On a balmy day in November 1990, a battered van that once delivered loaves of bread to Yale's dining halls set off on a voyage through New Haven's inner-city neighborhoods.
Its cargo was clean syringes for the city's drug users.
No one knew whether the new needle exchange program would do what was expected of it -- slow the spread of AIDS -- because supporters lacked the scientific evidence to confirm what intuitively made sense, that clean needles were less likely to spread disease. What they did know was that other approaches had fallen short. Intravenous drug users made up 80% of the AIDS cases in New Haven.
A lot was riding on the new program. It had taken three years of coalition and consensus building to persuade a wary state legislature to pass a bill exempting the program from laws that made needle possession a crime. Scientific data on the efficacy of clean needles were scarce and weak, and distributing clean needles was a political minefield. To succeed, the needle exchange had to win the trust of New Haven's drug users.
Outreach workers on the van's inaugural voyage were elated on Nov. 13 as they reached their first stop on Congress Avenue in the Hill neighborhood. "We had people waiting for us," remembered Dominick Maldonado, one of the city's first AIDS outreach workers, who today serves as the HIV/AIDS coordinator for the New Haven Health Department.
Also on the van was Kaveh Khoshnood, an assistant professor of epidemiology, who was then a graduate student in public health at Yale. "We had no idea whether people were going to come to this official program but, indeed, they came," he recalled. "The word got out rather quickly that this program was legit, that you wouldn't get arrested by the cops. It was reassuring to know that people trusted the program and trusted the staff."
Before a year had passed, a study by Yale faculty would prove that the program reduced the incidence of new HIV infections by a third. The study would be a watershed in the history not only of needle exchange, but also of public health -- the first that addressed the key question of whether clean needles would prevent AIDS. Other communities across the country would follow New Haven's example.
In November 2000, officials from the city and its health department joined Yale faculty to celebrate 10 years of New Haven's needle exchange program. Over the past decade the rate of infected needles in the city has dropped from 65% to below 40%. The program has resulted in other successes as well: More than 1,000 drug users have found their way into treatment through the needle exchange program, and the drop in the number of new AIDS cases, from 121 in 1991 to 38 in the fiscal year ending July 2000, is due in large part to programs such as the needle exchange.
The New Haven program's beginnings go back to the mid-1980s. At that time, little was being done to educate drug users about HIV, according to Maldonado, who chairs the Community Advisory Committee for the Yale Center for Interdisciplinary Research on AIDS. In 1986, then-Mayor Biagio DiLieto created the Mayor's Task Force on AIDS at the urging of Dr. Alvin Novick, a Yale professor of biology. Soon the city health department hired three full-time outreach workers to work with drug users, one of whom was Maldonado. Novick became chair of the task force.
"Immediately we hit the streets," Maldonado said. "At the time we just had the bleach, the water, the pamphlets and the condoms." But the health workers had begun to think about needle exchange. "We were called crazy," Maldonado recalled. "We were told it was political suicide, that this would never happen in Connecticut."
In fact, when in the winter of 1989 a delegation of public health officials, outreach workers, expert witnesses and city leaders made the case for needle exchange before the state legislature's health committee, the committee turned them down. Even members of the New Haven Task Force on AIDS were divided on the issue of needle exchange.
However, in the spring of 1990, advocates of a needle exchange program, this time joined as a larger coalition, went before the legislature's health committee again. "We had physicians, we had public health officials, we had the police, we had policy makers. It was a critical mass," said Khoshnood. This time the committee reversed itself, and the full legislature approved a needle exchange program in New Haven with the stipulation that the program be evaluated within a year.
At the time New Haven began its program, there was scarce data on needle exchanges. A handful of programs were operating in the United States -- in Washington, Colorado, Oregon, California and New York -- but most evaluations of their effectiveness were limited in scope, were often unpublished, and came from abroad, according to Dr. Peter Lurie, a leading researcher on the public health implications of the AIDS epidemic.
For help evaluating New Haven's new program, Novick turned to his friend Edward H. Kaplan, then an assistant professor in the School of Management and now the William N. and Marie A. Beach Professor of Management and professor of public health. Kaplan's mathematical modeling approach to HIV infection had caught Novick's eye, and the two had become collaborators.
For Kaplan, who had written a paper titled "Needles That Kill," the method to assess the new program was obvious. "You want to look at this from the perspective of the needles," he said. "It was like looking at malaria from the perspective of the mosquito." If needle exchange reduced the number of new HIV infections, it stood to reason that used needles would be less likely to carry traces of HIV.
