A sign shows needle exchange participants in Charleston where to return their used syringes. Photo by Lauren Peace

Public officials, volunteers, people living with substance use disorders and people in recovery came together in a parking lot where a local nonprofit was distributing clean needles and naloxone on a sunny Saturday afternoon on Charleston’s West Side.

This was in part a scheduled biweekly event, meant to provide a myriad of services to some of Charleston’s most vulnerable. But for city council members who were invited to attend, it was also a fact-finding mission.

A council member asked a woman about the need for sterile syringes. Another hopped behind a table and joined volunteers in handing out feminine hygiene products and used clothes. 

In a state that has the highest rate of opioid-involved overdose deaths in the country, where many struggle with poverty and mental health resources are few and far between, the scars created by the drug epidemic are undeniable. 

But how West Virginia’s capital city moves forward in addressing the crisis has proved to be a point of controversy. Harm reduction — and whether or not to provide people who inject drugs with sterile needles as a way to minimize risk and prevent the spread of infectious disease — remains at the center of the city’s current dispute.

During the past three months, public scrutiny has focused on a grassroots needle exchange operated by the nonprofit Solutions Oriented Addiction Response (SOAR). After a police investigation found no wrongdoing, Charleston city leaders are grappling with what’s next for the needle exchange and — in the bigger picture — what to do about the area’s rising rates of HIV linked to drug use. 

But as an emotional debate plays out during government meetings, many community members — and some city council members — say they need  more information and education before any decisions are made.

“I don’t really know enough about the topic to form an opinion,” said Charleston resident Patrick Krason, who has been following the debate.

“What are the pros and cons of a needle exchange? Is it enabling? Does it need to be run by a government entity or can a nonprofit [do it]?” Krason asked. “I want to better understand this issue. [There’s] so much I don’t know yet.”

The questions posed by Krason echoed those shared by other members of the community, including some lawmakers. Mountain State Spotlight spoke with experts to get answers.

What exactly is harm reduction?

In this context, the debate is about needles — and distributing them to people who inject drugs. But harm reduction is much broader than syringe exchanges.

The strategy refers to an approach that is used to address behaviors that are risky to public health. Rather than viewing risk as black and white, the approach acknowledges that humans are going to take varying levels of risk, and seeks to give people the tools they need to minimize harm when they do. 

The concept of harm reduction isn’t new, and can be applied across a number of health scenarios. In the context of substance use disorder, the goal of harm reduction is to reduce the additional risks associated with injection drug use, like the transmission of HIV and hepatitis C, while providing pathways to recovery for people struggling with addiction.

While a program might have recovery coaches available, refer people to treatment centers and offer additional medical services, an important principle of harm reduction is that treatment isn’t forced.

Instead, harm reduction is like a bridge. On one side is addiction and on the other is recovery. The goal is to provide a way to cross from one side to the other when a person decides the time is right, and to keep people who are struggling as healthy as possible in the interim.

Photo by Lauren Peace

An important part of that is providing people who inject drugs with access to overdose reversal medications. Also of importance is providing access to clean needles.

According to the U.S. Centers for Disease Control and Prevention, more than 2,500 new HIV infections occur each year among people who inject drugs as a result of sharing needles. And last year in Kanawha County, 32 new cases of HIV associated with injection drug use were identified. That’s an exponential increase from previous years, when the county would see fewer than five of these cases annually.

Experts say that beyond playing a crucial role in protecting public health and preventing the transmission of harmful disease, using harm reduction strategies, including syringe access programs, offer some of our most stigmatized community members compassion and connection.

“Syringe service programs are a crucial point of connection for people who use drugs. And I don’t mean that in the narrow ‘access to services’ sense,” said Christopher Abert, a national harm reduction consultant and the director of Southwest Recovery Alliance. “When we offer people refuge from an otherwise hostile world, we create space for love and respect.”

And that helps get people into recovery.

But isn’t giving people needles enabling drug use?

During recent Charleston city meetings, some council members have suggested that providing clean needles to people who inject drugs enables  drug use. 

Experts say that there is zero evidence to support those claims.

