Legal at last, but strapped for cash, needle exchanges seek federal funding

Ten minutes before six o’clock on the first cold, wet night of fall, Willie Dudley tells his team to “set up the tents.” A steady drizzle starts, and up go three pop-up canopies. One goes up over Dudley’s “kitchen,” where he is preparing a big vat of chicken noodle soup, a pot of hot coffee, and a plastic thermos filled with Kool-Aid. A second tent covers a pair of tables on which Andrea Natta is sorting vitamins and herbal teas into small plastic bags. The last tent goes up over the busiest and most popular table in this crowded Fruitvale cul-de-sac. Braunz Courtney and Emily Renteria pass out syringes, cookers, tourniquets, cotton swabs, ascorbic acid, alcohol pads, and vials of sterile water—everything used for shooting up.

People aren’t here to use drugs, but they are participating in something that used to be equally illegal in Oakland, and remains outlawed in many parts of California—syringe exchange. Injection drug users turn in used needles for new ones, reducing the potential for needle sharing and—health workers hope—slowing the spread of blood-borne diseases like HIV/AIDS and hepatitis C.

Every Tuesday night, staffers from the HIV Education and Prevention Project of Alameda County (HEPPAC), an Oakland-based non-profit organization, set up their tables and mobile RV clinic in this spot—a dead-end tucked under a freeway overpass, next to a vacant lot a block off of International Boulevard. The closest neighbors live out of shopping carts and sleeping bags in the shadows a few hundred yards away.

Five minutes before six, people eagerly amble over to the covered tables. Then right at the hour, the first person drops a plastic bag filled with used syringes into a big red plastic disposal bin. Courtney asks the man his age and zip code.  He records his race, whether or not this is his first time at the site, and how many needles he has turned in. For every syringe that is dropped into the red bin, Courtney gives out up to ten clean, new needles.

Dudley, the group’s exchange coordinator, explains that this Tuesday night is slow because of the rain, and also because it’s early in the month. “Close to the first, we usually get around 30 to 50 people, but at the end of the month we get about 50 to 80 a night,” Dudley says between serving bowls of soup. “And in the summer time, it gets crazy.”

The organization has been running a syringe exchange in this spot since 1994. It was illegal in Oakland until 2000, but early volunteers like Arthur Belton—then an Oakland paramedic, and who now serves on the group’s board of directors—risked legal action because they saw the need in their community. “The results of drug use, injection, and other health issues were clear,” Belton says. “I was willing to take a risk for something I believed in. We did what we could to minimize harm.”

“Harm reduction” methods like needle exchange became popular in the mid-1980s as urban centers grappled with the spread of HIV/AIDS and the growing use of heroin.  Hardest hit, New York City and the San Francisco Bay Area were pioneers in developing needle exchanges. In the East Bay, health and drug activists started small, volunteer-run exchanges in Berkeley and Oakland, which passed out clean needles and got used ones off the street. Doing so was against the law, considered distribution of drug paraphernalia.

Most needle exchanges operated under the radar until 2000, when California passed a law that allowed counties or cities to authorize legal needle exchanges, with the requirement that a “state of emergency” with regard to HIV/AIDS be declared within the jurisdiction. Alameda County was one of the first to use this designation, starting in 1998. The “emergency” requirement was removed by the state in 2005.

Earlier this month, Governor Jerry Brown took a step toward making needle exchange even more readily available when he signed a new law—introduced by Berkeley assembly member Nancy Skinner—that allows the California Department of Public Health to authorize needle exchanges in areas of need. In his signing memo, Brown directed the department to use restraint with its new power, and stressed the importance of taking local opinion into account. “I believe [this law] can reduce the spread of communicable disease and the suffering they cause and, at the same time, respect public safety and local preference,” Brown said.

Today, most Bay Area counties allow needle exchanges, including Alameda, Contra Costa, Marin, San Francisco, San Mateo, Santa Clara and Sonoma.  (Napa and Solano counties do not.) In addition to programs in Berkeley and Oakland, Alameda County also has needle exchanges in Fremont and Hayward, both run by the Tri-City Health Center.

Although these programs are increasingly accepted in the Bay Area, the same isn’t true throughout the rest of the state or the nation. As of June, the California Department of Public Health reports that only 19 of California’s 58 counties have authorized needle exchange programs. By May of this year, there were 211 needle exchange programs in 32 states across the United States, according to the Foundation for AIDS Research.  By comparison, Australia—which has a population equal to only 7 percent of the United States’—has roughly 3,000 programs.