Working with the needle exchange team, Kaplan and Robert Heimer, then a postdoctoral fellow and now associate professor of epidemiology at Yale, devised an elaborate system to track the needles. They bought European-made syringes that would stand apart from domestic ones. Each needle had an ID number. Drug users signed up for the program anonymously and were given an identity of their choosing, often a pseudonym that showed some humor, such as "Bugs Bunny" or "Dan Quayle."
Khoshnood conducted a brief interview with each ,client to gather demographic data. Users received one clean syringe for each dirty syringe they returned to the van. Logbooks recorded who took a needle and who returned it, when and where the needle left the van and when and where it was returned. Incoming needles went to Heimer's lab for testing. Once a week, data from the lab went to Kaplan's office.
"The level of infection went down as the number of needles in circulation went up," said Kaplan. He found another correlation: The longer a needle was in circulation, the more likely it was to come back HIV positive. "The most compelling data were the testing data, which demonstrated that the percentage of infected needles had decreased," said Heimer. "Ed, with his mathematical modeling, had concluded that there was a one-third reduction in new infections."
In July 1991, Heimer and Kaplan announced their results. "When the report came out and hit the front page of The New York Times, that was a huge deal," said Lurie, now deputy director of the Public Citizen's Health Research Group in Washington, D.C. "That put needle exchange research and the programs themselves on a vastly more secure footing. It added a measure of credibility to the programs and provided a scientific basis that had not been there before. It provided a number that people could use, and still do use, as an estimate of the effectiveness of needle exchange -- the well-known one-third reduction."
Other communities began approaching New Haven for help in starting their own needle exchanges. The Yale study led David Dinkins, mayor of New York City at the time, to reverse his opposition to needle exchange. Kaplan and then-Mayor of New Haven John Daniels, a former opponent of needle exchange, sang its praises on national television programs.
Yet there were others who weren't convinced that needle exchanges worked. Bor Martinez, the nation's drug czar in the early 1990s, weighed in against the Yale study and its authors, calling the study flawed. Charles Rangel, a Democratic congressman from New York City and a critic of needle exchanges, asked the General Accounting Office to review Heimer and Kaplan's research. The Centers for Disease Control and Prevention (CDC) commissioned a report on needle exchange from scientists at the University of California. The CDC report confirmed the Yale study and went even futher, saying the Yale study understated the value of needle exchange. Kaplan's modeling approach won him the prestigious Franz Edelman Award from the Institute of Management Sciences.
"When we began the work, people opposed to needle exchange said there is no evidence it works," Heimer said. "After our report they had to modify that statement to say there is no good scientific evidence. After the various panels of inquiry had concluded that our work was scientifically valid and independently verified, they were left saying that needle exchange sends the wrong message. The debate had been taken out of the realm of science and placed entirely in the realm of politics and morality."
The years that followed also brought a few victories for needle exchange. The state of Connecticut implemented five other programs and legalized over-the-counter sales of syringes. Other communities, most notably New York City, followed New Haven's example. More than 150 needle exchanges now operate in 36 states, the District of Columbia and Puerto Rico, according to the North American Syringe Exchange Network, a support organization based in Tacoma, Washington.
Kaplan and Heimer's methodology remains a landmark in evaluating needle exchanges. "The Yale research," said Lurie, "was, for its time and in some ways still, the most sophisticated attempt to evaluate needle exchange, not only because the methods were sophisticated, but also because it tried to answer the central question around needle exchange -- whether the programs really reduced the incidence of HIV."
New Haven's needle exchange van still plies the streets of the city, offering syringes on its regular route. The city's original van, which had been painted with bright murals by a Yale librarian and city high school students, has been replaced several times since it made its first voyage. The new van runs a regular route five days a week through the city's neighborhoods and even makes house calls.
From July to September of 2000, 518 drug users availed themselves of the van. The number of people using the van may have declined since passage of the 1992 state law that allows pharmacists to sell syringes without prescriptions. The van still leads drug users to treatment programs, and since 1997 it has operated with the Community Health Care Van, staffed by a physician assistant and outreach workers.
"It is clear that needle exchange does have an impact," said Matthew F. Lopes, M.P.H. '77, director of the New Haven Health Department's AIDS division.
Kaplan was even more emphatic when he spoke at the ceremony marking the program's 10th anniversary. "In simple terms," he said, "the program has saved lives."
This article was adapted from "What the Needles Said" by John Curtis, which appeared in the Summer 2001 issue of Yale Medicine.
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