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INTRODUCTION" We are out here saving lives.”1 Ron Daniels, Program

Manager Prevention Works!, a harm reduction program in Washington D.C .When I

wrote the original version of this paper in 1999, I understood that harm

reduction services that include pro-viding clean syringes to injecting drug

users (IDUs) and providing safe disposal of dirty syringes were saving lives. I

had visited harm reduction programs and needle exchange sites and had seen men and

women, young and old, who came to get clean needles so that they would not get

infected with HIV. However, as the years have gone by since the Public Welfare

Foundation began funding harm reduction programs and as I have spent more time at

needle exchange sites, I have a greater appreciation that this is indeed

life-saving work. Today, I would call this publication Harm Reduction: A

Life-Saving Strategy in the Fight against AIDS. Now more than ever, there is a

greater urgency for government, at all levels, to recognize the life-saving

nature of harm reduction strategies. As former U.S. Surgeon General

Joycelyn Elders stated: “We must recognize the spread of AIDS through dirty

needles as the public health problem that it is. We must accept the scientific

data and stand up for needle access pro-grams and begin to save precious

lives!”2When the Foundation distributed the first edition of this publication,

our primary audiences were policymakers and other funders to convince them of

the need for both public and private Harm Reduction: A Critical Strategy in AIDS

Prevention2

      Page 4

financial support for harm reduction services. We wanted to share our experience

of supporting harm reduction as a part of our fund-ing of efforts to prevent the

spread of HIV/AIDS. The Foundation received very positive responses about the

publication from other foundations, members of Congress, and officials in the

Clinton Administration, including Surgeon General Dr. David Satcher. To our

surprise, however, the biggest response came from organizations that are

providing harm reduction services across the country. They told us that they

appreciated the fact that a foundation had come forward with a public document

that in straightforward and accessible language made a case for support-ing

needle exchange as an AIDS-prevention strategy. They told us that they carried

the publication with them when they met with their local health and police

officials to get their support. They told us that they have copied it over and

over and taken it to every meeting where they advocate for harm reduction. This

response to the paper prompted us to prepare this update-ed and revised version

with a forward by Patsy S. Fleming, a White House director of AIDS in the Clinton

Administration. In addition, while the scientific evidence supporting the

Effectiveness of needle exchange was there in the past, today, there is an

even clearer picture of the relationship of needle exchange and the decline in

HIV/AIDS among populations with the highest rates. For example, in November 2005,

in New York, where needle exchange programs were introduced as a harm reduction strategy in 1992, a state health official acknowledged that such programs

helped explain declining HIV infection rates.3 In Philadelphia, an eight-year

study conducted by the University of Pennsylvania’s Center for Studies of

Addiction documented the relationship between the introduction of Prevention

Point Philadelphia’s syringe exchange 3

      Page 5

program, needle-sharing behaviors among injectors, and new infections of HIV. The study showed that among IDUs followed during the eight years of the study, the rate of new HIV

infections dropped from 6.8% per year to less than .05% per year.4A recent report

released from the Centers for Disease Control and Prevention (CDC) stated that

although African Americans are still eight times as likely as whites to be

diagnosed with AIDS, the rate of newly reported HIV cases among African Americans

has been dropping by about 5% a year since 2001. It stated that this falling rate

seemed to be tied to overlapping declines in diagnoses among injection drug users

