clean syringes. Currently, only approximately 164 syringe exchange programs (SEPs) operate in the United States, as compared to over two thousand SEPs in Australia, whose population is only 10% of the United States.11 As a result, Australia's IV drug using population has a 3% rate of infection, compared to levels of over 50% in other countries.12 In the United States, only 10% of intravenous drug users have access to a syringe exchange program that will give them new, sterile syringes in exchange for their used ones.13 The unavailability of sterile injection equipment, despite the CDC's recommendations, is a result of convoluted policies and laws that have been in place since long before the advent of the AIDS epidemic. While ostensibly these laws seek to protect the public, in reality they only have served to further the transmission of HIV--not only to drug users, but to their partners, who are many times unaware of their partner's drug use, and to their children. The National Institutes of Health has gone so far as to say that: "The behavior placing the public health at greatest risk may be occurring in legislative and other decision-making bodies. The Federal ban on funding for needle exchange programs as well as restrictions on selling injection equipment are absolutely contraindicated and erect formidable barriers to implementing what is known to be effective. Many thousands of unnecessary deaths will occur as a result."14 The United States is far behind other countries in stopping the spread of disease via unsafe injection practices. By the late 1980's, nearly all developed countries other than the United States had made access to sterile syringes legal as a means of preventing the spread of AIDS.15 The social rationales behind the U.S. political decisions against syringe exchanges seem to be relatively straightforward and easily disproven. Seven major government-funded reports agree that drug use does not increase with access to sterile syringes. A number of studies in the United States and Europe have shown that syringe exchange programs do not affect the rates of young users. A popular "not in my backyard" argument against syringe exchange programs cites the fear of discarded needles. In fact, access to sterile syringes does not increase the number of improperly discarded syringes, and in some neighborhoods it even decreased them.16 Once the arguments against syringe exchange programs are refuted, what remains behind the laws and policies that persecute intravenous drug users and those who try to provide them with services is the powerful, though unacknowledged, belief that those who use drugs are expendable, and that providing them with services is a futile endeavor. This attitude is clearly displayed in the United States' failure to federally fund syringe exchange programs. Under the terms of Public Law 105-78, federal funds to support syringe exchange programs were dependent on a determination by the Secretary of Health and Human Services that such programs reduce the transmissions of HIV and do not encourage the use of illegal drugs.17 In April 1998, the Secretary of Health and Human Services made that determination, but the restriction on federal funding was never lifted. In the United States, 48 states and the District of Columbia have laws that restrict the possession or distribution of "drug paraphernalia," which includes syringes for injection drug use.18 Moreover, syringe exchange programs are also subject to federal laws that prohibit the transportation and importation of drug paraphernalia. Many states also have laws that require a prescription to possess a syringe. In fact, some states such as Arkansas have laws on the books that go so far as to hold needle exchanges responsible for any crimes committed by, or treatment required by, their clients. The Arkansas codes state: "It is illegal to conduct, finance, manage, supervise, direct, or own any 'business' that manufactures, sells, stores, possesses, gives away, or furnishes drug paraphernalia. A drug paraphernalia 'business' can be held liable by a drug addict, a third party injured or killed by a drug user, a hospital patient or outpatient whose problems are drug abuse-related, or a federal or state agency paying for the care or treatment of a drug addict, if the business provided the drug user in question with drug use items." 