Top: The lobby of the Charleston Civic Center in West Virginia. Bottom: the Kanawha River; downtown Charleston.

CHARLESTON, W.Va. — To its critics here, the needle exchange was an unregulated, mismanaged nightmare — a “mini-mall for junkies and drug dealers” in the words of Danny Jones, the city’s mayor — drawing crime into the city and flooding the streets with syringes. To its supporters, it was a crucial response to an escalating crisis, and the last bulwark standing between the region and a potential outbreak of hepatitis and H.I.V.

When Charleston closed the program last month after a little more than two years of operation, it was the latest casualty of a conflict playing out in a growing number of American communities. At least seven other such exchanges have closed in the past two years, even as dozens of others have opened.

Needle exchanges dispense sterile syringes to drug users and give them somewhere to discard their used syringes safely. Often, as in Charleston’s case, an exchange will offer supporting services, too: on-site medical care, hepatitis/H.I.V. screening, counseling and connections to drug treatment.

They were once a largely urban phenomenon. But the opioid crisis is changing the landscape. After an H.I.V. outbreak among injection drug users in Scott County, Ind., in 2015, health officials opened many exchanges in suburbs, rural areas and small cities in more conservative parts of the country. Some of these communities have had second thoughts.

Syringe exchanges in the United States Sources: Centers for Disease Control and Prevention, Harm Reduction International, North American Syringe Exchange Network

Public health experts now find themselves relitigating questions that in their view were settled decades ago, while political leaders worry that harm reduction — that is, mitigating the risks from drug use — means enabling drug use.

The research is unambiguous: Needle exchanges reduce the spread of bloodborne diseases like hepatitis C and H.I.V. and do not increase drug use. They’ve been shown to reduce overdose deaths, decrease the number of needles discarded in public places and make it more likely that drug users enter treatment. They also save money: One recent study estimated that $10 million spent on needle exchanges might save more than $70 million in averted H.I.V. treatment costs alone.

Health experts say the programs create relationships between deeply addicted people and the health care system, an essential step if they are to be reintegrated into society. “It’s the most low-threshold way for people who use drugs to have contact with any kind of public health professional,” said Alex H. Kral, an epidemiologist with RTI International, a nonprofit research organization. “And that’s a powerful intervention.”

Yet needle exchanges — also called syringe exchanges or syringe services programs — have struggled to gain public acceptance in the United States, which still lags far behind many countries in their adoption. According to the North American Syringe Exchange Network, 333 such programs operate across the country, up from 204 in 2013. In Australia, a country with less than a tenth as many people, there are more than 3,000.

People who inject drugs per syringe exchange Includes O.E.C.D. countries of at least 10 million residents for which there is data on the number of operational syringe services programs. For each country, the number of people who inject drugs is an estimate. The years of these estimates differ. Sources: European Monitoring Centre for Drugs and Drug Addiction, Harm Reduction International

A gateway to treatment in Charleston

When Dr. Michael Brumage began working as director of the Kanawha-Charleston Health Department in August 2015, the lessons of Scott County were on his mind: He was determined to bring a syringe exchange to Charleston. The exchange opened four months later with broad support from local government, law enforcement and the wider community.

“I was really impressed by the thoughtfulness that went into planning the program and the care that went into making it effective at all levels,” said Daniel Raymond, the deputy director of planning and policy for the Harm Reduction Coalition, a nonprofit advocacy group. He said he had considered the Charleston program “to not only be a huge success story but also a potential model for other communities.”

Dr. Michael Brumage began working as the director of the Kanawha-Charleston Health Department determined to open a needle exchange. “The only way to address the opioid epidemic is to engage the people who are using,” he said.

This might have been its downfall: It was too successful. At its busiest, 483 drug users passed through the exchange in just eight hours — in a city of 50,000 people. “Nobody expected the numbers to grow so rapidly,” said Brenda Isaac, the president of the Kanawha County Board of Health, who explained that the pace left little room for individualized, focused care.

As the health department struggled to manage the crowds, it began to hear more complaints from law enforcement about discarded needles. By the summer of 2017, the initial enthusiasm for the exchange among city officials was waning. In early 2018, news accounts of a 5-year-old girl accidentally stuck with an uncapped syringe in a McDonald’s bathroom captured public attention. A local TV segment described Charleston as buried under “Needles Everywhere.”

Weekly visitors to Charleston’s harm reduction program Visitors to the health department exchange increased steadily since it opened. Source: Kanawha-Charleston Health Department

For the mayor, the location of the exchange made its existence untenable. It was housed in the health department building, a squat brutalist structure across the street from the gleaming, newly renovated civic center. The civic center — a $100 million development project — was intended to be the linchpin of a revitalized city.