and heterosexuals.5 Another purpose of this revised and updated version is to

pro-vide information about the organizations that we have supported. Through our

relationship with these grantees, we have learned about the complex challenges

harm reduction programs face, including: their legal vulnerabilities; their need

to address the serious Hepatitis C epidemic that is so prevalent among

injection drug users; their work to engage and garner the support of

the low-income communities where they work; their commitment to involve their

clients in setting the directions of their programs; their recognition of the

needs of a very diverse population of IDUs; and their tireless efforts to

advocate for policy changes, such as their work to increase resources for drug

treatment and federal funding of needle exchange programs. In spite of these

challenges, these organizations have successfully helped to prevent the spread

of HIV/AIDS and other blood-borne diseases, have helped injection drug users get

into treatment, have reached thousands of people who are out of the reach of

health and social services, and have saved lives. Adisa Douglas

      Page 6

Harm Reduction: A Critical Strategy in AIDS Prevention

H A R M R E D U C T I O N

In May 1992,  I was watching the local news on a Washington D.C. television

station with my friend. There on the TV screen was Mayor Sharon Pratt Kelly,

talking about the need to provide clean needles to injection drug users in order

to reduce the spread of HIV in the District of Columbia. Mayor Kelly kept

referring to this concept as needle exchange and was proposing that local

medical clinics provide sterile needles to drug addicts who turn in their used

syringes. I exclaimed, “She wants to do what?” I didn't understand. How could our

mayor be proposing something that enabled drug use? Won’t this just encourage

people to use injection drugs? My friend explained to me that contamination of

needles through injection drug use was one of the main reasons the AIDS epidemic

was growing so rapidly, particularly in the Black community. Two years later, I

came across a statistic that made me stop in my tracks: in 1991, the year

before Mayor Kelly advocated for needle exchange in D.C., 52% of AIDS cases among

African Americans and 45% of cases among Latinos were associated with intravenous

drug use. The corresponding percentage for whites was only 19%.6 I now

fully understood the importance of needle exchange. By then, I was a Program

Officer at the Public Welfare Foundation, responsible for the Population and

Reproductive Health Initiative (now the Reproductive and Sexual Health Program),

which included most…these organizations have helped to prevent HIV/AIDS... have

helped injection drug users get into treatment,… and have saved lives.

      Page 7

of the Foundation’s AIDS funding. I thought, as I read this statistic over and

over again, that the Foundation needed to find away to address this public

health problem. The Foundation was already well established as an AIDS funder,

having supported programs in this area since 1986. In 1994,the Foundation’s

Board of Directors further defined our AIDS funding as support for programs

that work to prevent the spread of HIV/AIDS among populations in which the rate

of infection is growing most rapidly, including women, teens, and people ofcolor.

This guideline was established in the context of the overall mission of the

Foundation to support low-income people in their development and implementation

of strategies to address the problems in their own communities. The Foundation’s

overall mission and board guidance provided the context for my review of our

first needle exchange propos-al, which came in 1996 from an organization called

Prevention Point Philadelphia. Prevention Point is a comprehensive harm reduction

program providing needle exchange, street outreach, basic medical care, referral

services, and a drop-in center. Its staff and volunteers, including then

Executive Director Julie Parr, educated me on the concept of harm reduction,

the broader term encompassing needle exchange. During my site visit to Prevention

Point, I joined staff and volunteers at a needle exchange site in North

Philadelphia. The site visit was on a beautiful day in early fall; so we

wearable to set up outdoors instead of operating from the mobile van. At a vacant

corner lot located on a block of mostly abandoned row houses, we placed folding

tables and chairs to create stations—one for informational brochures and

condoms, another for exchange of needles, and another for bleach kits. As if some

silent Harm Reduction: A Critical Strategy in AIDS Prevention6

      Page 8

bell had rung, in just a few minutes of our getting the site ready, people

started to line up. There were men and women, young and old; although most looked

old beyond their years. They seemed to come from nowhere and were clearly

representative of a very marginalized population that traditional social services

and health agencies were not reaching. However, they understood that in order to

prevent getting the HIV virus, they had to come" above ground” to get clean

needles. They knew the routine: pro-vide your identification number, the number

of needles being exchanged, and the number of people using the needles; bundle the

needles with a rubber band and carefully place them in the used-syringe bucket;

pick up bleach kits and condoms, maybe a brochure or two; and be on your way. For

the Reverend Edwin Sanders, an African American minister who initiated a harm

reduction program as part of his ministry at the Metropolitan Interdenominational

Church in Nashville, this routine is “sustaining life.” He sees harm reduction as

a medical intervention that saves lives. In response to the question often posed

to him as to why he provides bleach kits and clean needles to injection drug

users, he states: “I can’t reach people if they are dead. Needle exchange has

enabled us to reach a population in our community that has been totally ignored.