In places like Oakland, where local authorities treat syringe exchange as an accepted public health practice, groups like HEPPAC no longer face the risk of arrest. Today their challenge is going mainstream, and needle exchange programs are now reaching for the biggest government seal of approval of all—federal funding.

In the past, federal funding was prohibited for needle exchanges. As a result, exchange programs had to raise funds from state, county, and local bodies by offering more readily fundable  services like HIV testing and drug counseling. “When I try to pitch for funds, it’s sad,” says Loris Mattox, HEPPAC executive director. “I have to try and detach what we do from syringe exchange. Usually [funding agencies] don’t want to be associated with syringe exchange. It’s easier to raise funds for other services.”

But in 2009, a 21-year-old ban prohibiting federal money from going to needle exchanges was lifted. For the first time, Mattox and HEPPAC are on the verge of receiving federal grants through the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA)—all agencies  now able to fund needle exchanges directly for the first time.

HEPPAC staffers believe federal funding would allow needle exchange programs to integrate more fully with existing drug treatment and disease prevention programs, increasing their results and effectiveness. According to Mattox, with additional money HEPPAC could increase the availability of rapid hepatitis C testing, research and implement a methadone program, and increase the number of needle exchange sites and operating hours—services they have always wished they could offer.

“More money would mean reaching more people,” Mattox says. “Oh, my God. That is so needed.”

 

**

HEPPAC’s headquarters in the Fairfax Business District on Foothill Boulevard doubles as a drop-in clinic that offers a range of services, including HIV and hepatitis C testing, counseling and basic medical care. Situated among empty storefronts, liquor stores, and Mexican restaurants, the modest, single-story building has the words “Casa Segura” (“Safe House”) tiled outside, and a sign for “Free Testing” in the window.

Inside, on a mid-week afternoon, staff members sit around a large table sorting supplies as Willie Dudley wheels over a hand-truck loaded with boxes. Amid scattered papers, Loris Mattox is eating a microwavable pizza at her desk while she works frantically to finish a 65-page report for the CDC. The progress report, a requirement since HEPPAC began receiving CDC funds for non-needle exchange activities two years ago, is due the next day. Mattox, wearing glasses and with her dark hair pulled tight, is on page eight. “It’ll be a late night, but I’m used to not sleeping,” Mattox says, pointing to a picture of her 10-month-old son taped to the wall.

Mattox, who is in her mid-thirties, joined HEPPAC in 2004 as the group’s health enhancement coordinator. After graduating from college, she spent one year in a marriage and family counseling graduate program, but left before finishing. “Sitting at a desk all the time, it felt like a waste of time,” Mattox says. “I needed to be out in the field, doing something.” After a stint as HEPPAC’s deputy director, she became the executive director last October.

For the current fiscal year, the group’s operating budget is $947,000, which includes staff salaries, building expenses, and supplies. The cost of operating the needle exchange program is $430,000—nearly half of that budget. Most of the funding for the needle exchange—80 percent—comes from Alameda County’s Office of AIDS. That amount has remained flat since 1994, despite a steady 3 to 6 percent annual increase in needle exchange volume and visits, according to Mattox. In 2010, HEPPAC collected over 1.3 million used syringes and had around 24,000 visits to their exchange locations.

Because many counties surrounding the Bay Area have not authorized needle exchange, Alameda County funds service a population that extends beyond its borders. “It means that people from Stanislaus County will come to Oakland or San Francisco” to exchange needles, says Hilary McQuie, California director of the Harm Reduction Coalition, a national advocacy group. “Counties that have authorized it are supporting those that haven’t.” A 2008 HEPPAC survey estimated that around 2 percent of their needle exchange clients live outside Oakland. According to 2010 numbers, that is around 480 visits annually from clients outside of their jurisdiction.

The new law signed this month by Governor Brown is “a big step forward” toward making needle exchange programs more available, McQuie says. “But there is still a lot of work to do in implementing it.” While the changes taking effect January 1, 2012 “take away some of the political barriers to people supporting syringe exchange,” McQuie says it would likely take a few years for nearby counties to get their own exchange programs going, eventually lightening the load for groups like HEPPAC.

Meanwhile, the need for these services in Alameda County remains high; its AIDS infection rate routinely tops the statewide average. In 2006, the most recent year for which the Alameda County Public Health Department has published statistics, there were 10.9 cases per 100,000 people in the county, compared to a state case rate of 7.5. Intravenous drug use accounted for 14 percent of all AIDS cases in the county from 1980-2006, making it the second leading cause of transmission. The California Office of AIDS also estimates that 60 percent of all hepatitis C infections in the state are associated with injection drug use.