“The data is clear,” said Gregg Gonsalves, a professor of epidemiology at Yale University’s School of Public Health. “Syringe access programs prevent HIV and do not increase drug use.”

Gonsalves is a world-leading expert in HIV prevention and has received a MacArthur “genius grant” for his work. He said he understands the emotional reaction to needle exchanges, but the scientific evidence is explicit.

Although needle exchanges have been controversial in Charleston, the subject is relatively straightforward to the CDC, which supports harm reduction generally, as well as needs-based syringe services programs. These needs-based programs — like the one that SOAR is operating in Charleston — have low barriers to entry, don’t require people to bring a needle back to get another one, and don’t require the use of an ID.

“It’s not controversial to experts in the disease of substance use disorder,” said Dr. Judith Feinberg, a professor at West Virginia University who specializes in infectious disease related to drug use. “All the evidence is that syringe service programs decrease drug use, decrease crime, decrease health care costs, and people who have access to them are three times more likely to enter recovery.

Feinberg said there’s a huge need for conversation and education on the topic.

“It’s controversial in the public because people still think of substance use disorder as a moral failure and therefore they really see this through a judgmental lens,” Feinberg  said. “We need to sit down with people and say you have to start thinking about this in a different way, and this is why.”

What about the costs of running a harm reduction program?

Research has found that syringe access programs can save millions of dollars in health care costs for the communities where they exist.

That, according to David Holtgrave, dean of the School of Public Health at the University of Albany, is because while diseases like HIV and hepatitis C are incredibly expensive to treat, sterile syringes cost just a few cents.

A 2014 paper published by Holtgrave found that for every dollar invested in syringe access programs, communities actually save about $7 in health care costs.

“In a lot of jurisdictions you save around $330,000 when you prevent a case of HIV infection,” said Holtgrave, who was the vice chairman of the Presidential Advisory Council on HIV/AIDS during President Barack Obama’s administration.

And those costs of treating HIV, according to Christine Teague, the head of the Ryan White HIV intervention program at Charleston Area Medical Center, fall primarily on West Virginia’s Medicaid budget.

“HIV and Hepatitis C are really expensive to treat and most of the folks we diagnosed last year were Medicaid recipients,” Teague said. “So not only are these new cases devastating to the health of the individual and the community, they’re also really costly.”

Analysis by the West Virginia Center on Budget and Policy, a nonpartisan policy research organization, found that lifetime treatment for new cases of hepatitis C and HIV identified in Kanawha County in 2019 alone would cost more than $47 million. 

Well, what’s the deal in Charleston?

Although decades of scientific evidence and guidance offered by the CDC fully support syringe access programs, skepticism and fear have driven much of the conversation in Charleston. In  2018, the Kanawha-Charleston Health Department shut down its needle exchange in the midst of a contentious political debate.

The program, which was operated by the health department from 2015 to 2018, was thrust into the spotlight when, in his final term in office, then-Charleston Mayor Danny Jones waged an attack on the health department-run exchange, calling it a “needle mill” and pushing for its elimination.

Months of political debate and media scrutiny around the needle exchange ensued, and in March 2018, against the advice of public health experts, the program was shut down and hasn’t been replaced since.

There is another harm reduction program currently operating in Charleston through the free clinic WV Health Right. But that program has strict entry requirements that contradict best-practices, and gives out hundreds of thousands fewer sterile syringes annually than programs in cities of similar size across the state. Experts say that if that program were meeting the need on its own, HIV wouldn’t be rising.

After the 2018 fight, damage to public perception of harm reduction programs hasn’t completely gone away in Charleston.

“What happened with the health department really ruined a lot of people’s opinions about [syringe access programs],” said Councilman Bruce King. “When the controversy came up back in 2018, I had never really thought about the issue that much. But I started reading about how they were operating and it was just irresponsible, there was no accountability.”

The health department’s program was need-based and at its peak served close to 500 people in a single day. Although it was criticized by the state health department in 2018, experts in harm reduction and infectious diseases wrote letters saying the state’s analysis of the program was poorly done and did not evaluate the program against best practices. 