It provides us an opportunity. It can be a bridge to treatment and

recovery.”7Today, in 36 states and the District of Columbia, 162 known harm

reduction programs8are “sustaining life” by preventing the spread of HIV and

other blood-borne diseases, such as Hepatitis C, through infected needles. These

harm reduction programs are essential in the fight against AIDS because they

reduce HIV transmission among intravenous drug users, their sexual partners and

their children.7Harm Reduction: A Critical Strategy in AIDS Prevention

      Page 9

Harm reduction is more than needle exchange. Most harm reduction programs,

despite limited resources, provide a range of services that they consider

essential. In a survey of 126 programs in 102 cities in 31 states and the

District of Columbia, a broad range of services were identified: educational

materials on risk-reduction and risk elimination; distribution of male and

female condoms; alcohol pads and bleach kits; referrals for substance-abuse

treatment and other medical and social services; and on-site counseling and

testing for HIV, Hepatitis C and Hepatitis B. In addition, some programs provided

hepatitis vaccinations; sexually transmitted disease screening; on-site medical

care; tuberculosis screening; abscess prevention and care and vein care.9In

Health Emergency 1999, Dr. Dawn Day, an activist scholar and director of the

Dogwood Center, an independent research organization in Princeton, points out that

the concept of harm reduction is not new. She notes: “We as a society practice

harm reduction all of the time. We reduce the harm of riding a motor-cycle by

requiring riders to wear helmets. We reduce the harm from car accidents by

requiring people to wear seat belts. We reduce the harm to non-smokers by

requiring that smoking be done only in designated areas. The goal of needle

exchange isto reduce the harm from injection drug use.”10The critical nature of

needle exchange as a strategy in AIDS prevention becomes clear when one looks at

the extent to which injection drug use has played a role in the epidemic. In the

U.S.,Harm Reduction: A Critical Strategy in AIDS Prevention8The mode

of transmission in 37%of the reported AIDS cases among African American

women through 2003 was injection drug use, andit was the same for Latina women—37%.

      Page 10

24% of the reported AIDS cases cumulative through 2003 among adults and

adolescents in the U.S. were injection drug users. An additional 10% of reported

AIDS cases were sexual partners of injection drug users, both heterosexual and

male-to-male contact.11The HIV/AIDS epidemic has had an especially

disproportion-ate effect on people of color, especially among African

Americans and Latinos, and injecting drug use has been a significant mode of

transmission among these populations. In 2003, African Americans accounted for

49% of the estimated AIDS cases diag-nosed in the U.S. The rate of AIDS

diagnoses for African Americans was almost 10 times the rate for

whites.12WhileHispanics made up 14.2% of the U.S. population in 2004,

they represented an estimated 19% of total AIDS diagnoses.13Reported AIDS cases

cumulative through 2003 among African American men were mostly attributed to

sexual contact with other men (36.9%) and to heterosexual contact (9.6%). However

in 31%of the cases, injection drug use was the mode of transmission. For Latino

men, injection use was in 33% of the cases.14Women accounted for a growing

proportion of new AIDS diagnoses, rising from 8% in 1985 to 27% in

2003.15AfricanAmerican women accounted for 67% of new AIDS diagnoses among women

in 2003, and Latinas accounted for 16%.16Themode of transmission in 37% of the

reported AIDS cases among African American women through 2003 was injection drug

use, and it was the same for Latina women—37%. In addition, in 13%of the reported

