JEFFERSONVILLE, Indiana — There are boxes in the Clark County Health Department warehouse with “DO NOT USE” signs taped to them. They have stoves and sterile water, which people use to inject drugs.
The supplies, which came from the state and were paid for with federal money, were intended for a program in which drug users exchange dirty needles for clean ones, part of a strategy known as harm reduction. But under July decree from the president Donald TrumpFederal drug-addiction grants cannot pay for supplies such as hotplates and tourniquets, which he says “only promote illicit drug use.” Needles could no longer be purchased with federal money.
In some places, the order will galvanize support for needle exchange programs, which decades of research show are extremely effective in preventing illness among injection drug users and providing treatment for them.
In other countries, this fuels opposition that threatens the survival of the programs.
Republican-led Indiana passed legislation sharing permission ten years ago after the tiny city of Austin became the epicenter of the worst drug-induced HIV outbreak in US history. If lawmakers don't extend it, the law will expire next year and the number of exchanges will shrink. State officials have ordered remaining programs to comply with Trump's order and even eliminate federally funded supplies such as slabs and tourniquets.
For now, Clark County health officials have found a way to continue distributing the stoves and other items: buying them with private money and packaging them in “mystery bags” assembled by employees who are not paid with state or federal funds.
Meanwhile, Democratic-led California continues to use public funds for supplies such as tubes and syringes. California is home to a growing number of exchangers, with 70 of the more than 580 listed on the North American Syringe Exchange Network.
Some public health experts lament that syringe programs have become the target of increasing politicization and dissent.
Clark County Health Officer Dr. Eric Yazel says intravenous drug users are likely to inject themselves with or without clean materials. The exchanges prevent people from sharing needles and spreading disease, he said, “reducing the health risk to the entire population.”
But Curtis Hill, Republican former Indiana Attorney Generalis among critics who have expressed the same concerns as Trump's order: “We don't want to get into a situation where we are promoting drug use.”
When members come to the Clark County Health Department, they look at the list of services and say they are “#1” there.
They choose from a cart filled with needles, bandages, sharps containers and naloxone overdose reversal drug. They can be tested for HIV And hepatitis C; information about drug addiction treatment; and leaflets about food banks, housing and employment. There are even handmade knitted hats with encouraging messages like “You did it!”
“We spend half an hour, 45 minutes or so talking to them about where they are, whether they want treatment, whether they are ready,” said program director Dorothy Waterhouse. “These are our brothers, our sisters, our mothers, our fathers… We need compassion to make sure they go to treatment.”
It's the closest interchange to Austin, 35 minutes away. Scott County, where Austin is located, has already completed its program.
Joshua Gay lived in an apartment across the street when he used the Clark County Exchange. He injected methamphetamine daily.
“Addiction took everything from me. It took my life. It took my job, it took my health. I mean, it made my mind so bad that I wouldn't even shower,” said the 44-year-old, who now lives in Austin. “God told me, ‘You need to do something,’ and he led me to a needle exchange.”
He's sober today. He sought drug treatment from LifeSpring Health Systems after receiving support from medical professionals and now encourages others in recovery to stay healthy.
He believes the needle exchange not only saved him, but also helped him save someone else by providing naloxone, which he used to revive a friend who had overdosed on heroin.
After Trump order — which focused on homelessness — Indiana health officials told exchanges that some items they provided are now prohibited, citing letter from the US Substance Abuse and Mental Health Services Administration.
While Clark County workers have found ways to provide privately funded supplies for now, they are concerned that Indiana's exchange law is set to expire on July 1st. There are exchanges in six counties — up from nine in 2020 — despite the success of the programs.
Statewide, exchanges have made more than 27,000 drug treatment referrals and provided naloxone, which has prevented nearly 25,000 overdoses, according to information compiled by the Indianapolis-based nonprofit Damien Center.
Since its launch in 2017, the Clark County program alone has given out more than 2,000 doses of naloxone; more than 4,300 referrals for drug addiction treatment were issued; and has provided more than 4,400 referrals for HIV or hepatitis C testing. The syringe return rate is 92%.
Local and National Public health and addiction experts point to studies showing exchanges do not lead to more waste in the form of syringes, crime, or intravenous drug use—and that every dollar invested returns approximately $7 in avoided health care costs.
The Centers for Disease Control and Prevention estimates that the exchanges are associated with a 50 percent reduction in HIV and hepatitis C. In Scott County, where the HIV outbreak ultimately affected 235 people, there were fewer than five new cases per year in 2020 and 2021, just before the needle exchange program ended. The number remains low.
“When these programs first started, I thought, 'I don't know.' I didn’t understand that,” Yazel said. “And then I did a deep dive and started to understand the impact.”
Indiana is among 43 states with syringe programs, according to nonprofit research organization KFF.
Support remains strong in many places. This year in Hawaii, for example, lawmakers passed a law allowing people to get as many clean needles as they need, rather than just one at a time.
But bills in other countries, including two introduced in West Virginia this year, propose eliminating needle exchange programs.
The West Virginia Cabell-Huntington Health Department stopped issuing needles this month. Naloxone and fentanyl test strips remain available, along with services such as education, disease testing and links to health care.
“People who come to us will get the same smiles and the same hugs,” said Health Officer Dr. Michael Kilkenny. “We're just not going to hand out syringes or other things that are disfavored.”
Andrew Nixon, a spokesman for the U.S. Department of Health and Human Services, stressed in an email that federal funds can still be used for “vital services” such as education and naloxone, reflecting a “commitment to addressing the drug addiction and overdose crisis affecting communities across our country.”
Yazel expects a tough road ahead in Indiana.
“To put it bluntly,” he said, “we have an uphill battle ahead of us this legislative session.”
Damien Center CEO Alan Witchey, whose organization runs the needle exchange program, said he and a group of activists have created a website with information and ways to contact lawmakers. They met with elected officials and a state senator introduced a bill to extend the law until 2036.
“Without these programs, there will be one less tool available to combat substance use diseases, hepatitis C and HIV,” Witchie said. “And that could lead us to a very dangerous place. We've seen where that leads.”
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