Despite the obvious need for disease prevention, the county is still plagued by tough economic times. Every year, Mattox receives a letter from the Alameda County Board of Supervisors warning that HEPPAC’s funds might be cut. Each time, she goes in front of the board and pleads the organization’s case. Every year so far, the funding has remained intact.

It’s not that the county doesn’t support syringe exchange. In fact, says Alameda County Supervisor Keith Carson, “We are very fortunate to have organizations such as HEPPAC who have been tireless advocates for harm reduction and needle exchange programs, despite there being no financial support at the federal level.”

But, over the last few years, the county has faced an extremely tight budget. “Hey, things are tight. It’s a possibility that funds could be cut,” says Kabir Hypolite, executive director of the Alameda County Office of AIDS, which strongly supports the funding of syringe exchange programs. “The County Board of Supervisors wants to continue funding [needle exchange],” Hypolite says, but they must figure out “how to best distribute limited funds.”

For cash-strapped counties, there’s now a glimmer of hope: the federal funds the might soon become available. Congress’s 2009 lifting of its two-decade old ban funding ban, which had prohibited federal funds from directly supporting needle exchange programs, has so far not produced much actual financial support. “The fact that it’s now allowable is a good thing,” Mattox says. “But no additional money was made available” when the ban was lifted, she says, and federal agencies would have to take money from existing programs in order to free up funds for needle exchange—something they are reluctant to do.

Still, groups like HEPPAC now have the opportunity to apply for funds from several different federal agencies, each with its own set of complications. Federal money from the Health Resources and Services Administration (HRSA) is filtered through a regional body that will soon vote on a list of seven or eight “support services” that are eligible to receive funding. For the first time, needle exchange is eligible for consideration.

HEPPAC is also in the process of applying for funding through the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency that distributes money through Alameda County’s Behavioral Health Care Services Department. In the past, SAMHSA had not acknowledged needle exchange programs as substance abuse treatment. Following a February statement by Surgeon General Regina Benjamin that essentially authorized needle exchange programs as drug treatment, SAMHSA released new guidelines several weeks ago that made needle exchanges eligible for funding.

Two years ago, HEPPAC started receiving money from one federal agency, the CDC. However, according to the federal ban and CDC guidelines, those funds—$315,000 per year—were restricted to HIV/AIDS counseling, testing, and referral programs. While the money could not be used for syringe exchange, it did allow the group to shift its other funds around in order to continue operating its needle exchanges.

Restricted funds—money allotted for specific items—are common in the world of non-profit healthcare. Every dollar of HEPPAC’s operating budget is tied to a restricted fund. That leaves the organization without additional money to pay for things like a shared computer network, a new website, or assessment reports for potential new programs.

With more funding and some flexibility, Mattox says, her group would be able to increase hepatitis C testing and awareness campaigns; start a new methadone program; and increase their roving exchange program, which consists of an RV that staffers drive around to parks, shelters, and recycling centers in Oakland, providing outreach, supplies, and wound care three days a week.

“The goal is to expand and redirect funds,” Mattox says. “Man, with additional funds we could take off.”

 

**

Needle exchange programs sit at a unique intersection between disease prevention and drug treatment. Throughout its history, HEPPAC has continuously expanded its services to capitalize on funding from each of these separate public health branches, a practice that has been key to the organization’s economic survival. By offering a large portfolio of readily fundable services—like HIV testing and condom distribution—HEPPAC has created a buffer that helps float its most expensive and difficult to fund service, needle exchange.

On that rainy Tuesday night, in addition to handing out syringes, Braunz Courtney and the rest of the HEPPAC staff offered visitors counseling, treatment referrals, wound care and hot food. They handed out fruit, condoms, vitamins, hygiene kits—which contain things like soap, razors, and toothpaste—and “crack kits” that include disposable rubber crack pipes. (They’re meant to replace glass pipes, which can cause burns that lead to the transfer of communicable diseases.)

HEPPAC also offers Chinese medicine and other alternative health remedies, like acupressure. Under a tent in the Fruitvale cul-de-sac, Andrea Natta was describing acupressure to a woman complaining of a pain in her inner thigh. Natta, who has thin dreadlocks hanging to her lower back, opened a heavy book to a diagram of an ear. She explained that there are points all over the ear that correspond to different feelings and parts of the body.