AIDS cases among African American women and19% among Latina women, the mode of

transmission was sex with an injection drug user.17This means that 51% of

reported AIDS cases among African American and Latina women were related to

injecting drug use.9Harm Reduction: A Critical Strategy in AIDS Prevention

      Page 11

If harm reduction, in fact, does reduce the spread of HIV/AIDS and if 31% of

African American men and 33% of Latino men have been diagnosed with AIDS because

of their injecting drug use, and if 51% of the AIDS diagnoses of African American

and Latina women were related to injecting drug use, why are we as a country not

investing millions in harm reduction and drug treatment programs? A study

commissioned by CDC and conducted by the University of California shows: that

intravenous drug users utilizing harm reduction programs decrease HIV drug-risk

behaviors (e.g., decreased sharing of injection equipment, decreased frequency

of injection); that such programs are effective in recruiting intravenous drug

users to enter drug treatment; and that HIV prevalence in syringes returned to

needle exchange programs decreases.18I now realize that my initial reaction in

1992 to the idea of needle exchange is common. Most people who oppose

needle exchange believe that it only encourages people to use drugs, that it gives

the wrong message about drug use and that it hampers law enforcement’s ability to

combat drug use. As Beverly lemming, a recovering addict who in 1992 coordinated

street outreach in Washington, D.C. for the Whitman-Walker Clinic, said," A clean

needle has never made anybody start or stop drugs, but it will slow down the

virus out there.”19As the California study shows, harm reduction programs

can increase the number of injection drug users seeking treatment and, as Rev.

Sanders points out, can be a bridge to treatment. All harm reduction programs

give intravenous drug users information about treatment programs and provide

counseling for those who indicate they are ready to take this step. While not

everyone exchanging needles takes this step, a significant number do. Former

Surgeon Harm Reduction: A Critical Strategy in AIDS Prevention10

      Page 12

General David Satcher said in a 2002 interview on National Public Radio: “The

science showed, very clearly, that needle exchange programs could, in fact,

reduce the spread of HIV and that they did it without increasing drug use. In

fact, later, studies showed that people involved in the needle exchange program

were more like-ly to go into treatment programs and stop using drugs.”20Staff

and volunteers of needle exchange programs, many of whom are recovering addicts,

regularly ask clients about their readiness for treatment. For example,

Prevention Works! In Washington, D.C. operates its needle exchange program out of

avan that is designed with distinct areas. Each client can speak individually

with a staff or volunteer either to register as a new client, to make an

exchange, to pick up other supplies such as condoms and bleach kits, or to

discuss treatment, get referrals, or receive other counseling. On a site visit to

Prevention Works!, I volunteered to interview new clients and to conduct

exchanges. I was inter-viewing a man for whom this was his first visit to the

van. The staff coordinator of the van heard me ask, “So, you are exchanging

one needle today?” He came over and spoke with the man. “Look, man," he said, “You

only asked for one needle. One needle is so close to no needles. Would you

consider treatment?” On that day, the man declined the offer, but it was clear to

me the priority this program places on helping drug users begin treatment and

recovery. Efforts by harm reduction programs to refer clients to treatment can

be thwarted because of the woeful lack of drug treatment programs in this

country. “Medically appropriate treatment remains out of reach to the vast

majority of drug users who needit.”21In 2000, the national “treatment gap”

(persons who needed treatment for drug abuse in the previous year but did not

receive that treatment) was estimated to be 83.4% of the population11Harm

Reduction: A Critical Strategy in AIDS Prevention

      Page 13

Harm Reduction: A Critical Strategy in AIDS Prevention12needing

treatment. 22 “Only 15% of the estimated 1-1.5 million IDUs in the United States

are in drug treatment on any givenday.”23For some programs, this has meant

becoming advocates and working in coalition with others to increase funding for

drug treatment. In Chicago, a major hub for the distribution of illegal drugs

throughout the Midwest, the Chicago Recovery Alliance, one of the largest

harm-reduction programs in the U.S. started its own mobile treatment center,

Mobile Opiate Substitution Therapies, because of the difficulty in getting its

clients into treatment, particularly those who are not HIV-infected. The other

issue that has greatly affected the ability of harm-reduction programs to do

their work is the federal government's refusal to provide any federal funding to

support them. In 1998, just when things looked good for a reversal of this

policy, the ban on federal funding was reinforced. On April 20, 1998, after a

bitter debate within the Administration, President Clinton declined to lift the

nine-year old ban. Many Administration officials supported lifting the

ban, including Health and Human Services Secretary Donna E. Shalala. At a press

conference before the President announced he would not lift the ban, Shalala made