19 Although most states have not gone so far as Arkansas in their condemnation of syringe exchange programs, nearly every state in America has some sort of restriction that limits users' access to sterile syringes. The most common legal barriers are the already mentioned drug paraphernalia laws, which are present in every state except Alaska.20 Most states' statutes are based on a model drug paraphernalia act released by the Department of Justice in the late 1970s.21 The statute defines drug paraphernalia as "equipments, products and materials of any kind which are used, intended for use, or designed for use in planting, propagating, cultivating, growing harvesting, manufacturing, compounding, converting, producing, processing, preparing, testing, analyzing, packaging, repackaging, storing, containing, concealing, injecting, ingesting, inhaling, or otherwise introducing in into the human body a controlled substance in violation of this Act." 22 The act then goes on to list a number of examples of drug paraphernalia. What is particularly interesting about the act is that the intentions or acts of the defendant are what, in reality, define drug paraphernalia. For example, a pipe sold to someone who has the intention of using it for smoking tobacco would not be considered drug paraphernalia. The same pipe, if bought with the intention of smoking marijuana, would be determined to be drug paraphernalia. Of course, this gives law enforcement personnel wide latitude in determining a potential defendant's intention. Because these laws are so broad, and could encompass almost any household item, many states offer factors to take into consideration when determining if an item is drug paraphernalia. One of the factors taken into consideration is legitimate uses for the item in question. Some have suggested that a this law could potentially be interpreted to include infectious disease prevention as a legitimate use for a syringe. 23 Drug paraphernalia laws are enforced in many states, including some that charge a violation of the statute as a felony.24 These statutes are particularly damaging with regard to the spread of disease for several reasons. Anti-paraphernalia laws encourage intravenous drug users to not own or carry syringes, which often leads to the sharing of unclean injection equipment. By the same token, users are encouraged by these laws to dispose of their injection equipment immediately upon use so as to not have them on their person, which often results in syringes being discarded in public locations or unsafely disposed of in the septic or sanitation system. Anti-paraphernalia laws also encourage users, if they are arrested, to attempt to conceal the fact of their syringe possession from police officers in the hopes that the syringes won't be discovered. This can result in dangerous needle stick injuries to police that costs on average $4,400 per injury for medical care and follow up for each employee.25 Police officers are clearly aware of the danger. Thus the chief of the San Francisco Police called for the overhaul of California's drug paraphernalia and syringe prescription laws by saying, "Fixing California's outdated syringe laws will not only improve the health of our communities, it will remove the incentive for drug users to hide syringes, which endangers our police officers." 26 Another barrier to sterile syringe access are pharmacy regulations that require that intended buyers demonstrate a legitimate medical or legal purpose for the purchase of syringes, and that pharmacies keep detailed records of this information and require proof of identification from each buyer. Many states also have syringe prescription laws, which regulate the sale and possession of hypodermic needles by requiring a doctor's prescription for the purchase or possession of a syringe. Syringe prescription laws have at least as much of an impact as pharmacy regulations, and many states, including California, have both kinds of laws in place. Although most states have laws on their books that effectively ban needle exchanges by creating laws against "drug paraphernalia," many states and municipalities have found creative ways around these laws. The most popular method in recent years has been to attack or amend the syringe prescription laws to allow the deregulation of syringe sales. This has the effect of not giving the public the impression of federal endorsement of syringe exchange programs, while still allowing intravenous drug users access to sterile syringes. In 1992, Connecticut became the first state to deregulate and allow over-the-counter purchase of syringes at pharmacies.27 The move was an unprecedented success. In the first year of deregulation, syringe sharing was reduced by 40%, street purchase of syringes dropped by 62% and police incidents of needle stick dropped by 66%.28 In 2000 New York and New Hampshire passed laws that allow the sale of 10 or fewer syringes in pharmacies. The same year, Rhode Island deregulated syringe sales altogether.29 Also, people purchasing syringes under this law cannot be arrested or prosecuted for