King is one of nine Charleston City Council members to sponsor the bill to restrict needle distribution in the city. He said he understands the reasons why people advocate for needle exchanges, but that he personally does not support them. Instead, he said focus should be placed on providing more mental health services and improving treatment options for people living with substance use disorder.

But after the health department closed its needle exchange, the experts’ warnings came true. HIV began to rise. 

In 2019, the health department established an HIV task force to address the increasing cases, but took little substantive action. 

That’s when SOAR, the Charleston-based nonprofit, stepped in.

Since it was founded in 2018, SOAR’s mission has been to increase outreach and education around substance use disorder and eliminate stigma. In addition to hosting community meetings, the organization focused on efforts to distribute overdose reversal medications and street outreach to people in need. 

Alongside naloxone distribution, and in response to the needs of the people they were serving, SOAR began quietly distributing clean needles during street outreach clinics last year. As the biweekly clinics grew, SOAR expanded its offerings to include food, water, wound treatment and medical services, HIV testing and distribution of condoms and feminine hygiene products, too.

“I love that SOAR is trying to do the right thing,” said Councilwoman Deanna McKinney, who is also a sponsor of the bill to restrict needle distribution. “But what they should have done is come together with representatives first to ask what these communities need. The needles are not helping the African American community that you’re in.”

McKinney, who represents the neighborhood where SOAR currently sets up its clinic, said that she wants to see more resources offered to her constituents but she doesn’t support the distribution of needles.

What now?

The Charleston Police Department’s finding that SOAR didn’t violate the law didn’t mean that the topic of needle distribution was welcome.

In the two city council meetings during which the subject has been discussed since, there’s been a split reception to the push for increased harm reduction and needle distribution services in Charleston.

Some council members, like King, McKinney and Pat Jones, have spoken out against the work and raised concerns about syringe litter. Others, like Caitlin Cook, Keeley Steele, Mary Beth Hoover and Bobby Reishman have called for the acknowledgment of science and deferred to the CDC.

With an amendment that would restrict needle distribution in Charleston currently pending, the future of such programs remains up in the air.

If the bill isn’t passed, then SOAR will be allowed to continue to operate its grassroots program. The group has made it clear that it is open and eager to work with Charleston officials and the Kanawha-Charleston Health Department to pave a collaborative path forward.

If City Council passes the bill, that doesn’t necessarily mean the end of SOAR or needle exchanges. The group could reapply for certification by the state, which would allow it to continue distribution. But state certification requires proof of community support, and SOAR was denied certification in January on those grounds.

Still, the most likely and reasonable path forward, according to many council members, is to take time to discuss.

The bill is now on the agenda of council’s public safety committee meeting on Feb. 24 — pushed back from the original date of Feb. 4 — and members of the committee, including some of the bill’s sponsors, seem to agree on the decision not to rush.

On Saturday, in the midst of the debate, a rare sign of unity and hope emerged when a number of city council members on both sides of the issue attended SOAR’s street outreach and engaged in conversations with the nonprofit’s volunteers and with the people who rely on it.

“I don’t think this is a decision we can make in a week,” said Councilwoman Jennifer Pharr, who co-sponsored the bill, at the Saturday event. “It’s going to be a conversation, it’s going to be folks listening.”

Councilman King echoed that.

“I agree with 99% of the work that SOAR is doing,” King said, standing in the parking lot on Saturday. “I don’t support handing out needles, but I think that we’ve all got to be able to meet somewhere in the middle.”

Councilwoman Keeley Steele, chairwoman of council’s public safety committee, similarly called for the bill to be delayed. Steele said that a number of medical professionals and people who work with treating addiction will speak with council during or before the committee meeting on Feb. 24, to provide additional information.

At the meeting next Thursday, the committee will discuss ground rules, to make sure that all who wish to speak will be able to when the bill is discussed.

Steele said that she supports SOAR’s work and needs-based syringe programs.

“I hope we can make decisions that are based on data and science and not all emotion,” Steele said. “It’s clear that people in our community are hurting. I hope we can come together and find common ground.”

Lauren Peace is a Report for America Corps Member who covers public health.