Victoria Knight, Kaiser Health News
Once repellent to conservative politicians, needle exchanges are now being endorsed and legalized in Republican-controlled states.
At least four legislatures have considered bills to allow hypodermic needle exchanges, and two states, Georgia and Idaho, made them legal this year. In each of these states, the House and Senate are controlled by Republicans and the governor is a Republican.
Florida, Missouri, Iowa and Arizona have introduced bills this legislative session that would allow needle exchanges in their state. The measures were all sponsored or co-sponsored by Republicans.
As much as this has been a series of victories for public health officials who see how needle exchanges -- also called syringe exchanges -- stymie the spread of blood-transmitted diseases, it has been a triumph of public health policy research. For years, research has shown the benefit of needle exchanges, but now that the opioid epidemic and infectious diseases have affected their own communities, lawmakers are listening.
"The reality is maybe 10 or 15 years ago this wasn't where Georgia was," said Republican state Rep. Houston Gaines, the sponsor for Georgia's needle-exchange law. "But the medical and science community has shown that this works. My hope is as Republicans, we can always be willing to embrace programs and ideas if they're proven to work."
Republicans have not always held this mindset.
Needle-exchange programs, pioneered in Amsterdam in 1983, allow individuals to get sterile needles free of charge and safely dispose of dirty needles and syringes used for drug injection. The programs have been proved to reduce the risk of getting and transmitting HIV, viral hepatitis and other bloodborne infections through sharing needles.
Syringe exchange programs also give public health officials an opportunity to offer educational and medical services, such as referrals to substance use disorder programs and HIV or hepatitis testing.
Currently, 28 states and the District of Columbia allow needle exchanges.
In 1988, Tacoma, Wash., established the nation's first exchange program and with it came Republican opposition. North Carolina Republican Sen. Jesse Helms led Congress in banning the use of federal funds for needle-exchange programs that year. An ultra-conservative, Helms said allowing needle exchanges was the same as the government saying, "It's not only all right to use drugs, but we'll give you the needles."
Despite the federal government refusing to fund research on the exchange programs, public health evidence of their effectiveness started to stack up, as did the number of states allowing the programs.
Multiple studies found that exchanges reduced the spread of hepatitis B, hepatitis C and HIV. These programs could also be cost-effective; a 2014 study found that for every dollar invested in expanding a needle exchange, $6 could be saved in HIV treatment. Other research found that going to an exchange program led drug users to enroll in substance abuse treatment programs.
The tipping point for many Republicans, however, came in a 2015 HIV outbreak related to the injection-drug epidemic in Scott County, Ind., a strong GOP state. In a matter of months, more than 150 people were newly diagnosed with HIV in a rural county with 24,000 residents.
Mike Pence, then the governor and now the vice president, was initially opposed to needle-exchange programs. Two months after the HIV outbreak was detected, Pence declared a public health emergency and allowed a limited needle exchange in Scott County.
Pence's White House staff did not respond to several requests for comment.
Asal Sayas, director of government affairs at amfAR, the Foundation for AIDS Research, said this was a critical moment for Republicans with rural constituents. "A lot of communities realized they were also vulnerable and had situations similar to Scott County, where there was minimal HIV care and no syringe exchange," said Sayas.
The syringe exchange in Scott County was effective, and it had a ripple effect.
An analysis by amfAR found that after Scott County's needle-exchange program, the number of exchange programs across the country spiked. The organization's most recent count is at 320.
Other Republican-leaning states also passed legislation allowing needle exchanges -- Kentucky and Ohio in 2015, North Carolina in 2016 and Louisiana, North Dakota, Tennessee and Virginia in 2017.
Though critics said Pence waited too long to implement the program, the move has been hailed by conservative state lawmakers who in the ensuing years began supporting needle-exchange programs.
Attitudes among Republicans on the federal level are also shifting.
In December 2015, three congressional Republicans from states hit hard by the opioid crisis, Sen. Shelley Moore Capito of West Virginia and Senate Majority Leader Mitch McConnell and Rep. Hal Rogers, both of Kentucky, inserted language into an omnibus spending bill that partially repealed the federal funding ban. That provision allows federal dollars to be used for operating needle-exchange program operations, just not for the drug-injection devices themselves.
Following President Donald Trump's recent announcement that he wants to end the HIV epidemic, Secretary of Health and Human Services Alex Azar expressed his support for needle exchanges. "Syringe-services programs aren't necessarily the first thing that comes to mind when you think about a Republican health secretary, but we're in a battle between sickness and health, between life and death," Azar said at the National HIV Prevention Conference in Washington in March. "The public health evidence for targeted interventions here is strong."
AmfAR's Sayas said it's important to remember how effective needle exchanges could be in achieving Trump's HIV goals. "The administration's plan targets 48 counties with high HIV diagnoses and seven states with a high rural burden of HIV," said Sayas. "In six of those seven rural states, needle exchanges are illegal. If we're serious about wanting this plan to work, we need to consider that."
Despite the movement among some Republicans to accept needle exchanges, 13 states still have laws that make them illegal. All of those have Republican governors and Republican-majority legislatures, except for Kansas, which has a Democratic governor.
Nine states have either no law that prohibits syringe programs or only locally permitted needle exchanges, which means that it is up to each city or county to decide whether to operate needle exchanges.
In states that have given localities control of needle-exchange programs, there has been some movement to shut down the programs. Charleston, W.Va., suspended its needle exchange in 2018 after law enforcement officers complained about needles littering the streets and the mayor joined the opposition. Two programs in Indiana shut down in 2017 because of local opposition, although one has since reopened through a nonprofit health center.
Republican Rep. Ed Clere was one of the authors of Indiana's needle-exchange legislation. He said local control of the needle exchanges often means decisions now play out among local conservative lawmakers.
"I don't want you to think that I don't like local approval. It's just the way the approval process works, it just tends to be very political," Clere said in an interview. "The people who make the decision, the commissioners, don't have medical or research background. Instead of talking about the research evidence, the discussion ends up being about needles on playgrounds or drug use, which is just not useful."