syringe possession. Although California has one of the most antiquated statues regarding drug paraphernalia on the books-being one of the few states that still has strict syringe prescription laws-the state, and San Francisco specifically, has allowed syringe exchange programs to operate in its jurisdiction using techniques ranging from feigned ignorance during their inception to employing legal loopholes to allow their continued operation. In 1993, San Francisco was the first city in the state to provide public funding to a syringe exchange program, in defiance of the state law. Mayor Frank Jordan declared the city in a state of emergency,30 in a declaration which read in part: "I do hereby declare a public emergency to exist in connection with the AIDS epidemic and the high rate of HIV infection among injection drug users and the corresponding high rate of transmission of the disease. By virtue of said power, I do hereby direct the Department of Public Health, acting through the Health Commission and the Director of Public Health, to take immediate steps to implement a needle exchange program in order to prevent the further spread of HIV infection." 31 Since then, Salinas, Santa Clara, Los Angeles, Alameda and Marin Counties have all filed emergency declarations in order to allow syringe exchange programs to operate legally. It is clear that the policies behind laws that prevent syringe exchange programs from operating are the cause for thousands of deaths in the United States. Although significant progress has been made in the past decade, intravenous drug users are still contracting HIV in the United States at rates outrageously higher than those of countries such as Australia. What is particularly disturbing is the fact that these laws are based not on facts, but on prejudice. Moreover, this prejudice has proven to be terribly costly. Those who insist that the lives of drug users be treated as without value end up not only opposing harm reduction for drug users, but subjecting all of us to staggering social and financial costs and increased danger of disease. HIV - Human Immunodeficiency Virus. A retrovirus that causes AIDS by infecting helper T cells of the immune system. AIDS - Acquired Immune Deficiency Syndrome. A severe immunological disorder caused by the retrovirus HIV. AIDS is a serious (often fatal) disease of the immune system transmitted through blood products especially by sexual contact or contaminated needles. 32 IDUs - Intravenous Drug Users. CDC - Center for Disease Control and Prevention. A federal agency that developes and applies disease prevention and control methods. Hepatitis C - is a liver disease caused by the Hepatitis C virus (HCV), which is found in the blood of persons who have the disease. 33 SEP - Syringe Exchange Programs. The goal of SEPs is to reduce the transmission of HIV and other bloodborne infections associated with drug injection by providing sterile syringes in exchange for used, potentially contaminated syringes. 34 Harm Reduction - Harm reduction is a public-health approach to dealing with drug-related issues that places first priority on reducing the negative consequences of drug use rather than on eliminating drug use or ensuring abstinence.35 1. __.The Twin Epidemics of Substance Use and HIV. National Commission on Acquired Immune Deficiency Syndrome; 1991. 2. Association antiHIV. Harm Reduction: Drugs, AIDS and Prevention. Moldova: Mednet; 2001. < http://hr.mednet.md/en/> 3. Association antiHIV. Harm Reduction: Drugs, AIDS and Prevention. Moldova: Mednet; 2001. < http://hr.mednet.md/en/> 4. Paone D, Clark J, Shi Q, Purchase D, Des Jarlais DC. Syringe exchange in the United States, 1996: A National Profile. American Journal of Public Health, 1999: 89. 5. Luv, Matty and Giuliano, Ro. The Underage Exchange. Fall 1998 Harm Reduction Communication. 1998. <http://www.harmreduction.org/news/fall98/luv.html> 6. The Center for Disease Control, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention. Drug-Associated HIV Transmission Continues in the United States. CDC Fact Sheet, 2001. <http://www.cdc.gov/hiv/pubs/facts/idu.htm> 7. The Center for Disease Control, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention. Drug-Associated HIV Transmission Continues in the United States. CDC Fact Sheet, 2001. <http://www.cdc.gov/hiv/pubs/facts/idu.htm> 8.Hellinger, FK. Forecasts of the costs of medical care for persons with HIV: 1992-1995. Inquiry. 1992; 29. 9. Lurie, Peter, Reingold, A. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Prepared for the Centers for Disease Control and Prevention. University of California School of Public Health and Institute for Health Policy Studies; 1993. 