With the book on the table, she opened a plastic case and pulled out a small handheld device that looked like a hot-glue gun. She held it to the patient’s ear, pushed a button, and the device buzzed for about five seconds. Natta then pulled out a plastic case, peeled off a small rectangular sticker with a tiny “seed” in the center, and placed it on the spot that caused the buzz. “Whenever your leg starts to hurt, just push on this,” she said.

A few seconds later, the patient got up.  “Wow! It doesn’t hurt anymore. It worked!” she said, rubbing her thigh as she walked away.

Natta has worked for HEPPAC for close to four years. In addition to providing acupressure, Natta hands out Chinese herbs, teas, vitamins, and tinctures that help addicts with pain and other health issues. “White flower,” a pain-relieving salve, is popular because it soothes sore muscles, she said. “Resist,” an herbal antibiotic tincture used to disinfect abscesses, is by far Natta’s most popular item. Usually, she also offers acupuncture, but she is reluctant to do it on bad weather nights, like this wet Tuesday.

Even though Chinese medicine is HEPPAC’s second most popular service (behind needle exchange), for several years, Natta’s job has been in danger of being cut. Twice she was told that the group would have to let her go. Each time though, they managed to scrounge up the funds to keep her.

Two years ago, when CDC funding came through for the first time, Natta was told her position was safe for the next five years. The CDC funds went directly to HIV prevention services—services that HEPPAC had previously been using county money for. That county money could then be used for holistic health services like Chinese medicine and acupressure. This is the constant shifting of funds that Loris Mattox has been forced to master.

But still, money is tight, even for someone like Natta who runs a program on a tiny budget. Hers is roughly $600 per month. “I actually emailed Loris last week requesting a bigger budget,” Natta said. “I could always use more of everything.” Supplies are always low, and when she runs out of something it usually takes six to eight months to get it back in stock. “I’m out of milk thistle and I won’t have it for months,” she said. On a recent night, she didn’t have lids for the small tincture bottles she hands out. Clients stood around her tables drinking the bitter liquid because they couldn’t take it with them.

Natta’s Chinese medicine—along with clean clothes, fresh produce and hot soup—are all part of HEPPAC’s harm reduction model, and not just because they are more readily fundable. By taking advantage of free services like the needle exchange, clients are put in contact with a wide range of other health services. “At first, they just care about their immediate needs. They want ‘points,’” Mattox said, using a slang term for needles. “It’s more than just the act of exchanging old needles for new. People come to get food and end up getting tested for HIV.”

HIV testing is especially important to needle exchange programs because of the number of infections that result from injection drug use. Over 80 percent of California exchanges surveyed in a CDC-funded report in 2004 also offer HIV counseling and on-site testing. The report also showed that over 60 percent of needle exchanges in California offer hepatitis C counseling. All of the surveyed exchanges distributed condoms, first aid kits, and referrals to drug treatment services. Many also offer overdose prevention education and supplies, like naloxone—a drug used to counter the effects of heroin overdose.

These additional services not only increase funding and convince more people to seek treatment for their health needs, but they also demonstrate the importance of needle exchanges in the larger public health arena. “Needle exchange is such a good entry point for people without any health care,” says Hilary McQuie. But, she emphasizes, they are not sufficient by themselves. “They shouldn’t be stand-alone treatments. It used to be necessary because it was illegal. But now that you don’t have to put up firewalls for needle exchange, it should be integrated” with other services like methadone programs and behavioral health treatments, she says.

For HEPPAC staffers, this diversity is a sign of success—they’ve progressed from dealing with clients’ most immediate needs to becoming a trusted supplier of many health services. “The original goal back in the day was to just get sterile syringes out there,” Mattox says. “Things change, and so we also want to address the needs of our target population. Folks always need more services. They tell us what they need and we try hard to get it.”

 

**

HEPPAC has come a long way from the early controversy that surrounded needle exchange in the 1990s and 2000s.  The organization was formed in 1992 under the name Alameda County Exchange. Four local HIV/AIDS activists started the volunteer-run group with the mission of providing sterile syringes to intravenous drug users, even though according to California state law it was a misdemeanor to “deliver, furnish, or transfer drug paraphernalia.”

“We started with a gallon ‘sharps’ container on a corner in the ghetto,” says early volunteer Arthur Belton. “Police came and asked us what we were doing. We had to educate them.”