the following statement: “A meticulous scientific review has now proven that

needle exchange pro-grams can reduce the transmission of HIV and save lives

without losing ground in the battle against illegal drugs.”24In office for just

over two months, Surgeon General Satcher responded to the House vote to ban the

use of federal funds for needle exchange programs by stating: “Well, I’m

disappointed because I’m concerned that it’s a repudiation of science. And yet

I understand the complexity of this issue. And let me just briefly say that the

science which comes not only from the federal government’s scientists at NIH [National

Institutes of Health

      Page 14

13Harm Reduction: A Critical Strategy in AIDS Prevention

]and a consensus conference but the National Academy

of Science's Institute of Medicine, the American Medical Association, the American

Public Health Associational agree that when you examine needle exchange programs

scientifically, you find the following things: Number 1, needle exchange

programs, if conducted properly, can prevent the spread of the … HIV virus.

Number 2, the do it without encouraging drug use. And, more than that,

man needle exchange programs have been very successful at getting people who are

addicted to drugs into treatment programs.”25 Other leaders vehemently spoke out

against the federal ban For example, on the day President Clinton announced his

decision, Dr. Nancy W. Dickey, President-Elect of the American Medical

Association stated: “The American Medical Association recognized one year ago, in

a policy statement adopted by our House of Delegates, that important advances to

arrest the AIDS epidemic could be made through responsible needle exchange and

drug treatment programs. Traditionally, AMA policy follows science, and as

Secretary Shalala notes, scientific evidence clearly shows that needle exchange

is effective in curtailing HIV trans-mission and that the availability of clean

needles does not increase drug abuse.”26 In speaking for the Congressional

Black Caucus, which called on the Administration to reverse its position, U.S.

Representative Maxine Waters stated: “This is a life-and-death issue. We can

save lives with needle exchange as we try to work at getting rid of drugs in our

society.” 27 Well, I’m disappointed because I’m concerned that it's a repudiation of

science .And yet I understand the complexity of this issue. Former U.S. Surgeon

General Satcher

      Page 15

On July 11, 2002, former President Clinton, speaking at the XIV International

AIDS Conference in Barcelona, Spain, stated in response to a question about what

he had done to fight AIDS as a  president, said: “Do I wish I could have done

more? Yes, but I do not know that I could have done it.” In particular, he cited

hesitance on needle-exchange programs saying, “I think I was wrong about that; I

should have tried harder to do that.” At the time of his decision, Mr. Clinton’s

advisers said they feared apolitical disaster for him if he lifted the

ban.28Today, national health organizations, and leaders continue to speak out in

support of needle exchange. For example, in February2006, the American Academy

of Pediatrics toughened its 1994policy in which it stated that clean needle

programs should be" encouraged and expanded.” In its updated policy statement,

the Academy states that pediatricians should speak out in support of needle

exchange programs to reduce the spread of HIV among injection drug users. It

further states: “Pediatricians should advocate for unencumbered access to

sterile syringes and improved knowledge about decontamination of injection

equipment.”29While the controversy about needle exchange continues, the costs of

not doing it also continue to rise. According to a 1997study published in the

British medical journal, The Lancet, in the District of Columbia, 294 to 650

injection-drug users could have been prevented from getting AIDS and as much as

$16.4 million to $36 million could have been saved in medical treatment if the

city had started needle exchange 10 years before. The study was based on estimates

of how many drug addicts in the District were infected with HIV.30 Former U.S.