10. Lurie, Peter, Drucker, E. An Opportunity Lost: HIV Infections Associated With a Lack of a National Needle-Exchange Programme in the USA. Lancet; 1997. 11. National Institutes of Health Consensus Panel. Interventions to Prevent HIV Risk Behaviors. Washington, DC: National Institutes of Health; 1997. 12. Puplick, Chris. Needle and Syringe Programs: Your Questions Answered. Australian National Council on AIDS, Hepatitis C and Related Diseases; 2000. 13. Ruiz-Sierra, Julie. The Lindesmith Center- Drug Policy Foundation. Research Brief: Syringe Access. Sacramento, CA: Lindesmith Center; 2001. 14. National Institutes of Health Consensus Panel. Interventions to Prevent HIV Risk Behaviors. Washington, DC: National Institutes of Health; 1997. 15. Ruiz-Sierra, Julie. The Lindesmith Center- Drug Policy Foundation. Research Brief: Syringe Access. Sacramento, CA: Lindesmith Center; 2001. 16. Ruiz-Sierra, Julie. The Lindesmith Center- Drug Policy Foundation. Research Brief: Syringe Access. Sacramento, CA: Lindesmith Center; 2001. 17. Department of Health and Human Services Appropriation Act, 1998 (Pub. L. 105-78 Title II, Nov. 13, 1997, 111 Stat. 1477.) as quoted by Ruiz-Sierra, Julie. The Lindesmith Center- Drug Policy Foundation. Research Brief: Syringe Access. Sacramento, CA: Lindesmith Center; 2001. 18. Scott Burris, JD, David Finucane, JD, Heather Gallagher, JD, and Joseph Grace, JD. The Legal Strategies Used in Operating Syringe Exchange Programs in the United States. American Journal of Public Health, August 1996, p. 1161 19. Arkansas Codes. Definition: §5-64-101, Fraud - Drug Paraphernalia - Penalties: §5-64-403, Illegal Acts: §5-64-802, Addict's cause of action: §5-64-902, Third Party's cause of action: §5-64-903, Reimbursement for costs of hospitalization or outpatient care: §5-64-904, Action for costs incurred by state or federal agency: §5-64-905. 20. Burris, Scott. Deregulation of Hypodermic Needles as a Public Health Measure: A Report on Emerging Policy and Law in the United States. AIDS Coordinating Committee of the American Bar Association, December 28, 2000. 21. Reprinted in Annotation, Validity, under Federal Constitution, of So-called "Head Shop" Ordinances or Statutes, Prohibiting Manufacture and Sale of Drug Use Related Paraphernalia, 69 A.L.R. Fed. 15 (1984 & Supp. 1998) 22. The Model Drug Paraphernalia Act as found in: Deregulation of Hypodermic Needles as a Public Health Measure: A Report on Emerging Policy and Law in the United States. AIDS Coordinating Committee of the American Bar Association, December 28, 2000. 23. Burris, Scott. Deregulation of Hypodermic Needles as a Public Health Measure: A Report on Emerging Policy and Law in the United States. AIDS Coordinating Committee of the American Bar Association, December 28, 2000. 24. ___. Project Sero: State-by-State Legislation. The Drug Reform Coordination Network. < http://www.projectsero.org/statelaw.shtml> 25. Malcalino, GE, et al. Community Based Programs for Safe Disposal of Used Needles and Syringes. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998. 26. Stoll, Michael. Sanders: Loosen Needle Laws. San Francisco Examiner. 9/25/02. 27. Project Sero. A Brief Timeline of U.S. Needle Exchange. The Drug Reform Coordination Network. <http://www.projectsero.org/timeline.shtml> 28. Groseclose SL, Weinstein B, Jones TS, et al. (CDC and Connecticut State Health Dept) Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting Drug Users and Police Officers-Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology as reprinted on harmreduction.org. 29. AIDS Coordinating Committee. Deregulation of Hypodermic Needles and Syringes as a Public Health Measure. Presented At: Syringe Deregulation Working Group Meeting. AK. March 2001. 30. Paddock, Richard C. S.F. to Provide Clean Needles to Drug Users. Los Angeles Times--Washington Edition; March 16, 1993. 31. San Francisco (CA) Emergency Declaration. Declaration of a Local Emergency by the Mayor (Part 1 of 2). March 15, 1993. As reprinted by Project Sero, Syringe Exchange Resources Online. 32. Dictionary.com <http://dictionary.reference.com/search?q=AIDS> 33. Center for Disease Control. Viral Hepatitis. National Center for Infectious Diseases; October 23, 2000. 34. Morbidity and Mortality. Weekly Report Volume 46, Number 24. Centers for Disease Control and Prevention; June 20, 1997. 35. Conley, P., et al. Harm Reduction: Concepts and Practice. A Policy Discussion Paper, Canadian Centre on Substance Abuse (CCSA) National Working Group on Policy; 1996.
