In 2017, Virginia passed a law allowing some localities to launch needle exchange programs, an attempt to prevent the spread of infectious diseases like hepatitis C and HIV.

But it came with a hitch: the law is due to sunset in 2020.

The Virginia Department of Health’s goal was to collect enough data to illustrate the programs’ efficacy. But a year away from the sunset, only four sites have been approved, three of which are up and running: Health Brigade in Richmond, along with the Lenowisco and Mount Rogers health districts.

“It’s a new concept for Virginia, and I think even in the communities where there’s a lot of support, nobody’s really certain who wants to jump on as the lead agent,” said Elaine Martin, director of Virginia’s HIV and hepatitis prevention services.

Needle exchanges, also known as harm-reduction or syringe-services programs, allow injection drug users access to clean needles and a safe place to dispose of their used ones. Reams of public health research show they are an effective way to prevent the spread of deadly infections like HIV and hepatitis C through injection drug use, a particular concern nationwide in light of the opioid epidemic.

But even with only three programs up and running, VDH has data to show how the programs have worked, at least so far. Virginia’s sites have distributed 28,000 sterile syringes to participants, and nearly 25,000 have been returned — an 86 percent return rate.

Martin noted that neither VDH nor any of the sites have received complaints from the public or law enforcement about the programs. She said if the sunset is extended, the department could collect more valuable information on the sites.

“We would like more data because, obviously, only one site has been open for a year, and the others have been open for a few months,” Martin said.

“It’s clear that the opioid epidemic is not over, even though we are seeing some shifts in drug use to methamphetamines,” she continued. “For anybody who is injecting or needs referral to drug treatment — I think we want to keep those doors open.”

A fourth site

There have been several barriers keeping potential sites from opening. The nature of Virginia’s law calls for numerous agencies within each community to sign onto the idea, requiring letters of support from both the locality’s governing body and its law enforcement agency.

In Chesterfield County, though the sheriff was interested in starting a program, its Opioid Steering Committee tabled the idea. And in Roanoke, the chief of police refused to give his support for more than a year, though he changed course in April.

This week, VDH officially approved the Council of Community Services’ application to start a needle exchange in Roanoke.

Colin Dwyer, harm reduction and substance use program coordinator for the Council of Community Services, said the organization doesn’t have a concrete date for opening its program yet, but it hopes to do so sometime in the fall.

That might not provide much time to collect meaningful data on the program before the 2020 General Assembly session, when the sunset will have to be extended.

Dwyer pointed out that more sites coming online will make it easier for others to open, as seeing Health Brigade’s program made it easier for the Council of Community Services to pull together its application.

“The more people see it that works and is an effective intervention, the easier it’ll be to make it happen in other places,” he said.

Connecting clients to services, naloxone

The data that VDH does have shows that the sites aren’t just distributing clean needles — they’re also linking people to the services they need.

Of the 241 participants that have enrolled, 69 percent have been tested for HIV and hepatitis C, according to Martin. Thirty-six percent had confirmed hepatitis C, and 41 clients were connected to treatment. Though none tested positive for HIV, two others who were known to have the virus were successfully connected to care as well.

Another 85 participants received referrals to substance use disorder treatment, and 28 attended their first appointments. Eight participants reported becoming abstinent from drug use.

Breanne Forbes-Hubbard, population health manager with the Mount Rogers Health District, said in an email that some of the comprehensive harm reduction program participants have accepted a wide range of additional services, from medical care and birth control to food banks and parenting classes.

She said one of the participants who tested positive for hepatitis C received treatment and was cured, while three have stopped using substances.

“When we ask participants why they are involved with our services, some have responded that they want to get a better job than what they currently have, that they want to go back to school to get their master’s degree, or that they want to be a better parent to their children than their parents were to them,” she said.

The sites also distribute naloxone, the opioid-reversal drug, and Martin said that there have been 32 overdose reversals reported by participants.

“To me, that’s really compelling — that 32 lives may have been saved,” Martin said.

Slow starts

Not only has it taken time for the programs to get off the ground, but it is also a slow process to convince participants to trust that the needle exchanges aren’t simply traps intent on getting them in trouble with the law.

Colin King, comprehensive harm reduction program associate with Health Brigade in Richmond, said the program started slowly, but participation began improving around the start of the year, and now 10 or more participants typically visit during the days the site is open. Often those are returning clients, though they usually see at least one new participant, as well, he said.

Key to Health Brigade’s approach is meeting clients without judgment: allowing them to simply obtain clean needles or to be connected to additional services if they’re interested without pressuring them.

“Each participant that comes in here is different and unique and uses drugs for different reasons,” King said. “People use drugs for recreation, sometimes because it’s cheaper to buy on the street than it is from a pharmacy, because of past trauma or mental health issues… Substance use is a very complex space.”