Two members of the Berkeley-based Needle Exchange Emergency Distribution (NEED) were arrested in 1992. In 1995, five HEPPAC volunteers were also arrested for handing out needles. All charges were dropped and the volunteers were eventually acquitted. Belton, who says he was “cited numerous times” for handing out needles, says the police would regularly confiscate all of their boxes of new syringes, leaving them with the old, used ones.

“For me, there was complete clarity about what we were doing,” Belton says. “Drug use is looked at as a criminal problem, not a health care problem. There was a greater health issue, and it needed to be addressed.” After the 1995 arrest and acquittal, the Alameda County District Attorney labeled prosecution of needle exchange workers a “low priority” and the Berkeley and Oakland exchanges were allowed to continue.

Some critics of needle exchanges feel that handing out supplies to drug addicts supports their continued drug use. When the exchange started in Oakland, “it was not accepted socially,” Belton says. In 2000, HEPPAC was at the center of contentious community debate regarding the location of the original Casa Segura drop-in clinic, which was in the Fruitvale District. As part of the $100 million “Transit Village” development, City Councilman Ignacio De La Fuente and local groups, like The Unity Council, pushed hard for the group to move the clinic out of the district. (Representatives from the Unity Council declined to comment about HEPPAC and De La Fuente did not return multiple calls for comment.)

The discussion about the clinic’s location went unfinished, though, because on New Year’s Eve, 2001, the clinic and HEPPAC offices were completely destroyed in a fire. Suspicions of arson were raised, and while Oakland fire investigators labeled the fire “intentional,” no charges were ever filed.

Two years after the fire, the organization found a replacement building in the Fairfax Business District, and debate flared up again, both when staffers sought to purchase the building and again when they applied for the required permits to operate a drop-in clinic. In addition to protest from De La Fuente, they received complaints from their new next-door neighbors, the Fairfax Lighthouse Community Church. (Church leaders also could not be reached for comment.)

“They didn’t want us here,” Mattox says. “But once we moved in, people living [in boarding rooms] at the church were our first clients.”

While Oakland’s opponents of needle exchange seem reluctant to go on the record, in other cities they are much more vocal. In Modesto, a fierce debate over needle exchange has been raging for years. Despite the city’s large numbers of injection drug users and a rapidly growing rate of hepatitis C, the Board of Supervisors in Stanislaus County (the health jurisdiction that contains Modesto) voted against legalizing syringe exchange in 2008, despite recommendations by a civil grand jury and county health officials. “Giving a drug user a clean needle is not the best thing for him,” Supervisor Bill O’Brien told a reporter from StoptheDrugWar.org, a national advocacy group, in 2009. “Illegal drug use has a risk, and making it safer promotes it.”

Stanislaus County District Attorney Birgit Fladager argued that needle exchange sends the wrong message by making young people think the county will support them if they become addicted to drugs, and County Sheriff Adam Christianson agreed. “A syringe exchange program enables people to continue with their drug addiction,” he told a reporter in the same 2009 StoptheDrugWar.org story.

In defiance of the county’s vote, two volunteers working at an unauthorized exchange in Modesto’s Mono Park—nicknamed “Heroin Park”—were arrested in 2009. Their defense team argued the pair was responding to a public health crisis by preventing the spread of hepatitis C, which at the time had reached 12 new cases a week in Stanislaus County. After two years of legal wrangling, all charges were dropped. Needle exchange is still illegal in Modesto.

Although harm reduction practices aren’t accepted everywhere, the model seems to be working in Oakland. A recent HEPPAC survey found that it took injection drug users only two visits to an exchange site to change reported frequency of needle sharing from “always” to “never.” The same survey indicated that the more often people visit the exchanges, the more likely they are to share supplies with others who do not attend.

Meanwhile, the county’s percentage of AIDS transmissions from intravenous needle use has steadily fallen, from a high of 21.2 percent of all the county’s cases in 1995, down to 18.1 percent in 2001, and to 9.5 percent in 2006, when the county health department released its last comprehensive study.

County Supervisor Keith Carson attributes the dramatic drop mid-decade to increased funding for needle exchanges. “Prior to 2004, the number of AIDS cases was on the rise among intravenous drug users,” he says. “That year, money was allocated at the state and local level for needle exchange programs and the number of AIDS cases in Alameda County declined and have not increased since. 

A host of health organizations including the World Health Organization, the American Medical Association, and the National Institute of Health now support needle exchanges. Earlier this year, U.S. Surgeon General Regina Benjamin called them “an effective way of reducing HIV transmission among individuals who inject illicit drugs.”