Surgeon General Dr. Joycelyn Jones Elders cites the costs of not doing needle

exchange: “We have got to be about preventing disease! We have better drugs, Harm

Reduction: A Critical Strategy in AIDS Prevention 14

      Page 16

but we still don’t have a vaccine or a cure for this disease. We have watched

people die from this disease; now they must learn how-to live with HIV/AIDS. But

why can’t we help prevent this disease by providing clean needles? We do not

allow people to get the clean needles that would reduce the spread of HIV

disease, yet we spend thousands of dollars to treat each person who develops AIDS,

to take care of them to watch them die.”31The District began a much needed harm

reduction program in1996. However, after less than two years of operation,

Congress, using its veto power over Washington’s budget, prohibited the District

from using any of its own local funds for needle exchange. Washington's House

Delegate, Eleanor Holmes Norton, responded by saying," This Congress has said,

‘Drop dead’ to thousands of Americans, most of them people of color. I view it as

a callous death sentence with profound racial overtones. It puts the District in a

class by itself: the only jurisdiction that flies the American flag that can’t

prevent the AIDS epidemic from swallowing the city whole.”32Although some harm

reduction programs have been able to get funding from local and state government,

they mostly have to rely on private funding, contributions from individual donors

and grassroots fundraising. Some of these programs have not been able to survive

because of the lack of adequate funding, including two of the foundations

grantees. Among the earliest direct supporters of needle exchange was the New

York Community Trust through the New York City AIDS Fund. Other funding

organizations that have played a crucial role15Harm Reduction: A Critical

Strategy in AIDS Prevention But why can’t we help prevent this disease by providing

clean needles? Former U.S. Surgeon General Elders

      Page 17

in providing support include the George Williams Fund and the Syringe Access Fund

at the Tides Foundation, the Open Society Institute, the Comer Foundation, the

Drug Policy Foundation, and the Levi Strauss Foundation. Despite the controversy

and continued public debate on the issue of needle exchange, the Directors of the

Foundation continue to support this life-saving work. From its first grant

in1996 to the present (June 2006), the Public Welfare Foundation has made $2.2

million in grants to 13 organizations. These organizations include: Access Works

(formerly Women with a Point)Minneapolis, Minnesota www.accessworks.org AIDS

Resource Center of Wisconsin Milwaukee, Wisconsin (Offices throughout the

state)www.arcw.orgAtlanta Harm Reduction CenterAtlanta, Georgia Chicago Recovery

Alliance Chicago, Illinois www.anypositivechange.org Harm Reduction Coalition New

York, New York www.harmreduction.org North Carolina Harm Reduction

Coalition Jamestown, North Carolina www.ncharmreduction.org Harm Reduction: A

Critical Strategy in AIDS Prevention16

      Page 18

Point Defiance AIDS Project/North American Syringe Exchange Network Tacoma,

Washington www.nasen.org Prevention Point Philadelphia Philadelphia,

Pennsylvania www.preventionpointphilly.org Prevention Works! Washington, District

of Columbiawww.preventionworksdc.org17Harm Reduction: A Critical Strategy in

AIDS Prevention

      Page 19

E N D N O T E S
1 Ron Daniels, conversation on the Prevention Works! needle

exchange vanwith  Adisa Douglas, January 12, 2006.
2 Dr. Joycelyn Elders, Forward,

in Dawn Day, Health Emergency 2003, The Spread of Drug-related AIDS and other

Deadly Diseases Among African Americans and Latinos, the Dogwood Center and the

Harm Reduction Coalition, 2003.
3 “HIV Cases Among Blacks Show Decline Since

2001,” Washington Post(November 18, 2005) A2
4 D. S. Metzger, Navaline H., and G. E. Woody, “Drug Abuse Treatment asAIDS Prevention,” University of

Pennsylvania/VA Medical Center, Center forStudies of Addiction, Public Health

Reports. 1998 113(S1):97-106(www.preventionpointphilly.org)
5 Washington Post, November 18, 2005, A2.
6 Centers for Disease Control and Prevention (CDC) HIVAIDS

