The California Assembly Bill (AB) 136 was signed into law by former Governor Gray Davis on October 7, 1999 as a response to the growing demand for clean syringes to curtail the spread of bloodborne pathogens such as HIV and Hepatitis C amongst intravenous drug users (IDUs). The aim of AB 136 was to protect local jurisdictions from criminal prosecution for distributing syringes in syringe exchange programs (SEPs) following the declaration of a public health emergency (Collins, Summers, Regina, & Johnson, 2002). This paper will discuss the impact that AB 136 had on public health in San Francisco and will discuss some of the benefits, ethical considerations, and challenges that are still facing the city today.
Syringe exchange programs (SEPs) provide sterile syringes, collect used ones, and are considered to be a contact to health education and care for the people who are injecting drugs. San Francisco was home to the first SEP in California, which began to operate in the late 1980s. Upon encountering IDUs, volunteers would exchange needles and syringes, and provide condoms, alcohol wipes, bleach, and cotton (Lane, 1993).
Although still hotly debated, SEPs have continued to grow in number throughout California with the help of AB 547, which simplified the procedure for SEP authorization. In 2005, Governor Schwarzenegger signed AB 547, which amended AB 136s requirement to declare a local emergency prior to establishing SEPs.
As a foundation of SEPs operating in California, AB 136 brought about the legalization of public health efforts to put an end to the spread of HIV/AIDS and other blood borne pathogens amongst IDUs. The failure of AB 136 to mandate a one-for-one needle exchange has lead to enormous public health problems that require millions of dollars to alleviate the problems. For example, the City of San Francisco is currently undergoing immense efforts to remove used syringes and keep the hazardous waste off of sidewalks and streets. According to Rachael Kagan, spokeswoman of the San Francisco Department of Public Health, more than 400,000 syringes are handed out per month and only 246,000 come back, leaving more than 154,000 needles a month still circulating (Matier & Ross, 2018). Alternatively, placing limitations and requirements on SEP participants has its own set of consequences. Previous research has shown that people in cities with more permissive syringe access policies were significantly less likely to engage in HIV risk behavior (Bluthenthal et al., 2004).
Another failure of AB 136 was the lack of direction it provided local governments when it came to encountering IDUs looking to exchange needles. AB 136 would do well if it is amended to include a provision mandating SEP participants to meet with a substance abuse counselor and attend a support group (e.g. Narcotics Anonymous) at least once per month. The National Institute on Drug Abuse has shared data from multiple studies that show a 40 to 60 percent decline in drug use amongst individuals attending substance abuse treatment. The studies have also shown that criminal activity decreases significantly, violent and nonviolent criminal acts were reduced by at least 40 percent, and that treatment also increased employment prospects by 40 percent (n.d.). Once again, and as discussed above, the danger of setting pre-determined limits on syringe access could make it more likely for IDUs to re-use non-sterile or dull syringes on themselves.
Research on the benefits of SEPs in California and abroad consistently show significant and rapid decreases in HIV incidence rates and risk behavior amongst persons who inject drugs (Patel et al., 2018; Wodak & Cooney, 2006). While SEPs remain an effective tool to prevent HIV infections, it is important to note that they have not been shown to help IDUs come off of drugs and they have certainly not contributed to the fight against the current opioid overdose and death epidemic. A majority of the research on SEPs has focused on the effectiveness of HIV prevention, however, much less has been conducted on whether or not SEPs encourage or increase the rate of drug use. Additional research must be conducted to establish this as a consistent fact. It is important to note that a majority of research surrounding this aspect of SEPs focuses on self-reported behaviors of SEP beneficiaries. For example, in 1993 the CDC released a report strongly recommending SEPs despite multiple shortcomings of the studies reviewed. For instance, none of studies were randomized; outcomes were determined based on self-reported behavior; risk behavior was often roughly measured; and follow-up with SEP enrollees was often poor (Coutinho, 1995). Additionally, it is very likely that program beneficiaries are less likely to report an increase of use if they stand to lose something.
In conclusion, AB 136 sets an inadequate foundation for the authorization of SEPs. It is not reasonable to abolish them altogether, however, it is important to amend existing legislature to improve the distribution of drug paraphernalia so that the greatest impact could be made on this vulnerable population. Although a one-for-one needle exchange may detract some IDUs from using SEP services, it is a good practice to hold IDUs accountable and to protect the overall public health and safety of everyone else. This must take precedence over anything else. It is vitally important that additional studies be conducted should these amendments take place in order to assess their effectiveness.