A 2006 report from the Institute of Medicine called syringe exchange programs a “highly cost-effective” strategy for reducing the spread of HIV and compared the cost of a sterile syringe—around 15 cents—to the lifetime cost of treating one HIV-positive person—between $385,000 and $620,000.

But there is still a stigma surrounding syringe exchange. When he’s not working, Braunz Courtney sometimes forgets he’s wearing his “Clean Needles Save Lives” sweatshirt. At the grocery store, he often gets questions and strange looks. “Once I explain what we do, that we’re just out here helping people,” Courtney says, “you see that light go on, and they get it.”

 

**

Today, HEPPAC has nine full-time staff members and three part-timers. In addition to the Fruitvale needle exchange on Tuesday nights, HEPPAC runs a Thursday night exchange in East Oakland off of 100^th Avenue. Until two years ago, they also operated a West Oakland exchange location, but “it stopped because of gentrification,” Mattox says.  “We noticed kids were coming around to get cereal, but our other services weren’t getting used as much. There wasn’t a need in the area anymore.”

As one of the largest needle exchanges in California, HEPPAC is relatively stable compared to smaller, less established exchanges. During the recession years, other programs in the area haven’t fared as well.

Until August 2009, Berkeley’s program—Needle Exchange Emergency Distribution (NEED)—was directly funded through a state program that financed fifteen programs throughout California. “We used to have a state Office of AIDS grant, which was used for staffing,” says Savannah O’Neill, a part-time NEED coordinator. “But now we’re all-volunteer since that money got cut.”

Currently, NEED’s entire budget comes from Berkeley’s Department of Health Services. O’Neill isn’t sure federal money is on NEED’s horizon either. “Because we are all volunteer, it’s hard to have the capacity to research lots of new grants. We’re a small exchange, our capacity to go after things like that isn’t as great” as other programs, O’Neill says.

Richmond Exchange Works, Contra Costa County’s program, exchanges needles in Bay Point, Pittsburg, and Richmond. Bobby Bowens, the program’s director and only full-time staff member, says the county has funded the program since 2000, but those “funds don’t last all year.”

“We run out of money this time of year—August, September—every year,” Bowens says. “I flat run out of syringes. This is the dry period … it’s been happening forever.” In the past, Richmond Exchange Works has borrowed clean syringes from HEPPAC, as well as San Francisco exchanges. “We bring in our bio-hazard buckets filled with used needles, and they give us boxes of new ones on the promise that they will be repaid when our funding comes through,” Bowens says.

Bowens says “it’s nice” that federal agencies are changing their mind about needle exchange programs, but it’s not enough. “Perception has changed quite a bit, but there’s still no money. It’s the same old problem.”

For federal agencies with already tight budgets, every dollar that goes to needle exchange programs means a dollar cut from existing programs. “It’s an important time with a number of things changing structurally,” says Kabir Hypolite of Alameda County’s Office of AIDS. “We can’t fall into the trap of simply taking federal money and removing county money” from needle exchange programs, he says. “We need to redouble our efforts for HIV prevention.”

These days, much of Loris Mattox’s work at HEPPAC involves writing proposals and reports aimed at finally securing those elusive federal funds. After nearly two decades of work—first under the radar, then on a shoestring budget—federal recognition and backing would help elevate HEPPAC from the fringes of public health care, allowing them to integrate with established practices through increased disease testing, drug counseling, treatment and referrals.

“In 2004, when I started at HEPPAC,” Mattox says, “we were in crisis mode. But now we’re thinking of ways to expand, it’s a good place to be in.”

Even if the federal money is slow to arrive—or never comes—HEPPAC staffers will keep doing what they’ve done for close to twenty years, showing up under the overpass to help those caught in serious addiction do the best they can for their own health.

Mousey Durgin, who says she lives on the railroad tracks nearby, has been coming to the Tuesday night Fruitvale exchange for 15 years. She has a gaunt, sunken face, big smile and thin drawn-on eyebrows. Durgin holds two large grocery bags full of supplies from the exchange—cookers, condoms, oranges, bananas, vitamins, herbal tea, and hygiene kits with toothpaste, soap, and tampons. On a typical visit, she also gets up to 2,000 new syringes, which she said she passes out to up to 100 people. She rolls up the baggy sleeves of her stained sweatshirt and proudly shows off her bare inner arms. “I use a clean needle to fix every time and you can’t see any tracks,” Durgin says.

Durgin said disease spreads easily when you’re living on the street. Without the needle exchange, Durgin says, “There’d be a whole lot more AIDS.”