“We can do that,” Mr. Jones said, gesturing to pictures of needles sitting in front of him, “or we can do this,” he said, holding up a piece of paper where he’d outlined his administration’s economic development deals.

The mayor is in recovery himself — an alcoholic, he says, 24 years sober — and father to a son who has struggled with heroin addiction. He argues for prescription heroin, saying it should be provided to people where it can be used safely under supervision. He just wants those services far from Charleston, and definitely far from the new civic center. “I understand recovery,” Mr. Jones said. “I’m in it myself, and I believe in it. But I don’t believe we have to destroy a city over it.”

The location of the needle exchange, as seen from the steps of the newly renovated civic center.

In early March, the mayor began using his daily radio show to rally public sentiment against the health department, citing discarded needles and rising crime that he attributed to what he saw as a weekly influx of people using drugs.

Last month, the police chief imposed new rules on the program, loosely based on those used by a much smaller exchange run by West Virginia Health Right, a clinic nearby. Participation would be limited to people who could prove — with picture ID — that they lived in the county. Testing for hepatitis and H.I.V. would be mandatory. Needles would be dispensed only in strict one-for-one trades.

Public health experts condemned the measures. An ID requirement would be prohibitive for many people, said Mr. Raymond, particularly for the quarter of the program’s patients who are homeless. And strict one-for-one exchange goes against decades of public health research that shows greater flexibility to be a better policy. “I would rather close down the needle exchange altogether than follow those rules,” said Dr. Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco. “This is really truly backwards.”

Hours after the chief’s announcement, health department leadership suspended the syringe exchange rather than comply with the new regulations.

The mayor of Charleston, Danny Jones, rallied public sentiment against the syringe exchange program. “The people on the council who are pushing this — they would never accept it in their own neighborhood,” he said.

Drug users caught in the middle

In the middle of this dispute are the estimated 3 percent to 4 percent of Charleston’s residents who inject drugs, typically heroin or meth.

Trent Farr, 54, says he has cancer and is homeless. He has lived in Charleston almost 26 years and has multiple medical problems, many related to chronic drug use. “I go through more pain in a day than some people do in their entire lives,” he said while waiting for the Crossroads Shelter to begin meal service. “I hate — I absolutely hate — using needles,” Mr. Farr said, explaining that his drug use is the only thing he has found to mute his pain. For him, the health department’s closing “changes everything.”

Amber White, 24, agreed. “Now people have to go out and rob and steal to get points,” she said, referring to unused needles. She said that when the exchange was running, unused needles became so plentiful that people could afford to give them away. Now that they’re becoming scarce again, she said drug users would face a choice of either sharing them or resorting to crime to get money to buy unused ones.

With sterile syringes harder to find, Ms. White worries about contracting H.I.V. or hepatitis, both of which she has managed to avoid — to her surprise — despite heavy drug use. Twenty-six percent of the injection drug users looked at by the health department tested positive for hepatitis C.

Counties at risk of an H.I.V. outbreak C.D.C. researchers identified 220 counties in the United States that are most vulnerable to an outbreak of H.I.V. associated with injection drug use. Many, including Kanawha County, are clustered along the Ohio Valley and in Appalachia. Based on hepatitis C infection rates, overdose mortality, opioid sales, buprenorphine availability and county demographics. Source: Journal of Acquired Immune Deficiency Syndrome

Both Mr. Farr and Ms. White expressed frustration at what they said were the small minority of users who left discarded needles in the open. “If I see them laying on the ground, I’ll pick them up and throw them away,” Ms. White said. “Because, you know, I think it’s nasty — and I use drugs. So I can’t imagine what it looks like to somebody that doesn’t even use.”

Fears of the next H.I.V. outbreak

The harm reduction program remains active in Charleston, but is now seeing only a dozen clients each week for counseling, H.I.V. testing or medical care. The relationship between the health department and the city has become toxic, to the point that the mayor and city officials have spoken openly of dismantling the department altogether. “It’s our health department,” said Paul Ellis, the city attorney. “We created it. We can make it disappear.”

For the health department, the needle exchange was a way of getting drug users in the door, exposing them to medical care, keeping them connected to the community and giving them hope. “The only way to address the opioid epidemic is to engage the people who are using,” Dr. Brumage said. “These are modern-day lepers that no one wants to see or touch. The syringe services program was a place these people could go and be treated like real human beings.”