__.The Twin Epidemics of Substance Use and HIV. National Commission on Acquired Immune Deficiency Syndrome; 1991. __. Reprinted in Annotation, Validity, under Federal Constitution, of So-called "Head Shop" Ordinances or Statutes, Prohibiting Manufacture and Sale of Drug Use Related Paraphernalia, 69 A.L.R. Fed. 15 (1984 & Supp. 1998) __. The Model Drug Paraphernalia Act as found in: Deregulation of Hypodermic Needles as a Public Health Measure: A Report on Emerging Policy and Law in the United States. AIDS Coordinating Committee of the American Bar Association, December 28, 2000. ___. Project Sero: State-by-State Legislation. The Drug Reform Coordination Network. < http://www.projectsero.org/statelaw.shtml> __. Project Sero. A Brief Timeline of U.S. Needle Exchange. The Drug Reform Coordination Network. <http://www.projectsero.org/timeline.shtml> AIDS Coordinating Committee. Deregulation of Hypodermic Needles and Syringes as a Public Health Measure. Presented At: Syringe Deregulation Working Group Meeting. AK. March 2001. Arkansas Codes. Definition: §5-64-101, Fraud - Drug Paraphernalia - Penalties: §5-64-403, Illegal Acts: §5-64-802, Addict's cause of action: §5-64-902, Third Party's cause of action: §5-64-903, Reimbursement for costs of hospitalization or outpatient care: §5-64-904, Action for costs incurred by state or federal agency: §5-64-905. Association antiHIV. Harm Reduction: Drugs, AIDS and Prevention. Moldova: Mednet; 2001. < http://hr.mednet.md/en/> Burris Scott, David Finucane, JD, Heather Gallagher, JD, and Joseph Grace, JD. The Legal Strategies Used in Operating Syringe Exchange Programs in the United States. American Journal of Public Health, August 1996, p. 1161 Burris, Scott. Deregulation of Hypodermic Needles as a Public Health Measure: A Report on Emerging Policy and Law in the United States. AIDS Coordinating Committee of the American Bar Association, December 28, 2000. Center for Disease Control, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention. Drug-Associated HIV Transmission Continues in the United States. CDC Fact Sheet, 2001. <http://www.cdc.gov/hiv/pubs/facts/idu.htm> Center for Disease Control. Viral Hepatitis. National Center for Infectious Diseases; October 23, 2000. Center for Disease Control. Morbidity and Mortality. Weekly Report Volume 46, Number 24. Centers for Disease Control and Prevention; June 20, 1997. Conley, P., et al. Harm Reduction: Concepts and Practice. A Policy Discussion Paper, Canadian Centre on Substance Abuse (CCSA) National Working Group on Policy; 1996. Department of Health and Human Services Appropriation Act, 1998 (Pub. L. 105-78 Title II, Nov. 13, 1997, 111 Stat. 1477.) as quoted by Ruiz-Sierra, Julie. The Lindesmith Center- Drug Policy Foundation. Research Brief: Syringe Access. Sacramento, CA: Lindesmith Center; 2001. Dictionary.com <http://dictionary.reference.com/search?q=AIDS> Groseclose SL, Weinstein B, Jones TS, et al. (CDC and Connecticut State Health Dept) Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting Drug Users and Police Officers-Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology as reprinted on harmreduction.org. Hellinger, FK. Forecasts of the costs of medical care for persons with HIV: 1992-1995. Inquiry. 1992; 29. Lurie, Peter, Drucker, E. An Opportunity Lost: HIV Infections Associated With a Lack of a National Needle-Exchange Programme in the USA. Lancet; 1997. Lurie, Peter, Reingold, A. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Prepared for the Centers for Disease Control and Prevention. University of California School of Public Health and Institute for Health Policy Studies; 1993. Luv, Matty and Giuliano, Ro. The Underage Exchange. Fall 1998 Harm Reduction Communication. 1998. <http://www.harmreduction.org/news/fall98/luv.html> Malcalino, GE, et al. Community Based Programs for Safe Disposal of Used Needles and Syringes. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998. National Institutes of Health Consensus Panel. Interventions to Prevent HIV Risk Behaviors. Washington, DC: National Institutes of Health; 1997. Paddock, Richard C. S.F. to Provide Clean Needles to Drug Users. Los Angeles Times--Washington Edition; March 16, 1993. Paone D, Clark J, Shi Q, Purchase D, Des Jarlais DC. Syringe exchange in the United States, 1996: A National Profile. American Journal of Public Health, 1999: 89. Puplick, Chris. Needle and Syringe Programs: Your Questions Answered. Australian National Council on AIDS, Hepatitis C and Related Diseases; 2000. Ruiz-Sierra, Julie. The Lindesmith Center- Drug Policy Foundation. Research Brief: Syringe Access. Sacramento, CA: Lindesmith Center; 2001. San Francisco (CA) Emergency Declaration. Declaration of a Local Emergency by the Mayor (Part 1 of 2). March 15, 1993. As reprinted by Project Sero, Syringe Exchange Resources Online. Stoll, Michael. Sanders: Loosen Needle Laws. San Francisco Examiner. 9/25/02.
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