Surveillance Report, 1992
7 Adisa Douglas, interview, March 5, 1999
8 North American Syringe Exchange Network, 2005
9 CA McKnight, D.C. Des Jarlais, T. Perlis, K. Eigo, Baron Edmond deRothschild, M. Krim, J. Auerback, D. Purchase,

A. Solberg, T.S. Jones, R.S.Garfein, Update: Syringe Exchange Programs—United

States, 2002, JAMA,October 19, 2005, Vol 294, No. 15.
10 Dawn Day, Health Emergency 1999: The Spread of Drug-related AIDS andother Deadly Diseases Among

African Americans and Latinos (1998) 14
11 CDC, HIVAIDS Surveillance Report, 2003, vol. 15, Table 17
12 CDC, Fact Sheet: HIV/AIDS Among African Americans, 2005, p. 2
13 HIV/AIDS Among Hispanics, The Leadership Campaign on AIDS, U.S.Department of Health and Human Services, the Office of HIV/AIDS Policy,2005.
14 CDC, HIV/AIDS Surveillance Report, 2003, vol. 15. Table 19
15 “HIV/AIDS Policy Fact Sheet”, The Henry J. Kaiser Family Foundation, September 2005, p. 1
16 CDC, Fact Sheet, p. 2.
17 CDC, HIV/AIDS Surveillance Report, 2003, vol. 14, Table 21Harm Reduction: A Critical Strategy in AIDS Prevention18

      Page 20

18 University of California, Berkeley/ San Francisco, The Public Health Impact of

Needle Exchange Programs in the United States and Abroad 1993 on website The

Lindesmith Center, “Review of University of California Report on Needle Exchange

and Recommendations on Needle Exchange.”
19 Rene Sanchez, “Clean Needles for Drug Users Approved in D.C. AIDS fight," The Washington Post, June 24, 1992.
20 Bob Edwards interview with Surgeon David Satcher, “Morning Edition," National Public

Radio, February 11, 2002.
21 AIDS Treatment Activists Coalition, “U.S. Support of Needle Exchange Needed to Curb HIV/AIDS Epidemic, Open Letter to the global AIDS Coordinator,” Human Rights News, Human Rights Watch, June 6, 2005.
22 Office of Applied Studies, National and State Estimates of the Drug Abuse Treatment Gap:

2000 National Household Survey on Drug Abuse, Rockville, MD, Substance Abuse and

Mental Health Services Administration (SAMHSA), 2002.
23 Peter Lurie and Ernest Drucker, “An Opportunity Lost: HIV Infections Associated with Lack of a National

Syringe-exchange Programme in the USA,” The Lancet, vol. 349 (March 1, 1997), 604-608.
24 Chris Lanier and Alan Greig, “Shalala’s Lack of Determination” Harm Reduction Communication, Spring 1998 No. 6 (Journal of the Harm Reduction Coalition, New York City).

25 Dr. David Satcher, The News Hour with Jim Lehrer

Transcript (April 29,1998), www.pbs.org/newshour/bb/health/jan-june98/satcher_4-29.html.

26 Nancy W. Dickey, MD, American Medical Association (April 20, 1999)[Online], AIDS stories: Stories

from the Front Line. Available: http//www.aidstories.com
27 Dawn Day, pp 5-6
28 Lawrence K. Altman, “Clinton Urges Global Planning to Halt HIV,” New York Times,

July 12, 2002.
29 Carla K. Johnson, “Doctors Back Needle Exchange Programs,” Associated Press, 2005.
30 Amy Goldstein, “Study Funds Needle Swap Is Imperative,” The Washington Post, March 5, 1997
31 Dr. Joycelyn Elders, Forward, in Dawn Day, Health Emergency 2003, the Dogwood Center and the Harm Reduction Coalition, 2002.
32 Avram Goldstein, "Norton Blasts Funding Ban on D.C. Needle Exchange," The Washington Post, October 22, 1998 A 4-519 Harm Reduction: A Critical Strategy in AIDS Prevention

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1200 U Street, NW Washington, DC 20009-4443202.965.1800 www.publicwelfare.org